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Hodgkin's Lymphoma in Younger Patients: Lessons Learned on the Road to Success

Hodgkin's Lymphoma in Younger Patients: Lessons Learned on the Road to Success

ABSTRACT: Despite significant improvements in the treatment of Hodgkin's lymphoma over the past 2 decades, physicians continue to face dilemmas in therapy for the disease, and many cured patients live with complications of treatment. Newer therapeutic options are still needed for the disease, to minimize complications and to improve the treatment of patients in relapse. This review considers the treatment of Hodgkin's lymphoma in younger patients, addressing such issues as which patients with early-stage disease may require radiotherapy, what prognostic factors provide information that can affect treatment choices in patients with advanced disease, and what we have learned about treatment complications in this setting.

Hodgkin's lymphoma (HL) is a rare, curable malignancy, and investigators have made remarkable improvements in treatment of the disease over the past 20 years. Still, physicians face dilemmas in therapy for the disease, and many cured patients live with complications of treatment. The type of therapy given to these patients determines long-term survival rates. The young patient with HL treated in the past had a greater chance of dying of some malignancy other than HL, and at an earlier age than someone who has not had the disease. Relapse therapy can cure approximately 50% of patients, depending on patient- and disease-related features, and failure of initial therapy, once considered an ominous sign, may not be such a poor feature any longer.

Newer therapy options are needed for the disease—not only novel initial therapy designed to treat the patient with minimal complications, but also therapy for those in relapse. In this review, we consider the treatment of HL in younger patients, first evaluating recent clinical trials for early-stage disease, with a special focus on which patients may still need radiotherapy (RT). For advanced disease, prognostic factors may provide information for those wishing to use treatment other than the ABVD regimen (Table 1) or other standard chemotherapy regimens. Finally, investigators should develop methods that minimize the complications of therapy.

Treatment of Early-Stage HL

Most US studies of HL in the past were performed in patients treated with radiotherapy followed by laparotomy. Investigators used these results to form the current staging system for HL. However, following the development of MOPP chemotherapy (Table 1), it became possible to cure patients with chemotherapy, and laparotomy became unnecessary. At the same time, chemotherapy and adjuvant RT was the standard of care in Europe. For these reasons, prognostic-factor systems developed by investigators in Europe and the United States have differed, making comparisons between trials difficult (Table 2).

Regardless, MOPP and therapies that have relied on MOPP-based regimens have gradually given way to treatment with ABVD and similar regimens, not only in the United States, but also in Europe (Table 1). Recent trials suggest that ABVD or variants of this combination with or without RT may still be the best therapy for early-stage HL, regardless of the type of disease presentation, and the potential for complications of therapy may ultimately direct choices of treatment. Guidelines for therapy also still include ABVD as a standard (Table 3).

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