A discourse: the 2002 Wataru W. Sutow lecture. Hodgkin disease in children--perspectives and progress

Gonadal function in patients treated for Hodgkin's disease in childhood

Background

The long-term survival of patients treated for Hodgkin`s disease (HD) in childhood is high and the chief concern is now being directed toward the late effects of the treatment, including the endocrine dysfunction.

Patients and methods.

Testicular and ovarian functions were assessed in 64 long term survivors (24 females, 40 males) treated for HD in childhood in Slovenia between 1972 and 1994. At diagnosis they were 3–16 years old and had gonadal evaluation 4–27 years later at the age of 13–34. Fifty-four (84%) patients received chemotherapy (ChT), 49 in combination with radiation therapy (RT), 10 received RT alone. Gonadal function was assessed by the clinical examination and measurement of serum concentrations of estradiol and testosterone. Serum levels of LH and FSH were determined in the basal state and after the stimulation.

Results

Primary hypogonadism (PH) was found in 30 (47%) patients. Twenty-four of 40 (60%) males had PH with evidence of damage of germinal epithelium, 4 of them had evidence of damage of Leydig cells (LC) and 10 had evidence of dysfunction of LC as well. PH was found in 6 of 24 (25%) females.

Conclusions

After therapy for HD PH was more frequent in males than in females. Not only RT but also alkylating agents and procarbazine alone caused damage of LC. Age of patient at the time of treatment was not an important risk factor for gonadal toxicity. Pelvic RT in combination with ChT is the most important risk factor of the development PH both, in males and females.

Serum protein expression profiling in pediatric Hodgkin lymphoma: a report from the Children's Oncology Group

BACKGROUND

The prognosis for children with Hodgkin lymphoma (HL) treated with a risk adjusted combination of radiation therapy and multi-drug chemotherapy has markedly improved. There remains a group of patients whose disease either recurs or does not respond to therapy. Protein expression profiling has been used to define protein characteristics of serum from adult patients in order to improve screening for early diagnosis. However, profiling for the purpose of staging and defining prognostic characteristics of childhood diseases is not well studied. The current stage-based risk assignment of HL cannot predict the patients within a risk group that are destined to recur or do not respond to therapy. Thus, a need exists to develop new methodologies to better stratify the risk classification of pediatric HL.

PROCEDURE

We have completed a preliminary project to identify characteristic serum protein peaks determined by protein expression profiling in serum of 22 subjects with HL, 13 with stage II HL and 9 with stage III or IV.

RESULTS

Protein profiling successfully discriminated between high grade (III/IV) HL and low grade (II) HL.

CONCLUSION

These data lay the basis for prospective studies to identify protein expression profiles useful for diagnosis, prognosis, treatment stratification, and the follow-up of minimal residual disease.

Successful ambulatory treatment of Hodgkin's disease in Iranian children based on German-Austrian DAL-HD 85-90: single institutional results

BACKGROUND

Hodgkin's disease (HD) accounts for 7.5% of childhood malignancies in Iran. In order to minimize chemotherapy toxicity and avoid eventual hospitalization and psychological and financial burdens we have applied since 1988, for the first time in Iran, a treatment regimen based on subsequently revised DAL-HD 85-90 and later GPOH-HD 95 protocols.

PATIENTS AND METHODS

During the period 1988-2004, 40 children with HD received DAL/GPOH-HD-adapted treatment; 25 males (62.5%) and 15 females (37.5%) (male/female ratio 1.7; age 4-14 years, mean 8.8). Clinical evaluation and staging was performed in all patients. Constitutional symptoms: 24 patients were asymptomatic (A; 60%) and 16 had constitutional complaints (B; 40%). Staging was as follows: stage I; seven (17.5%); II, 11 (27.5%); III, 11 (27.5%); and IV, 11 (27.5%). Histopathology: 22 patients had mixed cellularity (MC; 55%), 13 nodular sclerosis (32.5%), four lymphocyte predominance (LP; 10%) and one patient lymphocyte depletion (2.5%). Stage IA and IIA patients (n = 15) received either OPA x2 (vincristine, prednisolone, doxorubicin) or OPPA x2 or OPEA x2 (vincristine, prednisolone, procarbazine and doxorubicin), the latter receiving etoposide instead of procarbazine, and applied to males. Stages IIB, IIIA/B and IV received OPPA x2, followed by CO(P)P x4 (cyclophosphamide, vincristine, prednisolone in alternate courses and procarbazine). Twenty nine patients (72.5%) received radiotherapy (20-25 Gy); four to the involved field (stage I), 25 to the upper mantel (stage II and also III with either residual or mediastinal mass) and three additionally to spleen and para-aortic lymph nodes. Eleven patients received only chemotherapy.

RESULTS

All patients achieved complete remission (CR). Relapse occurred in eight patients (20%); seven stage IV (MC) and one stage IA (LP) with progression to IIIB. Salvage chemotherapy consisted of MOPP/ABVD hybrid; six patients achieved a second sustained remission and three patients died: two due to relapse and progressive disease and the third one in CR, owing to thrombocytopenic hemorrhage and foudroyant pneumonia. The achieved overall and event-free survival was 88.1% and 75.4%, respectively. Aside from minor acute toxicities, three patients demonstrated azoospermia at the age of 18 years and one of these patients suffered non-Hodgkin lymphoma as a second malignancy. HD occurred as a second malignancy in two patients with acute lymphoblastic leukemia. Both received appropriate treatment and are over 10 years in CR.

CONCLUSIONS

The DAL/GPOH-HD-based treatment approach proved to achieve long-term sustained cure even in children with advanced HD disease. The essentially outpatient diagnosis and treatment modus did not compromise the disease outcome, and was well tolerated and accepted by the patients and their parents. The employed drugs are easily available and affordable. This treatment approach is suitable for ambulatory use in developing countries. However, male infertility remains the major obstacle to procarbazine and cyclophosphamide use.

Prognostic factors and treatment outcome in childhood Hodgkin disease

BACKGROUND

The goals of this study included: (1) Identification of factors prognostic for event-free survival (EFS) and overall survival (OS), and (2) Definition of risk groups for risk adapted therapy in children with Hodgkin disease (HD).

PROCEDURE

From 1991 to 2003, 69 children with newly diagnosed, untreated biopsy-proven stage I-IV HD were treated with chemotherapy (CT) and low-dose involved field radiotherapy (LD-IFRT). The relationship of pretreatment factors to EFS and OS was analyzed by univariate and multivariate analysis.

RESULTS

The 5-year EFS and OS for all patients were 90.77% and 96.22%, respectively with a median follow-up of 73 months (3-137 months). Male to female ratio was 3:1 and 21 children (32.3%) were less than 7 years of age. Mixed cellularity was the predominant histologic subtype (38.5%). Factors associated with inferior EFS by univariate analysis were extranodal disease, hemoglobin level <11 g/dl, number of involved lymph node regions and stage. By multivariate analysis only stage IV disease was significant.

CONCLUSION

Our study confirms that excellent results are achievable with combined modality therapy in childhood HD. In order to use risk-adapted therapy in children with HD, clinical prognostic factors should be validated with large, multicentered prospective clinical studies.

Treatment of pediatric Hodgkin disease avoiding radiotherapy: excellent outcome with the Rotterdam-HD-84-protocol

BACKGROUND

To reduce radiotherapy (XRT) induced toxicity of treatment of children with Hodgkin disease (HD) while maintaining a high cure rate, we introduced a risk-adapted protocol consisting of chemotherapy (CT) alone in 1984.

PROCEDURE

The outcome of 46 children treated for HD from 1984 until 2000 according to the Rotterdam-HD-84-protocol was determined. Children with stage I-IIA disease (n = 23), were treated with six courses of epirubicin, bleomycin, vinblastine, and dacarbazine (EBVD). Children with stage IIB-IV disease (n = 23), were treated with three to five alternating cycles of EBVD and mechlorethamine, vincristine, procarbazine, and prednisone (MOPP).

RESULTS

At a median follow-up time of 8.6 years (range 2.6-18.3 years), the 10-year overall survival (OS) is 95% and the event-free survival (EFS) 91%. In 5/46 patients XRT was administered because of residual mediastinal mass. Four children relapsed, two of them died. Up until now only one patient developed hypothyroidism; no symptomatic cardiac or pulmonary dysfunction, no second malignancy has been diagnosed.

CONCLUSIONS

Risk-adapted treatment consisting of CT alone is highly efficacious for children with HD and toxicity is low. XRT was administered in only a small minority of children with HD. CT should be the first choice for HD in children and XRT should preferably be used for those with refractory or histologically proven residual disease or relapse.

Paediatric radiotherapy in Australia and New Zealand: An anachronism in 2003?

This report reviews the activities of the Paediatric Special Interest Group of the Royal Australian and New Zealand College of Radiologists in terms of its involvement with the Australian and New Zealand Children's Cancer Study Group and its research and educational activities. Examples of when and how radiotherapy is currently used in the management of paediatric malignancies are provided. Some thoughts for the future of both paediatric radiotherapy and our subspecialty are also presented.