Childhood stage IV Hodgkin disease: therapeutic results of the Polish pediatric leukemia/lymphoma study group

Treatment of pediatric hodgkin lymphoma

OPINION STATEMENT

We are increasingly successful in the treatment of Hodgkin lymphoma. Current risk adapted trials seek to maintain the excellent efficacy of older therapies, while simultaneously limiting their late toxicities. Current management of early stage/favorable disease involves the use of two to four cycles of tailored chemotherapy, often followed by low-dose, involved field radiation. Those with intermediate and advanced stage disease require more intense chemotherapy and radiation regimens. Functional imaging using [(18)F]-2 fluoro-D-2-deoxyglucose is increasingly used to determine complete vs. partial response and to detect relapse. Given the success of primary therapy, retrieval of patients remains a highly individualized challenge. The majority of children failing combined-modality treatment undergo high-dose chemotherapy followed by autologous hematopoietic stem cell rescue, oftentimes with consolidative radiotherapy.

The Use of Gallium-67 Scintigraphy to Monitor Tumor Response Rates and Predict Long-Term Clinical Outcome in Patients with Lymphoma

The aim of this study was to determine whether gallium (Ga)-67 scintigraphy can monitor the treatment response rates and predict the long-term clinical outcome in patients with lymphoma. Gallium-67 scintigraphy was performed upon admission (baseline Ga) in 33 consecutive, newly diagnosed patients. Twenty-eight patients (Hodgkin's disease, n = 18; non-Hodgkin's lymphoma, n = 13) with Ga avid tumors were included in the study. All the patients were treated with induction chemotherapy. Gallium-67 scintigraphy was performed in all patients after the first cycle of chemotherapy (post-cycle 1 Ga) and repeated after the fourth cycle (post-cycle 4 Ga) or after completion of treatment (end-of-chemotherapy Ga). Nineteen patients had a fast response (68%, negative in post-cycle 1 and end-of-chemotherapy Ga), 4 intermediate response (14%, partial positive post-cycle 1 Ga that progressed to negative post-cycle 4 Ga), 3 slow response (11%, partial positive in both post-cycle 1 and post-cycle 4 Ga) and 2 no response (7%, positive in both post-cycle 1 and end-of-chemotherapy Ga). In patients who had either fast or intermediate response, 22 (96%) were free of disease at a median follow-up period of 30 months (range, 11-45 months). All 5 patients (100%) who had slow or no response had progressive disease or residual disease. In conclusion, the findings indicate that Ga could effectively be used to monitor the treatment response rates and predict the long-term clinical outcome in patients with lymphoma and should be used in treatment modifications aimed at reducing toxicity of effective therapy in patients with fast response and replacing treatments early in patients with slow or no response.

Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy

PURPOSE

Current standard therapy for children and adolescents with Hodgkin's disease includes combination chemotherapy and low-dose involved-field radiation (LD-IFRT). Because radiation may be associated with adverse late effects, the Children's Cancer Group (CCG) investigated whether radiation could be omitted in patients achieving a complete response to initial chemotherapy without jeopardizing the excellent outcome obtained with combined-modality therapy.

PATIENTS AND METHODS

Between January 1995 and December 1998, 829 eligible patients were enrolled onto CCG 5942. A total of 501 patients who achieved an initial complete response after risk-adapted combination chemotherapy were randomized to receive LD-IFRT or no further treatment. Event-free survival (EFS) and overall survival were assessed from the date of study entry or the date of randomization, as appropriate.

RESULTS

The projected 3-year EFS from study entry for the entire cohort was 87% +/- 1.2%. Among patients who achieved a complete response to initial chemotherapy, 92% +/- 1.9% of those randomized to receive LD-IFRT were alive and disease free 3 years after randomization, versus 87% +/- 2.2% for patients randomized to receive no further therapy (stratified log-rank test; P =.057). With an "as-treated" analysis, 3-year EFS after randomization for the radiation cohort was 93% +/- 1.7% versus 85% +/- 2.3% for patients receiving no further therapy (stratified log-rank test; P =.0024). Three-year survival estimates for patients treated with and without LD-IFRT were 98% +/- 1.1% for patients who received radiation and 99% +/- 0.5% for patients who did not receive radiation.

CONCLUSION

LD-IFRT after an initial complete response to risk-adapted chemotherapy improved EFS. At this time, there is no survival advantage for LD-IFRT, but follow-up remains short.