In their review of the history of the management of stage I/II Hodgkin’s disease, Drs. Ng and Mauch describe the results of various treatment protocols and outline the questions posed by ongoing European, Canadian, and American trials. In a broad sense, the questions posed by these trials will help clinicians understand the benefits and complications of these treatments. However, as clinically oriented as they are, the current studies have yet to answer some common problems faced by private practitioners—the clinicians who, in North America, manage most patients with Hodgkin’s disease.
Staging Methods
Most investigators currently rely on computed tomography (CT) to evaluate patients for the presence or absence of Hodgkin’s disease, and the lymphangiogram is only of historical interest to private practitioners. However, staging by positron-emission tomography (PET) scan is rapidly becoming routine practice. Investigators, especially from European studies, have reported the value of this test in the management of aggressive lymphomas when performed by experts; however, no large database has yet concluded that the PET scan is of value in making treatment decisions for patients with Hodgkin’s disease. Both true- and false-positives have been reported with this test; therefore, all clinicians must exercise caution when ordering a PET scan and should consider it ancillary to CT and biopsy for confirmation of persistent or recurrent disease.
Investigators must better define the prognostic factors for Hodgkin’s disease. As outlined by Ng and Mauch, ongoing studies have addressed historically valid factors for stage I/II Hodgkin’s disease. However, serologic studies have rarely been addressed in large-scale trials. These reproducible quantitative factors, including interleukin-10 (IL-10), soluble CD30, beta-2-microglobulin, and cellular expression of bcl-2, are indirect measurements of the biological activity of the disease, and may determine extent of disease, resistance to chemotherapy or radiotherapy, and the ultimate survival of patients with either early- or late-stage disease.[1-6]
Besides the studies mentioned by Ng and Mauch, other investigators have also used clinical features to address the problem of predicting outcome. The International Prognostic Index (IPI) for advanced-stage disease has been applied to the management of early-stage disease and may be useful in this setting. Other groups, basing their efforts on the early work of Specht, have attempted to better measure tumor burden and the number of involved sites, especially for advanced disease treated with chemotherapy.[7-12]
Investigators should further confirm the reproducibility and value of these methods. Nevertheless, in the hands of experienced investigators (including academic clinicians and private practitioners alike), these systems may identify patients with very good and very poor prognoses when treated with combined-modality therapy or chemotherapy alone.
Special Features
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
