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Controversies in Early-Stage Hodgkin’s Disease

Controversies in Early-Stage Hodgkin’s Disease

The optimal choice of treatment for early-stage Hodgkin’s disease depends
on (1) knowledge of the prognostic factors that may influence treatment outcome
and (2) the risk of acute and long-term complications incurred by
treatment. For prognostic and therapeutic considerations, patients are divided
into those with early-stage, favorable-prognosis disease (clinical stage I/II
without risk factors) and those with early-stage, unfavorable-prognosis or
intermediate-stage disease (clinical stage I/II with risk factors).

Based on the results of earlier trials, the European Organization for
Research and Treatment of Cancer (EORTC) has defined clinical stage I/II
(supradiaphragmatic only) patients as having favorable-prognosis, early-stage
disease if none of the following risk factors are present: age > 50 years,
asymptomatic disease with an erythrocyte sedimentation rate > 50 mm/h,
B symptoms with an erythrocyte sedimentation rate > 30 mm/h, and a large
mediastinal mass. In previous trials, stage II disease, mantle-cell or
lymphocyte-predominant histology, and multiple involved regions had also been
considered adverse factors.[1]

Since 1988, the German Hodgkin’s Lymphoma Study Group (GHSG) has defined
clinical stage I/II patients as having favorable-prognosis, early-stage disease
in the absence of the following adverse factors: large mediastinal mass,
multiple involved regions, elevated erythorcyte sedimentation rate, localized
extranodal infiltration (so-called E lesions), and massive splenic
involvement.[2]

The Revised European-American Lymphoid (REAL) and World Health Organization
(WHO) classifications of Hodgkin’s disease contained one important
modification of the Rye system—the definition of the lymphocyte-predominant
(paragranuloma) subtype. Most patients with the lymphocyte-predominant subtype
present with early-stage disease and enjoy an excellent prognosis despite a
propensity for local relapse. Current treatment strategies favor limited
radiation therapy for these patients.[3]

Early-StageDisease With Favorable Prognosis

Extended-field radiotherapy alone produces a complete remission in 90% to 98%
of patients with early-stage favorable-prognosis Hodgkin’s disease.[4]
Although 30% to 40% will relapse, salvage chemotherapy or combined-modality
therapy will yield new remissions in most cases. Approximately 75% to 85% of
patients with early-stage favorable-prognosis disease who receive extended-field
radiotherapy as first-line therapy are alive after 10 years.

Increasing concern about the long-term consequences of treatment prompted
many investigators in the 1970s and 1980s to reexamine the aggressive approaches
developed for the staging and treatment of early-stage favorable-prognosis
disease. In several follow-up studies, an increased risk of secondary cancer was
reported for surviving patients.

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