Objective: Hodgkin Lymphoma (HL) constitutes 10 percent of lymphomas. It is one of the most curable malignancies with a response rate of around 85%. Most recent guidelines recommend ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) regimen in the first-line treatment of classical HL. Epidemiological studies showed that around 20% of patients treated with bleomycin developed bleomycin pulmonary toxicity (BPT). Risk factors for BPT are under investigation by most lymphoma working groups. Some studies suggested that bleomycin dose could be a risk factor for BPT. Sarcopenia is defined as a syndrome characterized by the loss of muscle mass, strength, and performance. Recent studies suggested that psoas muscle indexes could be used to identify sarcopenic patients. We hypothesized that the same bleomycin dose especially in patients with muscle loss due to the subsequent chemotherapy cycles might be a risk factor BPT.

Methodology: A total of 48 patients with newly diagnosed classical HL were included in the study. All of the patients received at least 2 cycles of a standard dose of ABVD chemotherapy. Sarcopenia was assessed using the psoas muscle index (PMI), which was calculated using values measured on PET/CT images before ABVD chemotherapy and the following formula: cross-sectional area of the bilateral psoas muscle/height2. Patients were divided into two groups according to the PMI: the sarcopenia group (≤443mm2/m2 for men and ≤326mm2/m2 for women) and the non-sarcopenia group (>443mm2/m2 for men and >326mm2/m2 for women). PMI was calculated both prior to the initial chemotherapy and after 2 cycles of ABVD. chemotherapy-related complications such as bleomycin toxicity, hospitalizations, the time course of neutropenia, and hospitalization due to the neutropenic fevers were recorded. Chi-square test and Mann Whitney U tests were used for statistical analyses. A p-value less than 0.05 were considered as statistically significant.

Results: 29 (60.4%) of the patients were male. 13 of 48 patients (27%) developed BPT after starting chemotherapy. Body Mass Index (BMI) status of these patients with BPT did not change after 2 cycles of ABVD. Mean psoas indexes prior to chemotherapy were 581.36[PLUSMN]188.08 in patients who did not have BPT and 465.29[PLUSMN]149.64 in patients with BPT (p=0.052). Mean psoas indexes after 2 cycles of ABVD were 597.43[PLUSMN]207.38 in patients who did not have BPT and 400.46[PLUSMN]109.21 (p<0.001). 11 of 13 patients with BPT had sarcopenia after 2 cycles of ABVD. There were no statistically significant association with stage, mortality status, time of neutropenia, relapsed disease, neutropenic fever episodes, and psoas muscle indexes.

Conclusion: Sarcopenia after 2 cycles of chemotherapy may be a risk factor for BPT. All patients with sarcopenia received same dose of bleomycin in this study. A significant relation between loss of muscle mass and BPT indicates that higher bleomycin doses in accordance with muscle mass may be a risk factor for BPT development. Dose reductions according to muscle mass can be more logical even if the BMI status of the patients remains the same after 2 cycles of chemotherapy. Randomized clinical trials are needed in this very important topic.