DISCUSSION ISSUES IN TREATMENT OF ADVANCED STAGES OF HODGKIN’S LYMPHOMA

Abstract

The best treatment strategy for advanced stage Hodgkin lymphoma (HL) is still a matter of debate. There are three questions which discuss.

1. What is better: starting with the less toxic ABVD regimen which relapse free survival only of 60‑70 % at 5 years and try to salvage relapsing patients with high‑dose chemotherapy (CT) or starting with the more effective, but more toxicity BEACOPP escalated (FFTF at 5 years 87 %) in order to cure as many patients as possible at once. Several modification of BEACOPP escalated were tested to reduce toxicity. Meta‑analysis of 14 trials, including 10,011 patients shows that only 6 cycles of BEACOPP escalated and 8 cycles of BEACOPP‑14 were associated with the lowest risk for death of any cause and have the advantage of a five‑year survival rate for ABVD. In Russian protocol LHMoscow‑1‑3 for advanced stage HL the efficacy of another modified regime 6EACOPP‑14 was similar to 8BEACOPP‑14 by progression‑ free survival rate (PFS) 89 %, overall survival (OS) 96.3 % and toxicity.

2. Which dose radiotherapy (RT) and whom are need? After MOPP regimen, there might be a potential advantage of involved field RT (IFRT) as detected by a meta‑analysis of 16 randomized studies, whereas this advantage is not evident after ABVD. In the past decades, increasing knowledge on the long‑term effects of ionizing radiation, such as secondary malignancies, pulmonary toxicity, and cardiovascular damage, has led to increasing skepticism towards RT among patients and physicians. However, long term analysis (median of follow up more then 10 years) shows that 12‑years OS better without RT because less secondary malignancies and cardiovascular damage. But tumor control (PFS) is better with RT. With the development of modern radiation techniques, smaller field sizes, and lower doses, the side effects of radiotherapy and the expected long‑term effects can be reduced substantially.

3. Early PET response after two cycles CT is an important tool for planning risk‑adapted treatment in advanced HL. Many prospective trails are in going to answer this question. Therefore, current concepts include early response evaluation, guided by FDG‑PET, into treatment strategies and will hopefully define a new standard of care in which each patient receives as much therapy as needed.