Overview of the treatment of classical Hodgkin lymphoma in adults
- Peter M Mauch, MD
Peter M Mauch, MD
- Professor of Radiation Oncology
- Harvard Medical School
- George P Canellos, MD
George P Canellos, MD
- Editor-in-Chief — Oncology
- Section Editor — Miscellaneous Tumors
- Professor of Medicine
- Harvard Medical School
The treatment of patients with Hodgkin lymphoma (HL, formerly called Hodgkin's disease) is primarily guided by the clinical stage of disease as determined by the Cotswolds classification (table 1). This staging system is important in determining not only prognosis and treatment, but is also important for the comparison of results obtained with different types of treatment in different studies. (See "Staging and prognosis of Hodgkin lymphoma".)
This topic will provide a brief review of the selection of treatment based upon disease stage. The initial evaluation, diagnosis, and staging of patients with HL are discussed separately, as is a more detailed description of treatment selection for patients with early or advanced stage HL. This topic reviews classical HL. The rare subtype of nodular lymphocyte predominant Hodgkin lymphoma is presented separately. (See "Initial evaluation and diagnosis of classical Hodgkin lymphoma in adults" and "Staging and prognosis of Hodgkin lymphoma" and "Epidemiology, pathologic features, and diagnosis of classical Hodgkin lymphoma" and "Treatment of nodular lymphocyte-predominant Hodgkin lymphoma".)
OVERVIEW OF SELECTION OF THERAPY
Over the past century, Hodgkin lymphoma (HL) has been converted from a uniformly fatal disease to one that is curable in approximately 75 percent of patients worldwide. While the majority of patients will be cured of their lymphoma, treatment-related toxicities have become a competing cause of late mortality. As such, the selection of therapy must balance the desire to maintain a high rate of cure and the need to minimize long-term complications. Treatment has evolved such that patients with early stage disease can achieve long term remission with less intensive therapy, while more intensive therapy is reserved for patients with advanced stage disease. Despite agreement that therapy should be tailored to the stage of disease, there is some disagreement regarding what should constitute intensive and less intensive therapy.
The endpoint of many clinical trials is freedom from recurrence. Although in many studies an increased relapse risk in one treatment arm does not translate into a survival difference, survival differences are often seen in the following situations:
●A large difference in number of recurrences seen
- Cosset JM, Henry-Amar M, Meerwaldt JH, et al. The EORTC trials for limited stage Hodgkin's disease. The EORTC Lymphoma Cooperative Group. Eur J Cancer 1992; 28A:1847.
- Engert A, Plütschow A, Eich HT, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med 2010; 363:640.
- Bonfante V, Santoro A, Viviani S, et al. ABVD in the treatment of Hodgkin's disease. Semin Oncol 1992; 19:38.
- Santoro A, Viviani S, Villarreal CJ, et al. Salvage chemotherapy in Hodgkin's disease irradiation failures: superiority of doxorubicin-containing regimens over MOPP. Cancer Treat Rep 1986; 70:343.
- Brusamolino E, Lazzarino M, Orlandi E, et al. Early-stage Hodgkin's disease: long-term results with radiotherapy alone or combined radiotherapy and chemotherapy. Ann Oncol 1994; 5 Suppl 2:101.
- Colonna P, Jais JP, Desablens B, et al. Mediastinal tumor size and response to chemotherapy are the only prognostic factors in supradiaphragmatic Hodgkin's disease treated by ABVD plus radiotherapy: ten-year results of the Paris-Ouest-France 81/12 trial, including 262 patients. J Clin Oncol 1996; 14:1928.
- Andrieu JM, Bayle-Weisgerber C, Boiron M, et al. The chemotherapy--radiotherapy sequence in the management of Hodgkin's disease. Results of a clinical trial. Eur J Cancer 1979; 15:153.
- Colonna P, Andrieu JM, Ghouadni R, et al. Hodgkin's disease, clinical stages IA to IIIB: combined modality therapy (3 MOPP followed by curative and prophylactic radiotherapy including the spleen). Six-year results. Eur J Haematol 1987; 39:356.
- Hasenclever D, Diehl V. A prognostic score for advanced Hodgkin's disease. International Prognostic Factors Project on Advanced Hodgkin's Disease. N Engl J Med 1998; 339:1506.
- OVERVIEW OF SELECTION OF THERAPY
- Treatment selection
- - Early stage Hodgkin lymphoma (Stage I-II)
- Favorable prognosis
- Unfavorable prognosis
- - Advanced stage Hodgkin lymphoma (Stage III-IV)
- - Primary refractory disease
- - Relapsed disease
- Early stage disease
- International prognostic score
- MINIMIZING LONG-TERM COMPLICATIONS OF THERAPY
- Fertility preservation
- Smoking cessation
- INFORMATION FOR PATIENTS