Treatment of unfavorable prognosis early (stage I-II) classical Hodgkin lymphoma
- Richard T Hoppe, MD
Richard T Hoppe, MD
- Professor of Radiation Oncology
- Stanford University School of Medicine
- Peter M Mauch, MD
Peter M Mauch, MD
- Professor of Radiation Oncology
- Harvard Medical School
- Ann S LaCasce, MD
Ann S LaCasce, MD
- Associate Professor of Medicine
- Harvard Medical School
Once the diagnosis of Hodgkin lymphoma (HL, formerly called Hodgkin's disease) has been established, subsequent therapy and prognosis are based upon the stage of the disease, as currently defined by the Ann Arbor staging system with Cotswolds modifications (table 1). (See "Staging and prognosis of Hodgkin lymphoma" and "Overview of the treatment of classical Hodgkin lymphoma in adults".)
In this discussion, early stage HL is defined as those patients with stage I or II disease:
●Stage I – Involvement of a single lymph node region (I) or of a single extralymphatic organ or site (IE)
●Stage II – Involvement of two or more lymph node regions on the same side of the diaphragm alone (II) or with involvement of limited, contiguous extralymphatic organ or tissue (IIE)
Among patients with early (stage I-II) disease, there is subsequent stratification into favorable and unfavorable prognosis disease based upon the presence or absence of certain clinical features, such as age, B symptoms, erythrocyte sedimentation rate (ESR), large number of regions involved, and large mediastinal adenopathy. Cooperative research groups have used varying definitions of favorable and unfavorable prognosis disease. These are described in more detail separately. (See "Staging and prognosis of Hodgkin lymphoma", section on 'Favorable or unfavorable risk early stage disease'.)
- 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.
- Carde P, Hagenbeek A, Hayat M, et al. Clinical staging versus laparotomy and combined modality with MOPP versus ABVD in early-stage Hodgkin's disease: the H6 twin randomized trials from the European Organization for Research and Treatment of Cancer Lymphoma Cooperative Group. J Clin Oncol 1993; 11:2258.
- von Tresckow B, Plütschow A, Fuchs M, et al. Dose-intensification in early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD14 trial. J Clin Oncol 2012; 30:907.
- Gordon LI, Hong F, Fisher RI, et al. Randomized phase III trial of ABVD versus Stanford V with or without radiation therapy in locally extensive and advanced-stage Hodgkin lymphoma: an intergroup study coordinated by the Eastern Cooperative Oncology Group (E2496). J Clin Oncol 2013; 31:684.
- Advani RH, Hong F, Fisher RI, et al. Randomized Phase III Trial Comparing ABVD Plus Radiotherapy With the Stanford V Regimen in Patients With Stages I or II Locally Extensive, Bulky Mediastinal Hodgkin Lymphoma: A Subset Analysis of the North American Intergroup E2496 Trial. J Clin Oncol 2015; 33:1936.
- Advani RH, Horning SJ. Treatment of early-stage Hodgkin's disease. Semin Hematol 1999; 36:270.
- Brusamolino E, Anselmo AP, Klersy C, et al. The risk of acute leukemia in patients treated for Hodgkin's disease is significantly higher aft [see bined modality programs than after chemotherapy alone and is correlated with the extent of radiotherapy and type and duration of chemotherapy: a case-control study. Haematologica 1998; 83:812.
- Bonfante V, Santoro A, Viviani S, et al. ABVD in the treatment of Hodgkin's disease. Semin Oncol 1992; 19:38.
- Bauer K, Skoetz N, Monsef I, et al. Comparison of chemotherapy including escalated BEACOPP versus chemotherapy including ABVD for patients with early unfavourable or advanced stage Hodgkin lymphoma. Cochrane Database Syst Rev 2011; :CD007941.
- Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol 2010; 28:4199.
- Behringer K, Thielen I, Mueller H, et al. Fertility and gonadal function in female survivors after treatment of early unfavorable Hodgkin lymphoma (HL) within the German Hodgkin Study Group HD14 trial. Ann Oncol 2012; 23:1818.
- Fermé C, Eghbali H, Meerwaldt JH, et al. Chemotherapy plus involved-field radiation in early-stage Hodgkin's disease. N Engl J Med 2007; 357:1916.
- Noordijk EM, Thomas J, Foerme MB, et al. First results of the EORTC-GELA H9 randomized trials: the H9-F trial (comparing 3 radiation dose levels) and H9-U trial (comparing 3 chemotherapy schemes) in patients with favorable or unfavorable early stage Hodgkin's lymphoma (abstract). Proc Am Soc Clin Oncol 2005; 16:6505.
- Specht L, Yahalom J, Illidge T, et al. Modern radiation therapy for Hodgkin lymphoma: field and dose guidelines from the international lymphoma radiation oncology group (ILROG). Int J Radiat Oncol Biol Phys 2014; 89:854.
- Meyer RM, Hoppe RT. Point/counterpoint: early-stage Hodgkin lymphoma and the role of radiation therapy. Blood 2012; 120:4488.
- Eichenauer DA, Bredenfeld H, Haverkamp H, et al. Hodgkin's lymphoma in adolescents treated with adult protocols: a report from the German Hodgkin study group. J Clin Oncol 2009; 27:6079.
- Darabi K, Sieber M, Chaitowitz M, et al. Infradiaphragmatic versus supradiaphragmatic Hodgkin lymphoma: a retrospective review of 1,114 patients. Leuk Lymphoma 2005; 46:1715.
- Vassilakopoulos TP, Angelopoulou MK, Siakantaris MP, et al. Pure infradiaphragmatic Hodgkin's lymphoma. Clinical features, prognostic factor and comparison with supradiaphragmatic disease. Haematologica 2006; 91:32.
- PRETREATMENT EVALUATION
- INITIAL THERAPY
- Choice of therapy
- Combined modality therapy
- - Chemotherapy regimen
- - Number of cycles
- - Radiation field size
- - Radiation dose
- Is there a role for chemotherapy alone?
- SPECIAL SCENARIOS
- Pregnant women
- Older adults
- HIV-infected patients
- Infradiaphragmatic disease
- Nodular lymphocyte predominant Hodgkin lymphoma
- PATIENT FOLLOW-UP
- CLINICAL TRIALS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS