Early Favorable Hodgkin Lymphoma
Drug combinations described in this section include the following:
- ABV: doxorubicin, bleomycin, and vinblastine.
- ABVD: doxorubicin, bleomycin, vinblastine, and dacarbazine (1 cycle = 1 month of therapy).
- AV: doxorubicin and vinblastine.
- AVD: doxorubicin, vinblastine, and dacarbazine.
- MOPP-ABV: mechlorethamine, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, and vincristine.
Patients are designated as having early favorable Hodgkin lymphoma (HL) if they have clinical stage I or stage II disease and no adverse risk factors. Adverse risk factors include the following:
- B symptoms (fever ≥38°C, soaking night sweats, weight loss ≥10% within 6 months). (Refer to the PDQ summary on Fever, Sweats, and Hot Flashes for more information.)
- Extranodal disease.
- Bulky disease (≥10 cm or >33% of the chest diameter on chest x-ray).
- Three or more sites of nodal involvement.
- Sedimentation rate ≥50 mm/h.
Historically, radiation therapy alone had been the primary treatment for patients with early favorable HL, often after confirmatory negative staging laparotomy. A randomized, prospective trial involving 542 patients with early favorable HL compared MOPP-ABV for three cycles plus involved-field radiation therapy (IF-XRT) with subtotal nodal radiation; with a median follow-up of 7.7 years, combined modality was favored in terms of 5-year event-free survival (98% vs. 74%, P < .001) and 10-year overall survival (97% vs. 92%, P = .001).[Level of evidence: 1iiA] The late mortality from solid tumors, especially in the lung, breast, gastrointestinal tract, and connective tissue, and from cardiovascular disease makes radiation therapy a less attractive option for the best-risk patients, who have the highest probability of cure and long-term survival.[2-6] Recent clinical trials have focused on regimens with chemotherapy and IF-XRT or with chemotherapy alone.
A randomized, prospective trial from the National Cancer Institute of Canada involving 123 patients with early favorable HL compared ABVD for four to six cycles to subtotal nodal radiation; with a median follow-up of 11.3 years, no difference was observed in event-free survival (89% vs. 86%; P = .64) or in overall survival (OS) (98% vs. 98%; P = 0.95).[Level of evidence: 1iiA]
In a randomized study from the Milan Cancer Institute of patients with clinical early-stage HL, 4 months of ABVD followed by either IF-XRT or extended-field radiation therapy (EF-XRT) showed similar OS and freedom-from-progression with a 10-year median follow-up, but the study had inadequate statistical power to determine noninferiority of IF-XRT versus EF-XRT.[Level of evidence: 1iiDii]
The German Hodgkin Lymphoma Study Group (GHSG) randomly assigned 1,190 patients with early favorable HL to the following:
- Two cycles of ABVD plus 30 Gy of IF-XRT.
- Two cycles of ABVD plus 20 Gy of IF-XRT.
- Four cycles of ABVD plus 30 Gy of IF-XRT.
- Four cycles of ABVD plus 20 Gy of IF-XRT.
The ongoing GHSG study is comparing reduced chemotherapy schedules while maintaining IF-XRT at 30 Gy: two cycles of ABVD, two cycles of ABV, two cycles of AVD, or two cycles of AV.
A specialized approach to therapy can be taken when patients with nonbulky lymphocyte–predominant disease presenting in unilateral high neck (above the thyroid notch) or epitrochlear locations require only IF-XRT after clinical staging. A retrospective report of 426 cases of lymphocyte-predominant HL (including the so-called nodular lymphocyte–predominant and lymphocyte-rich classical subtypes) showed that more patients died of treatment-related toxicity (both acute and long term) than from recurrence of HL.[Level of evidence: 3iiiA] Limitation of radiation dose and radiation fields and avoidance of leukemogenic chemotherapeutic agents, along with watchful waiting policies, should be investigated for these subgroups. Patients with nonbulky nodular sclerosing disease presenting in the anterior mediastinum only after clinical staging also do well with mantle radiation alone.
Treatment options include the following:
- ABVD for four to six cycles.
- ABVD for two cycles plus IF-XRT (20 Gy or 30 Gy).
- Radiation therapy alone in special circumstances.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I adult Hodgkin lymphoma and stage II adult Hodgkin lymphoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.References
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