Hodgkin's disease in children. Results of therapy in a mixed group of 178 clinical and pathologically staged patients over 13 years

Reproductive ability in survivors of childhood, adolescent, and young adult Hodgkin lymphoma: a review

BACKGROUND

Owing to a growing number of young and adolescent Hodgkin lymphoma (HL) survivors, awareness of (long-term) adverse effects of anticancer treatment increases. The risk of impaired reproductive ability is of great concern given its impact on quality of life. There is currently no review available on fertility after childhood HL treatment.

OBJECTIVE AND RATIONALE

The aim of this narrative review was to summarize existing literature on different aspects of reproductive function in male and female childhood, adolescent, and young adult HL survivors.

SEARCH METHODS

PubMed and EMBASE were searched for articles evaluating fertility in both male and female HL survivors aged <25 years at diagnosis. In females, anti-Müllerian hormone (AMH), antral follicle count, premature ovarian insufficiency (POI), acute ovarian failure, menstrual cycle, FSH, and pregnancy/live births were evaluated. In males, semen-analysis, serum FSH, inhibin B, LH, testosterone, and reports on pregnancy/live births were included. There was profound heterogeneity among studies and a lack of control groups; therefore, no meta-analyses could be performed. Results were presented descriptively and the quality of studies was not assessed individually.

OUTCOMES

After screening, 75 articles reporting on reproductive markers in childhood or adolescent HL survivors were included. Forty-one papers reported on 5057 female HL survivors. The incidence of POI was 6-34% (median 9%; seven studies). Signs of diminished ovarian reserve or impaired ovarian function were frequently seen (low AMH 55-59%; median 57%; two studies. elevated FSH 17-100%; median 53%; seven studies). Most survivors had regular menstrual cycles. Fifty-one studies assessed fertility in 1903 male HL survivors. Post-treatment azoospermia was highly prevalent (33-100%; median 75%; 29 studies). Long-term follow-up data were limited, but reports on recovery of semen up to 12 years post-treatment exist. FSH levels were often elevated with low inhibin B (elevated FSH 0-100%; median 51.5%; 26 studies. low inhibin B 19-50%; median 45%; three studies). LH and testosterone levels were less evidently affected (elevated LH 0-57%, median 17%; 21 studies and low testosterone 0-43%; median 6%; 15 studies). In both sexes, impaired reproductive ability was associated with a higher dose of cumulative chemotherapeutic agents and pelvic radiotherapy. The presence of abnormal markers before treatment indicated that the disease itself may also negatively affect reproductive function (Females: AMH<p10 9%; one study and Males: azoospermia 0-50%; median 10%; six studies). Reports on chance to achieve pregnancy during survivorship are reassuring, although studies had their limitations and the results are difficult to evaluate. In the end, a diminished ovarian reserve does not exclude the chance of a live birth, and males with aberrant markers may still be able to conceive.

WIDER IMPLICATIONS

This review substantiates the negative effect of HL treatment on gonadal function and therefore young HL survivors should be counseled regarding their future reproductive life, and fertility preservation should be considered. The current level of evidence is insufficient and additional trials on the effects of HL and (current) treatment regimens on reproductive function are needed. In this review, we make a recommendation on reproductive markers that could be assessed and the timing of (repeated) measurements.

WITHDRAWN: Interventions for early stage Hodgkin's disease in children

BACKGROUND

Hodgkin's disease is one of the most curable cancers in children, particularly at the early stages. However it is not clear which combinations of treatment strategies are most effective at maintaining high cure rates and minimising long term harmful effects or sequelae of treatment.

OBJECTIVES

To assess the effects of radiotherapy, chemotherapy or combined radiotherapy and chemotherapy on relapse free survival and overall survival rates in children with early (stage I to IIA) Hodgkin's disease.

SEARCH STRATEGY

We searched the Cochrane Library (issue 4, 2001), MEDLINE (1966 to July 2001), EMBASE, Cinahl, Cancer-CD and reference lists of relevant articles. We also handsearched six journals.

SELECTION CRITERIA

Randomised controlled trials of involved field radiotherapy, extended field radiotherapy, anthracycline based chemotherapy regimens, or alkylating chemotherapy agents in children to 19 years of age with Hodgkin's disease.

DATA COLLECTION AND ANALYSIS

Trial eligibility and quality were assessed and study authors were contacted for additional information.

MAIN RESULTS

Four trials involving 334 children were included. It was not possible to combine the outcomes as they covered different treatment regimens. The trials were of variable quality. One trial comparing radiotherapy alone showed no discernible difference in relapse free survival (relative risk 0.73, 95% confidence interval 0.49 to 1.09) or overall survival (relative risk 0.92, 95% confidence interval 0.79 to 1.07) between involved field and extended field radiotherapy. No discernible difference was found between involved field radiotherapy plus chemotherapy and extended field radiotherapy and chemotherapy (based on one small trial). In another trial, involved field radiotherapy plus chemotherapy appeared to increase relapse free survival compared to either involved field or extended field radiotherapy alone, although a discernible difference was found for overall survival. Extended field radiotherapy alone appeared to increase relapse free survival compared to extended radiotherapy plus chemotherapy (relative risk 0.34, 95% confidence interval 0.14 to 0.83) but no discernible difference was apparent for overall survival (based on one trial).

AUTHORS' CONCLUSIONS

There is little evidence from randomised controlled trials to evaluate the consensus approach of short course chemotherapy and local radiotherapy, although no discernible difference in survival was detected between involved field and extended field radiotherapy in one randomised trial.

Pediatric Hodgkin Lymphoma: Maximizing Efficacy and Minimizing Toxicity

Historically, both adult and childhood Hodgkin lymphoma (HL) were treated with full-dose (35-45 Gy) extended-field radiation therapy (RT). Although this treatment was the first to produce reliable disease control, the resulting late toxicity led pediatric oncologists to pioneer the use of combined chemotherapy and low-dose (15-25 Gy) involved-field RT for all stages of HL. Currently, standard treatment of childhood HL is risk adapted; those with favorable risk disease typically receive 2 to 4 cycles of multi-agent chemotherapy with low-dose IFRT, whereas those with higher-risk disease receive more intensive chemotherapy before IFRT. This approach produces long-term survival rates >90% while limiting exposure to anthracyclines, alkylators, and radiation to normal tissues. In contrast to adult HL, IFRT remains an important component of the treatment of advanced-stage HL in pediatric patients. Current clinical trials for children with HL aim to further segregate patients into risk strata such that those who are highly curable can receive less toxic therapy, whereas high-risk patients can receive augmented therapy. Response-adapted therapy, in which overall treatment intensity is modified according to the initial response to chemotherapy, is emerging as a potential means of further reducing therapy for some while maintaining high cure rates. The challenge is to refine therapy in a rare disease in which long-time intervals are necessary to observe an adequate number of events (treatment failure or late effects) to answer judicious questions.

Prognostic factors for children with Hodgkin's disease treated with combined-modality therapy

PURPOSE

Evaluation of pretreatment factors to identify children at high risk for relapse after combined-modality therapy for Hodgkin's disease.

PATIENTS AND METHODS

From 1990 to 2000, 328 pediatric patients with clinical stage I to IV Hodgkin's disease were treated with chemotherapy and low-dose involved-field radiotherapy on prospective, collaborative, risk-adapted protocols at three institutions. Pretreatment factors were analyzed by univariate and multivariate analysis for prognostic significance for 5-year disease-free survival (DFS) and overall survival (OS).

RESULTS

With a median follow-up of 59 months (range, 8 to 125 months), the 5-year DFS and OS for all patients were 83% and 93%, respectively. Several factors were associated with inferior DFS and OS by univariate analysis. By multivariate analysis, male sex; stage IIB, IIIB, or IV disease; bulky mediastinal disease; WBC more than 13.5 x 10(3)/mm3; and hemoglobin less than 11.0 g/dL were significant for inferior DFS. A prognostic index was developed incorporating the five significant factors from the multivariate analysis, assigning each a score of 1. The 5-year DFS and OS for children with a prognostic score of 0 to 1 were 94% and 99%; score 2, 85% and 96%; score 3, 71% and 92%; and score 4 or 5, 49% and 72%, respectively. There was a significant difference in DFS among each of these groups, with significantly worse OS in those with a score of 4 to 5.

CONCLUSION

A prognostic index that was based on five pretreatment factors correlated with inferior DFS by multivariate analysis stratified patients by outcome; this may be useful in assigning children with Hodgkin's disease to risk-adapted therapy.

Interventions for early stage Hodgkin's disease in children

BACKGROUND

Hodgkin's disease is one of the most curable cancers in children, particularly at the early stages. However it is not clear which combinations of treatment strategies are most effective at maintaining high cure rates and minimising long term harmful effects or sequelae of treatment.

OBJECTIVES

To assess the effects of radiotherapy, chemotherapy or combined radiotherapy and chemotherapy on relapse free survival and overall survival rates in children with early (stage I to IIA) Hodgkin's disease.

SEARCH STRATEGY

We searched the Cochrane Library (issue 4, 2001), MEDLINE (1966 to July 2001), EMBASE, Cinahl, Cancer-CD and reference lists of relevant articles. We also handsearched six journals.

SELECTION CRITERIA

Randomised controlled trials of involved field radiotherapy, extended field radiotherapy, anthracycline based chemotherapy regimens, or alkylating chemotherapy agents in children to 19 years of age with Hodgkin's disease.

DATA COLLECTION AND ANALYSIS

Trial eligibility and quality were assessed and study authors were contacted for additional information.

MAIN RESULTS

Four trials involving 334 children were included. It was not possible to combine the outcomes as they covered different treatment regimens. The trials were of variable quality. One trial comparing radiotherapy alone showed no discernible difference in relapse free survival (relative risk 0.73, 95% confidence interval 0.49 to 1.09) or overall survival (relative risk 0.92, 95% confidence interval 0.79 to 1.07) between involved field and extended field radiotherapy. No discernible difference was found between involved field radiotherapy plus chemotherapy and extended field radiotherapy and chemotherapy (based on one small trial). In another trial, involved field radiotherapy plus chemotherapy appeared to increase relapse free survival compared to either involved field or extended field radiotherapy alone, although a discernible difference was found for overall survival. Extended field radiotherapy alone appeared to increase relapse free survival compared to extended radiotherapy plus chemotherapy (relative risk 0.34, 95% confidence interval 0.14 to 0.83) but no discernible difference was apparent for overall survival (based on one trial).

REVIEWER'S CONCLUSIONS

There is little evidence from randomised controlled trials to evaluate the consensus approach of short course chemotherapy and local radiotherapy, although no discernible difference in survival was detected between involved field and extended field radiotherapy in one randomised trial.

Hodgkin's disease

Despite incomplete understanding of the etiology of Hodgkin's disease and its malignant cell of origin, the majority of children and adolescents diagnosed with Hodgkin's disease will be longterm survivors. Staging and treatment for pediatric Hodgkin's disease has evolved over the past 30 years in attempts to reduce late treatment sequelae. Today, most children are clinically staged and treated with multitreatment chemotherapy, either alone or in conjunction with low-dose, involved field radiation therapy. Initial results with "risk-adapted" combined modality regimens limiting chemotherapy cycles and radiation doses and volumes demonstrate maintenance of cure rates for early stage, favorable Hodgkin's disease. Challenges for the future include identification of prognostic factors in patients at risk for treatment failure who may benefit from intensification of therapy.

Treatment of childhood Hodgkin's disease with ABVD without radiotherapy

Seventeen previously untreated children with Hodgkin's disease were treated with six courses of the combination adriamycin, bleomycin, vinblastine, and DTIC (ABVD), without radiotherapy, from 1984-1987. In all patients, complete remission was attained. After a median follow-up period of 73.5 months (range 59-98 months) five patients had a relapse after 4, 5, 11, 21, and 34 months, respectively, from attainment of complete remission. In 12 patients with stages I and II, two relapses occurred. Three out of five patients with stage III and stage IV developed a relapse. Based upon these results, we conclude that ABVD might be an appropriate treatment for newly diagnosed children with Hodgkin's disease stages I and II. However, for children with stages III and IV more intensive treatment is needed. Radio-therapy should be withheld for children with refractory disease, residual disease, or relapse.

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.

Vancouver hybrid: preliminary experience in the treatment of Hodgkin's disease in childhood and adolescence

OBJECTIVE

To describe our preliminary experience with 19 young patients with newly diagnosed Hodgkin's disease who received the Vancouver hybrid chemotherapeutic regimen.

DESIGN

We summarized the characteristics of our 19 study patients, the treatment administered (between June 1988 and June 1992), and the outcome.

RESULTS

The Vancouver hybrid, which consists of mechlorethamine, vincristine sulfate (Oncovin), procarbazine hydrochloride, prednisone, doxorubicin hydrochloride (Adriamycin), bleomycin, and vinblastine sulfate (MOPP/ABV), was based on the hypothesis of preventing drug resistance by early introduction and alternation of all active agents and was aimed at decreasing the severity and frequency of treatment-related complications. Of our 19 patients with Hodgkin's disease (age range, 6 to 20 years) treated with this regimen, 2 had clinical stage I disease, 10 had stage II, 6 had stage III, and 1 had stage IV. Only two patients had systemic symptoms, and nodular sclerosis was the most common histologic feature. Patients were given four to eight cycles of chemotherapy, depending on the clinical stage of disease. In addition, 10 patients received irradiation, including 6 of 9 patients with bulky disease. In all patients, complete remission was achieved. After a median follow-up of 3.3 years, only two patients had had a relapse; both underwent autologous bone marrow transplantation and were alive and well with no evidence of disease at last follow-up. The treatment was well tolerated, and delivery of treatment was excellent. The only severe toxicity was myelosuppression; 8 patients experienced a total of 15 episodes of fever and neutropenia that necessitated hospitalization and antibiotic therapy, but no systemic infections were confirmed during 104 cycles of therapy.

CONCLUSION

The MOPP/ABV hybrid is an effective and well-tolerated therapy in most young patients with Hodgkin's disease. Long-term monitoring is needed to evaluate late effects.

Treatment of pediatric Hodgkin disease tailored to stage, mediastinal mass, and age. An Italian (AIEOP) multicenter study on 215 patients

BACKGROUND

Attempting to optimize treatment results in pediatric Hodgkin disease while minimizing major side effects, at least in early-stage patients, in 1983 the Italian Association of Pediatric Hematology and Oncology (AIEOP) conceived a multicenter study tailored according to stage, bulky mediastinal mass, and age.

METHODS

Between December, 1983 and January, 1989, 215 evaluable patients (median age, 9.9 years, range, 1-15 years) received the AIEOP-MH 1983 Hodgkin disease protocol of low-dose radiation therapy (20-25 Gy), with three cycles of adriamycin, bleomycin, vinblastine, and imidazole carboxamide (ABVD) for children with early-stage and favorable disease, and with alternating cycles of an eight non-cross-resistant drug combination regimen (nitrogen mustard, vincristine, procarbazine, and prednisone [MOPP]/ABVD) for 6 months for those with bulky and unfavorable disease. Patients in advanced stages received four additional courses of MOPP/ABVD as maintenance therapy.

RESULTS

The overall survival and freedom from progression (FFP) probabilities at 7 years are 85.7% and 81.5% respectively. FFP probabilities at 7 years in Groups 1 (58 patients in Stages I and IIA with mass/thorax [M/T] < 0.33), 2 (56 patients in Stages IEA, IB, IIA with M/T > 0.33, IIB, and IIIA), and 3 (38 patients in Stages IIIB and IVA and B) were 94.8%, 81.4%, and 60.3%, respectively. Multivariate analysis showed B symptoms, M/T > 0.33, and stage to be significant, independent prognostic factors affecting survival and FFP curves.

CONCLUSIONS

The encouraging results in early-stage disease indicate the validity of using less toxic treatment in this subgroup to maximize quality of life. Patients with bulky mediastinal disease tended to fare worse than those with M/T < 0.33 or without mediastinal involvement (FFP at 7 years: 69.4% versus 93.3%) and showed early local recurrence. In advanced stages, the eight-drug combination regimen (MOPP/ABVD) plus low-dose radiation therapy provided no major improvement in outcome; here, alternative chemotherapeutic regimens should be tested in a large, randomized, clinical trial to evaluate their efficacy and determine the frequency of delayed toxicity.

MR imaging of infradiaphragmatic lymphadenopathy in children and adolescents with Hodgkin disease: comparison with lymphography and CT

The ability of short-inversion-time inversion recovery (STIR) magnetic resonance imaging to depict infradiaphragmatic lymphadenopathy was evaluated in 25 consecutive patients with newly diagnosed Hodgkin disease. All patients underwent computed tomography (CT) and multiplanar STIR imaging prior to lymphography (LAG). The STIR and CT images were evaluated for paraaortic and parailiac node enlargement. Findings were compared with LAG findings, which showed the architectural pattern of the opacified lymph nodes. In the upper paraaortic region, STIR imaging showed more abnormal nodes than did CT or LAG. In the lower paraaortic and parailiac regions, lymph node enlargement was shown equally well with STIR and LAG, whereas CT showed fewer enlarged lymph nodes. LAG showed paraaortic or parailiac focal tumor infiltration in three patients with normal-size nodes, and hyperplasia in two patients with enlarged nodes. STIR imaging showed more abnormal infradiaphragmatic nodes than did CT because of improved lymph node conspicuity. STIR imaging may be a useful addition to CT for staging pediatric Hodgkin disease.

The 'urn' portal; an alternative to the 'mantle' portal in the chemoradiotherapy management of paediatric Hodgkin's disease

The experience of St Bartholomew's Hospital with a less than full mantle radiation field in the treatment of 31 children with clinically staged Hodgkin's disease is reported over a ten year period (1977-1987). The major indication for this portal was initial bulk, or residual disease after chemotherapy. Primary treatment consisted of radiotherapy alone (two children) or in combination with chemotherapy (29 children). An 'Urn' radiation portal has been used to encompass mediastinal and neck nodes, but with the aim of reducing radiation doses to lung, breast, axilla, lateral end of clavicle and humeral head. More recently, a further modification has employed partial heart shielding when anthracyclines have been part of the chemotherapy schedule. The majority have received 35 Gy in 20 fractions over 4 weeks with 4-6 Mv photons, and no child received in excess of 35 Gy to the mediastinum. An overall 5-year actuarial survival of 85% was achieved, and a 5-year relapse-free survival of 77%. Seven relapses and five deaths have been reported, all of which occurred in children who presented with nodular sclerosing histology. Six children relapsed within the radiation portals, and one with systemic disease alone. Only a single child relapsed in the unirradiated axilla, and this simultaneously with cervical, mediastinal and paraortic nodes. To date no second malignancies have been reported.

The effects of different cumulative doses of chemotherapy on testicular function. Results in 75 patients treated for Hodgkin's disease during childhood or adolescence

Testicular function was evaluated in 75 boys after treatment for Hodgkin's disease with involved-field or extended-field irradiation and stage-dependent chemotherapy (vincristine, prednisone, procarbazine, Adriamycin [doxorubicin], and cyclophosphamide [OPPA/COPP]). Although pubertal development and testosterone levels were normal in all patients, 18 of 75 (24.0%) had elevated basal and 65/74 (87.8%) elevated stimulated luteinizing hormone (LH) levels, demonstrating chemotherapy-induced Leydig cell damage. In addition, there was a 40.5% and 53.4% incidence of elevated basal and stimulated FSH values, respectively, indicating severe impairment of spermatogenesis as confirmed by azoospermia in four patients. Testicular dysfunction was observed in patients treated before as well as during puberty. The incidence of elevated basal follicle stimulating hormone (FSH) and LH values was significantly higher in patients who had received higher cumulative doses of chemotherapy, i.e., 28.9% and 13.2% with two OPPA, 45.5% and 36.4% with two OPPA/two COPP, and 62.5% and 43.8% with two OPPA/four to six COPP, respectively. Chemotherapy for Hodgkin's disease causes a high and apparently dose-related incidence of testicular dysfunction in prepubertal as well as in pubertal boys affecting Leydig cell function as well as spermatogenesis. Circumstantial evidence indicates that procarbazine is the major gonadotoxic agent involved.

Hodgkin's disease in children: treatment with MOPP and low-dose, extended field irradiation without laparotomy. Late results and toxicity

The 10 year results of a trial of bimodal treatment of Hodgkin's disease in children with 6 cycles of MOPP and low-dose extended field irradiation, without staging laparotomy, were for 57 children in all stages as follows: survival 85%, relapse-free survival 80%, and survival-free of second relapse 86%. There were three fatal toxic events, two due to viral infection and one to a second malignant tumor (NHL). Three other patients developed a second malignant tumour, and one developed a thyroid adenoma. No patient developed acute leukemia. These results are compared with the results of treatment of surgically staged children by extended field irradiation alone, with bimodal treatment reserved for relapse or advanced disease at diagnosis. Initial bimodal treatment improved the overall 10 year survival free from a second relapse rate by 20% (86% vs. 66%). No major difference in treatment toxicity between these two groups has emerged during the first 10 years of follow-up. We conclude that, except for favourable CS-1 presentations, children with Hodgkin's disease confined to the lymphatic system should be given bimodal treatment, but that the least morbid effective combination remains to be determined.

Hodgkin's disease in childhood: the British National Lymphoma Investigation experience (BNLI Report No 27)

The experience of the British National Lymphoma Investigation in the treatment of 68 children with Hodgkin's disease is reported over a 14 year period from 1970. The presenting histology was reviewed by a single histopathologist; 87% of the cases were classified as nodular sclerosis (NS) and further subdivided into NSI (53%) and NSII (35%). Primary treatment consisted of local (involved field) or prophylactic (extended field) irradiation, combination chemotherapy alone or low dose irradiation and chemotherapy. An overall 5 year survival of 87% was achieved and a 5 year relapse-free survival of 64%. Eight deaths were reported during the study, all of which occurred in children who presented with NSII histology. Each child was in relapse and undergoing chemotherapy at the time of death. This histological subtype was also associated with both a lower complete remission rate and a reduced response to second line chemotherapy.