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Controversies in Early-Stage Hodgkin’s Disease

Controversies in Early-Stage Hodgkin’s Disease

Drs. Ng and Mauch do an excellent job of summarizing the current conventional
wisdom regarding the management of patients with clinical early-stage Hodgkin’s
disease, although their citation of some studies is selective. Today nearly all
patients with Hodgkin’s disease receive combined-modality therapy—usually an
abbreviated course of a chemotherapy regimen (often one that has not been shown
to cure the disease when used alone) followed by 20 to 40 Gy of involved-field
radiation therapy. This approach certainly hides a multitude of sins. If you don’t
give chemotherapy well, you can still achieve good disease control with the
radiation therapy. If you can’t design a radiation port that encompasses known
sites of disease, you can still get by because the systemic chemotherapy will
leave relatively little for the radiation therapy to do.

Nearly all of the field’s intellectual capital is now being spent on
attempts to define how little chemotherapy you can give and how small the
radiation ports and doses can be without paying the price of higher recurrence
rates. The strategy of using both chemotherapy and radiation therapy in every
patient is, in my opinion, poorly considered and disregards much of what has
been learned about Hodgkin’s disease treatment over the past 30-plus years.

Clinical Staging

It is important to understand why anatomic staging was ever important in the
management of patients with Hodgkin’s disease. The major importance of
anatomic staging was to identify patients who could be safely treated with
radiation therapy alone. Ng and Mauch note that it is possible to use
limited-field radiation alone with good results in patients who are shown at
laparotomy to have no intra-abdominal disease. We have silently and with no
remorse let lymphangiography disappear from the tool kit, although it was
documented to be the single most sensitive way to detect intra-abdominal Hodgkin’s
disease short of laparotomy.

Laparotomy has also largely been abandoned. The clinical staging work-up that
is usually performed today omits lymphangiography and relies on abdominal
computed tomography (CT) or magnetic resonance imaging (MRI) scanning to detect
intra-abdominal disease. These techniques will miss at least two-thirds of
patients with intra-abdominal involvement of Hodgkin’s disease. By current
clinical staging methods, about 80% of patients will be considered to have
early-stage Hodgkin’s disease when only 40% actually do. The abdomen has, by
unofficial consensus, been declared a safe haven for Hodgkin’s disease
clinical staging.

The take-home message is that if you are going to ignore intra-abdominal
Hodgkin’s disease by making only a cursory attempt to detect it, you must use
systemic chemotherapy to treat the disease because nearly half of the patients
believed to have early-stage disease do not. This lesson has been amply learned
in the studies (cited by Ng and Mauch) in which radiation therapy alone was used
in clinically staged patients.

However, some clinicians have been slow to learn the lesson. They reason that
patients who relapse can, in large part, be salvaged by combination
chemotherapy....so what’s the harm? In fact, these clinicians note, because
some patients are cured by radiation therapy alone, they do not need to receive
chemotherapy, and thus, maximum disease control can be achieved while limiting
exposure to combined-modality therapy to only 40% or so of patients rather than
100%.

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