Hodgkin's disease in children: seventeen years experience at the Instituto Português de Oncologia de Francisco Gentil

Characteristics and Survival Outcomes of Children With Hodgkin Lymphoma Treated Primarily With Chemotherapy

BACKGROUND

Hodgkin disease is a malignant tumor of the lymphatic system that comprises ∼6% of childhood cancers. In developing countries, efforts are made to ensure adherence to standard protocol/regimens, study patients' outcomes, and compare with that in developed world.

MATERIALS AND METHODS

We conducted a retrospective medical records' review of 212 children younger than 20 years presenting to The Indus Hospital in Pakistan with previously untreated Hodgkin lymphoma between August 2000 and December 2012. We collected demographic and other epidemiologic variables such as age, sex, stage, subtype of disease, and survival outcomes.

RESULTS

The mean±SD age of patients at time of diagnosis was 9.0±3.8 years with a male to female ratio of ∼4.7:1. In total, 44 (20.8%) patients were 5 years of age or above at presentation. Overall, 131 (61.8%) patients presented with B-symptoms and mixed cellularity was the most frequently diagnosed subtype in 65.1% of cases. In total, 170 (80.2%) achieved full remission after completion of chemotherapy. Patients were treated with alternating cycles of ABVD (Adriamycin, Bleomycin, Vincristine, and Dacarbazine) and COPDAC (Cyclophosphamide, Vincristine, Prednisolone, and Dacarbazine). The majority (n=114, 59.1%) received 6 cycles of chemotherapy, 44 (22.8%) received ≤4 cycles followed by 24 (12.4%) receiving 8 cycles. Radiotherapy was administered only to those patients with significant residual disease at the end of chemotherapy (n=20, 10%). The 5-year overall survival and event-free survival in our cohort was 89.6% and 82.1%, respectively.

CONCLUSION

Our findings suggest that treatment with 4 to 8 alternating cycles of ABVD/COPDAC has an excellent outcome in childhood Hodgkin disease.

Hodgkin's disease in Indian children: outcome with chemotherapy alone

BACKGROUND

To assess the efficacy of chemotherapy alone, using four cycles of COPP alternating with four cycles of ABVD in all stages of childhood Hodgkin's disease (HD).

PROCEDURE

Between January 1991 and February 2001, 148 previously untreated patients were investigated, treated, and analyzed for remission and survival.

RESULTS

There were 134 boys and 14 girls with a median age of 8 years, 75% were less than 10 years old. 63.5% had advanced stage disease (IIB-IV). B symptoms were present in 54.4% of cases; bulky mediastinal mass in 18 cases (12.2%); spleen and bone marrow involvement in 22 (14.9%) and four cases (2.7%), respectively. Mixed cellularity (MC) subtype was found in 86.0%. Response to treatment was evaluated in 133 patients: complete remission (CR) was achieved in 121 patients (91.0%), partial remission (PR) in seven (5.3%), progression occurred in two (1.5%), and three (2.3%) died on therapy. Four patients with mediastinal residual disease were given additional involved field radiotherapy. Out of 111 patients analyzable, five (4.5%) have relapsed 6-30 months after completing chemotherapy, and were treated with additional cycles of ABVD and low-dose involved field radiotherapy. The 5-year actuarial overall survival (OS) and event-free survival (EFS) are 91.5 and 87.9%, respectively. Advanced stage, B symptoms, anemia, spleen, and marrow involvement were adverse prognostic factors for survival.

CONCLUSIONS

Chemotherapy alone with alternating COPP/ABVD, without additional radiotherapy, provides high rates of durable remission and is an effective therapy in childhood HD, even in case of large mediastinal mass and peripheral or abdominal bulky disease.

The many faces of Hodgkin's disease around the world: what have we learned from its pathology?

In the past decade there have been many advances in our understanding of Hodgkin's disease. Among the most important is the discovery that the Reed-Sternberg cell is a lymphoid cell, in most cases a B cell, and that it is clonal, and thus a true lymphoma, deserving of a name change, to 'Hodgkin's lymphoma' (HL). Based on a combination of immunophenotype and morphology, the R.E.A.L. Classification recognizes two main types of HL: classical types (nodular sclerosis, mixed cellularity, lymphocyte-rich classical HL, and lymphocyte depletion) and nodular lymphocyte predominance type (NLPHL), which probably represent distinct biological entities. The immunophenotype and genetic features of both classical HL and NLPHL have been defined. These are useful in the subclassification of HL and in distinguishing HL from two recently-described, aggressive lymphomas that were in the past often diagnosed as HL: anaplastic large-cell lymphoma, T-cell type (ALCL), and T-cell/histiocyte-rich large B-cell lymphoma (T/HRBCL). Epstein-Barr virus has been detected in approximately 40% of the cases of classical HL, and is clonal, suggesting that this virus may play a role in the pathogenesis of at least some types of HL. The frequency of HL varies in different populations, and the frequency of EBV-positive HL appears to be inversely related to the overall frequency of HL in a given population. Thus, it is possible that its presence may simply reflect the prevalence of EBV-infected B cells in the individual. Despite the advances of the past ten years, many questions remain to be answered, and these will provide the challenges of the next decade.

Incidence of childhood lymphoma in northern Israel, 1973-1990

We retrospectively analyzed all 164 cases of pediatric lymphoma diagnosed in northern Israel during the 18-year period from 1973 to 1990. Our findings generally conformed to those of other studies with regard to annual incidence (24.7/million), age at diagnosis (5 to 9 years for Jewish males, later for others), histology (Hodgkin's disease most commonly), and male predominance. The northern Israeli pediatric lymphoma pattern of incidence is similar to the Asian-African-South American pattern and unlike that of Europe or North America; in Israel, lymphoma rather than brain tumor is the second most common childhood malignancy. The nodular sclerosing variant was the most common histology seen in Hodgkin's lymphoma (especially in females), followed by mixed cellularity. Malignancies are generally more common in Jewish children but lymphomas in particular were seen more often in Arabs (28.7/million), while the Ashkenasi (20.8/million) and Sephardi (21.6/million) Jewish populations had similar incidences. The high rate of consanguineous marriages among Arabs and their lower socioeconomic level may explain the high incidence of lymphomas in this group.

Hodgkin's disease in children 4 years of age or younger

The natural history of Hodgkin's disease in children younger than 4 years of age is unknown. Thirty-eight patients younger than 4 years of age at the time of diagnosis of Hodgkin's disease were treated at the member institutions of the Pediatric Oncology Group. They were found to be predominantly white and male with early-stage disease. Mixed cellularity and nodular sclerosing histologies were most commonly seen and occurred in equal frequency. They responded to therapy extremely well attaining a complete remission rate of 92% to 94%. Even after relapse, they can be successfully retrieved with salvaging therapy.

Nasopharyngeal Hodgkin's disease with intracranial extension in a child

Childhood Hodgkin's Disease rarely involves the nasopharynx or the brain. This is a report of a 12-year-old boy who presented with a 3-month history of headache, diplopia, dizziness, and early morning vomiting. Computerized axial tomography (CT) scan revealed a nasopharyngeal mass with intracranial extension through the skull base. Biopsy of the nasopharyngeal mass and an upper cervical lymph node was consistent with Hodgkin's disease of mixed cellularity. This, to the author's knowledge, is the first report of a child having the combination of nasopharyngeal and intracranial involvement in Hodgkin's disease.

Hodgkin's disease in children in Kuwait

Between 1968 and 1981, 78 children younger than age 15 years were diagnosed, staged, treated, and followed up for a minimum period of 2 years. Most cases (64%) were in their first decade and the male-to-female ratio was 1.9:1. Mixed cellularity type occurred in 49% and nodular sclerosis in 32%. Lymphocytic depletion type was rare and occurred in only 4% of the cases. More than one half (53%) had Stages III and IV at presentation. The mediastinum was involved in 38%. The treatment of Stages I and II was mainly by radiotherapy, and Stages III and IV by combination of radiotherapy and chemotherapy. The total survival was 75% and relapse-free survival was 53%. Since 1975, lymphography became a routine investigation and staging laparotomy was performed in selected case. The mantle field was extended to include the para-aortic bar and spleen in Stage II with enlarged mediastinum, Stage IIIs after laparotomy, and cases in which laparotomy was thought to be indicated but was not performed. The new policy resulted in marked improvement in survival (from 56% to 87%) and relapse-free survival (from 32% to 70%). The stage at presentation was the main prognostic factor, although in the second period of the study, the difference between Stage I and II disappeared.

Involved field (IF) irradiation with or without chemotherapy in the management of children with Hodgkin's disease

The present policy at Memorial Sloan Kettering Cancer Center (MSKCC) of treating children with Hodgkin's disease [HD] is as follows: involved field (IF) irradiation only (3,600 rad) for Stages IA and IIA; IF irradiation (2,400 or 2,000 rad) combined with multidrug chemotherapy (MDP) protocol for all other stages. A somewhat higher recurrence rate is accepted for Stages IA and IIA in view of the good salvage rate for these recurrences and in view of side effects of more aggressive types of radiation treatment. One hundred forty-two patients with HD, 2-19 years of age, were treated at MSKCC between 1970 and 1981; 98 of these were treated according to the present policy (SP group), and 44 (NP group) were treated differently. All SP patients underwent staging laparotomy. The follow-up time was 12 to 146 months with a median of 65 months; two patients were lost to follow-up. For the SP group, all stages, 10-year disease-free survival is 77%, and 10-year survival is 93%. By comparison, in the NP group 10-year disease-free survival is 64%, and 10-year survival is 80%. The disease-free survival of SP patients in Stages IA and IIA treated with IF radiation alone is 72%, and survival is 95%. The disease-free survival of SP patients in advanced stages treated with combined radiation and chemotherapy is 87%; the salvage rate of recurrent disease in these stages is poor. The survival was apparently better (P = 0.07) in the SP group as compared to the NP group. All 6 patients of the SP group who died had a nodular sclerosing type of HD. None of the patients in the SP group have developed secondary malignancies, and no severe bone growth retardations or late effects to other organs were observed. In our opinion, IF irradiation alone might at present be suitable treatment for children in Stages IA and IIA of Hodgkin's disease, and addition of IF radiation with low doses of MPD improves the survival of patients in advanced stages.

Hodgkin disease clinical stages I, II, and III (A, B): results of radiotherapy with or without chemotherapy

Between 1961 and 1976, 387 patients with Hodgkin disease were examined, evaluated, and treated at the Instituto Portugues de Oncologia de Francisco Gentil. After reviewing histological and clinical staging presentation, the authors retrospectively analyzed the results obtained with 303 patients classified in clinical stages I, II, and III (A, B) who were treated with or without chemotherapy in two time periods (before and after 1970) according to individual therapeutic modalities. The improvement of the 5-year survival rates in the last period was associated with the introduction of extended-field irradiation and multidrug chemotherapy (MOPP). However, the incidence of serious complications was higher in the group of patients subjected to combined field irradiation and MOPP. The authors suggest a stricter protocol based on the current recommendations for the treatment of Hodgkin disease in order to achieve better results with minimum possible hazards.