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Controversies in Early-Stage Hodgkin’s Disease

Controversies in Early-Stage Hodgkin’s Disease

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.

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