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Follow Up

Most patients with Hodgkin lymphoma, especially those below the age of 65 years at diagnosis, can be cured with the treatments described in this section. Most cured patients experience minimal long-term toxicity from the treatments, however, certain predictable and occasional rare and unpredictable late effects may occur and require preventive measures and/or recognition and treatment.

The following late effects of Hodgkin lymphoma or its treatment should be considered when patients are reviewed in follow-up.

Risk/Problem

Incidence/Response

Relapse

10% to 30% of patients relapse depending on stage and bulk of presentation. Careful attention should be directed to lymph node sites, especially if previously involved with disease.

Dental caries

Neck or oropharyngeal irradiation may cause decreased salivation. Patients should have careful dental care follow-up and should make their dentist aware of the previous irradiation.

Hypothyroidism

 After external beam thyroid irradiation to doses sufficient to cure Hodgkin lymphoma at least 50% of patients will eventually become hypothyroid. Also, there is an increased risk of secondary thyroid carcinoma after irradiation. All patients whose TSH level becomes elevated should be treated with life-long thyroxine replacement in doses sufficient to suppress TSH levels to low normal for two purposes: to maintain euthyroidism and to minimize the risk of thyroid carcinoma by reducing overstimulation with endogenous TSH.

Infertility

ABVD is not known to cause any permanent gonadal toxicity based on longterm follow-up of thousands of patients. Direct or scatter radiation to gonadal tissue may cause infertility, amenorrhea or premature menopause but this seldom occurs with the fields used for the treatment of Hodgkin lymphoma. Thus, with the current chemotherapy regimens and radiation fields used, most patients will not develop these problems. In general, after treatment, women who continue menstruating are fertile, but men require semen analysis to provide a specific answer.

Secondary neoplasms

Although uncommon, certain secondary neoplasms occur with increased frequency in patients who have been treated for Hodgkin lymphoma. These include acute myelogenous leukemia, thyroid, breast, lung and upper gastrointestinal carcinoma and melanoma and cervical carcinoma-in-situ. It is appropriate to screen for these neoplasms for the rest of the patient's life because they may have a lengthy induction period.

The following minimum follow-up tests and examinations should be performed on all patients after treatment of Hodgkin lymphoma. Visits should be every 3 months for 2 years, then every 6 months for 3 years, then annual. Patients should be strongly encouraged to perform careful breast and skin examination on a regular basis. Immunizations should be updated as recommended in Appendix III.


Interval

Test

Every visit

Lymph node, abdominal, thyroid, and skin examination
CBC, alkaline phosphatase

Every visit for 2 years then every other visit

Chest radiograph

Annually

  • TSH level (only if the thyroid was irradiated)
  • Mammography for womenbeginning 10 years after diagnosis of Hodgkin lymphoma or at age 40 years, whichever comes first
  • Pap smear
  • Influenza immunization (Appendix III)
SOURCE: Follow Up ( )
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