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Heneghan MB, Belsky JA, Milgrom SA, Forlenza CJ. The pediatric approach to Hodgkin lymphoma. Semin Hematol 2024:S0037-1963(24)00061-1. [PMID: 38851951 DOI: 10.1053/j.seminhematol.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 06/10/2024]
Abstract
Hodgkin lymphoma (HL) occurs throughout the lifespan but is one of the most common cancers in adolescents and young adults (AYA; 15-39 years). HL has become a highly curable disease with survival rates surpassing 90%, including patients with high-risk and advanced stage disease. Unfortunately, intensive treatment carries a risk of short- and long-term toxicity. Given the decades pediatric HL survivors are expected to live after treatment, the pediatric approach to treatment has focused on improving the therapeutic index through response adapted treatment and more recently the incorporation of novel agents. The efforts of pediatric and medical oncologists in research and clinical trial development have long occurred in parallel, but recent efforts have laid the foundation for collaboration with the goal of standardizing AYA care and allowing earlier incorporation of novel therapy for younger patients. This review focuses on the evolution of the management of pediatric HL including epidemiology, biology, and approaches to upfront and salvage treatment regimens.
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Affiliation(s)
- Mallorie B Heneghan
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah/Primary Children's Hospital, Salt Lake City, UT.
| | - Jennifer A Belsky
- Department of Pediatrics, Riley Hospital for Children/Indiana University School of Medicine, Indianapolis, IN
| | - Sarah A Milgrom
- Department or Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
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Castellino SM, Giulino-Roth L, Harker-Murray P, Kahn J, Forlenza C, Cho S, Hoppe B, Parsons SK, Kelly KM. Children's Oncology Group's 2023 blueprint for research: Hodgkin lymphoma. Pediatr Blood Cancer 2023; 70 Suppl 6:e30580. [PMID: 37505794 PMCID: PMC10660893 DOI: 10.1002/pbc.30580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Abstract
The goal of therapy in pediatric Hodgkin lymphoma (HL) is to maximize overall survival while minimizing the morbidity of curative therapy. Key findings from recent Children's Oncology Group (COG) trials include: (i) superior event-free survival with the addition of brentuximab vedotin (Bv) in frontline regimens for high-risk disease, (ii) successful reduction in myeloablative regimens with demonstrated safety and efficacy of Bv and checkpoint inhibitor therapy in relapsed disease, and (ii) the potential to select a population that can be salvaged after relapse without receiving a stem cell transplant. The COG HL committee will lead a National cancer Institute National Clinical Trials Network phase 3 trial to evaluate the combination of Bv/nivolumab in early-stage disease. Ongoing advances in technology and blood biomarkers are increasing the ability to deliver biologically driven, personalized treatment for HL.
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Affiliation(s)
- Sharon M. Castellino
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta/ Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Lisa Giulino-Roth
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Justine Kahn
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York, New York
| | | | - Steve Cho
- Department of Radiology, University of Wisconsin/ University of Wisconsin Carbone Comprehensive Cancer Center, Madison, WI
| | - Bradford Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - Susan K. Parsons
- Department of Medicine, Tufts University School of Medicine/ Department of Pediatrics, Tufts University School of Medicine/ Institute for Clinical Research and Health Policy Studies, Reid R. Sacco AYA Cancer Program/ Division of Hematology/Oncology, Tufts Medical Center, Boston, MA
| | - Kara M. Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center/ Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
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3
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Munir F, Hardit V, Sheikh IN, AlQahtani S, He J, Cuglievan B, Hosing C, Tewari P, Khazal S. Classical Hodgkin Lymphoma: From Past to Future-A Comprehensive Review of Pathophysiology and Therapeutic Advances. Int J Mol Sci 2023; 24:10095. [PMID: 37373245 DOI: 10.3390/ijms241210095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Hodgkin lymphoma, a hematological malignancy of lymphoid origin that typically arises from germinal-center B cells, has an excellent overall prognosis. However, the treatment of patients who relapse or develop resistant disease still poses a substantial clinical and research challenge, even though current risk-adapted and response-based treatment techniques produce overall survival rates of over 95%. The appearance of late malignancies after the successful cure of primary or relapsed disease continues to be a major concern, mostly because of high survival rates. Particularly in pediatric HL patients, the chance of developing secondary leukemia is manifold compared to that in the general pediatric population, and the prognosis for patients with secondary leukemia is much worse than that for patients with other hematological malignancies. Therefore, it is crucial to develop clinically useful biomarkers to stratify patients according to their risk of late malignancies and determine which require intense treatment regimens to maintain the ideal balance between maximizing survival rates and avoiding late consequences. In this article, we review HL's epidemiology, risk factors, staging, molecular and genetic biomarkers, and treatments for children and adults, as well as treatment-related adverse events and the late development of secondary malignancies in patients with the disease.
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Affiliation(s)
- Faryal Munir
- Department of Pediatrics, Pediatric Hematology/Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Viney Hardit
- CARTOX Program, Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Irtiza N Sheikh
- Department of Pediatrics, Pediatric Hematology/Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shaikha AlQahtani
- Department of Pediatrics, Pediatric Hematology/Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jiasen He
- Department of Pediatrics, Pediatric Hematology/Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Branko Cuglievan
- Department of Pediatrics, Pediatric Hematology/Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Pediatrics-Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chitra Hosing
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Priti Tewari
- CARTOX Program, Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sajad Khazal
- CARTOX Program, Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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4
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Parikh RR, Kelly KM, Hodgson DC, Hoppe BS, McCarten KM, Karolczuk K, Pei Q, Wu Y, Cho SY, Schwartz C, Cole PD, Roberts K. Patterns of Initial Relapse from a Phase 3 Study of Response-Based Therapy for High-Risk Hodgkin Lymphoma (AHOD0831): A Report from the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2022; 112:890-900. [PMID: 34767937 PMCID: PMC9038118 DOI: 10.1016/j.ijrobp.2021.10.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE The Children's Oncology Group protocol AHOD0831, for pediatric patients with high-risk classical Hodgkin lymphoma (cHL), used response-adapted radiation fields, rather than larger involved-field radiation therapy (IFRT) that were historically used. This retrospective analysis of patterns of relapse among patients enrolled in the study was conducted to study the potential effect of a reduction in RT exposure. METHODS AND MATERIALS From December 2009 to January 2012, 164 eligible patients under 22 years old with stage IIIB (43%) and stage IVB (57%) enrolled on AHOD0831. All patients received 4 cycles of doxorubicin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide (ABVE-PC). Those patients with a slow early response (SER) after the first 2 ABVE-PC courses were nonrandomly assigned to 2 intensification cycles with ifosfamide/vinorelbine before the final 2 ABVE-PC cycles. Response-adapted RT (21 Gy) was prescribed to initial areas of bulky disease and SER sites. Rapid early response (RER) sites without bulk were not targeted. Imaging studies at the time of progression or relapse were reviewed centrally for this retrospective analysis. Relapses were characterized with respect to site (initial, new, or both; and initial bulk or initial nonbulk), initial chemotherapy response, and radiation field (in-field, out-of-field, or both). RESULTS Of the entire cohort, 140 patients were evaluable for the patterns of failure analyses. To investigate the pattern of failure, this analysis focuses on 23 patients who followed protocol treatment and suffered relapses at a median 1.05 years with 7.97-year median follow-up time. These 23 patients (11 RER and 12 SER) experienced a relapse in 105 total sites (median, 4; range, 1-11). Of the 105 relapsed sites, 67 sites (64%) occurred within an initial site of involvement, with 12 of these 67 sites (18%) at an initial site of bulky disease and 63 of these 67 relapses (94%) occurring in sites that were not fluorodeoxyglucose (FDG)-avid after 2 cycles of ABVE-PC (PET2-negative). Of the 105 relapsed sites, 34 sites (32%) occurred in a new site of disease (that would not have been covered by RT); and, overall, only 4 of 140 patients (2.8%) (occurring in 3 RER and 1 SER) experienced isolated out-of-field relapses that would have been covered by historical IFRT. CONCLUSIONS For a cohort of high-risk patients with cHL patients, most failures occurred in nonbulky, initially involved sites, largely due to response-based consolidation RT delivered to patients with bulky disease. In this analysis, we discovered low rates of failures outside of these modern risk-adapted radiation treatment volumes. Also, FDG uptake on PET2 did not identify most relapse sites.
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Affiliation(s)
- Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, New Jersey.
| | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Kathleen M McCarten
- Imaging and Radiation Oncology Core Group Rhode Island (IROC-RI). Lincoln, Rhode Island
| | - Katie Karolczuk
- Imaging and Radiation Oncology Core Group Rhode Island (IROC-RI). Lincoln, Rhode Island
| | - Qinglin Pei
- Department of Biostatistics, University of Florida, Children's Oncology Group, Statistics and Data Center, Gainesville, Florida
| | - Yue Wu
- Department of Biostatistics, University of Florida, Children's Oncology Group, Statistics and Data Center, Gainesville, Florida
| | - Steve Y Cho
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Cindy Schwartz
- Division of Pediatric Hematology, Oncology and BMT, Medical College of Wisconsin Milwaukee, Wisconsin
| | - Peter D Cole
- Division of Pediatric Hematology/Oncology, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Kenneth Roberts
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
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5
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Combination Brentuximab Vedotin and Bendamustine for Pediatric Patients with Relapsed/Refractory Hodgkin Lymphoma. Blood Adv 2021; 5:5519-5524. [PMID: 34559223 PMCID: PMC8714712 DOI: 10.1182/bloodadvances.2021005268] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/21/2021] [Indexed: 12/02/2022] Open
Abstract
BVB was an effective and tolerable retrieval regimen for pediatric patients with R/R HL and resulted in minimal toxicity. Stem cell mobilization and collection was successful in patients before autologous stem cell transplant.
In patients with relapsed/refractory (R/R) Hodgkin lymphoma (HL), achieving a complete metabolic response (CMR) after salvage therapy is associated with superior outcomes, and optimal treatments must be identified. The combination of brentuximab vedotin and bendamustine (BVB), although highly active in adult patients, has not been extensively evaluated in pediatric patients with R/R HL. We performed a multicenter, retrospective review of pediatric patients <21 years of age with R/R HL treated with BVB from January 2016 through July 2019. Response was assessed by local radiologists according to Lugano classification criteria. Twenty-nine patients (17 relapsed, 12 refractory) with a median age of 16 years (range, 10-20) were treated with BVB and received a median of 3 cycles of therapy (range, 2-7). Patients received an infusion of 1.8 mg/kg of BV on day 1 with bendamustine 90 mg/m2 on days 1 and 2 of 3-week cycles. Nineteen patients (66%) achieved a CMR (95% CI, 46-82). An objective response was observed in 23 patients (objective response rate, 79%; 95% CI, 60-92). The most common grade 3 and 4 toxicities were hematologic, and 3 patients (10%) experienced grade 3 infusion reactions. Seventeen of 18 patients underwent successful mobilization and collection of stem cells. Sixteen patients (13 autologous, 3 allogeneic) received a consolidative transplant after BVB. The 3-year post-BVB event-free and overall survival were 65% (95% CI, 46-85) and 89% (95% CI, 74-100), respectively. For pediatric patients with R/R HL, BVB was well tolerated and compared favorably with currently accepted salvage regimens.
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6
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Fernández KS, Mavers M, Marks LJ, Agarwal R. Brentuximab Vedotin as Consolidation Therapy After Autologous Stem Cell Transplantation in Children and Adolescents (<18 y) With Early Relapse Hodgkin Lymphoma. J Pediatr Hematol Oncol 2021; 43:e191-e194. [PMID: 31876780 DOI: 10.1097/mph.0000000000001703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/01/2019] [Indexed: 01/06/2023]
Abstract
We describe 6 pediatric patients (12 to 18 y) with relapsed or refractory Hodgkin lymphoma treated with consolidative Brentuximab vedotin (Bv) following reinduction chemotherapy and autologous stem cell transplantation. The progression-free survival after autologous stem cell transplantation was 12, 18, 22, 24, 30, and 30 months. Most patients tolerated Bv well although 2 patients developed grade 3 neuropathy that prevent them from completing the scheduled 16 doses of Bv. Consolidative Bv in children and adolescents, as currently recommended for adult patients with early relapsed or refractory Hodgkin lymphoma, is feasible but with some significant toxicities.
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Affiliation(s)
- Karen S Fernández
- Pediatric Hematology/Oncology, Cancer and Blood Disorders Center, Valley Children's Hospital, Madera.,Stanford University, School of Medicine, Palo Alto, CA
| | - Melissa Mavers
- Division of Stem Cell Transplantation and Regenerative Medicine.,Stanford University, School of Medicine, Palo Alto, CA
| | - Lianna J Marks
- Pediatric Hematology/Oncology, Lucile Packard Children's Hospital.,Stanford University, School of Medicine, Palo Alto, CA
| | - Rajni Agarwal
- Division of Stem Cell Transplantation and Regenerative Medicine.,Stanford University, School of Medicine, Palo Alto, CA
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7
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Marr K, Ronsley R, Nadel H, Douglas K, Gershony S, Strahlendorf C, Davis JH, Deyell RJ. Ifosfamide, gemcitabine, and vinorelbine is an effective salvage regimen with excellent stem cell mobilization in relapsed or refractory pediatric Hodgkin lymphoma. Pediatr Blood Cancer 2020; 67:e28167. [PMID: 31925920 DOI: 10.1002/pbc.28167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022]
Abstract
We describe 12 pediatric patients (8-16 years) with primary refractory (N = 6) or first relapse (N = 6) Hodgkin lymphoma (HL) treated with ifosfamide, gemcitabine, and vinorelbine (IGEV). The overall response rate to IGEV was 100%, with seven (58%) complete responses (CR) and five (42%) partial responses. Successful CD34+ stem cell mobilization was achieved in all patients. Following subsequent autologous stem cell transplantation, 10 patients (83%) achieved CR. At a median follow-up of 71 months, 11 patients had no evidence of disease. Five-year second event-free survival and overall survival were 83% ± 11.0% and 90.0% ± 9.5%, respectively. IGEV is an effective salvage regimen for children with relapsed/refractory HL.
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Affiliation(s)
- Kristin Marr
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Rebecca Ronsley
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Helen Nadel
- Division of Nuclear Medicine, Department of Radiology, Stanford University, Stanford, California
| | - Kate Douglas
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Sharon Gershony
- Division of Nuclear Medicine, Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Caron Strahlendorf
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada.,Michael Cuccione Childhood Cancer Research Program, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Jeffrey H Davis
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Rebecca J Deyell
- Division of Pediatric Hematology, Oncology and Bone Marrow Transplantation, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada.,Michael Cuccione Childhood Cancer Research Program, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
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8
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Mascarenhas L, Chi YY, Hingorani P, Anderson JR, Lyden ER, Rodeberg DA, Indelicato DJ, Kao SC, Dasgupta R, Spunt SL, Meyer WH, Hawkins DS. Randomized Phase II Trial of Bevacizumab or Temsirolimus in Combination With Chemotherapy for First Relapse Rhabdomyosarcoma: A Report From the Children's Oncology Group. J Clin Oncol 2019; 37:2866-2874. [PMID: 31513481 DOI: 10.1200/jco.19.00576] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The primary aim of this clinical trial was to prioritize bevacizumab or temsirolimus for additional investigation in rhabdomyosarcoma (RMS) when administered in combination with cytotoxic chemotherapy to patients with RMS in first relapse with unfavorable prognosis. PATIENTS AND METHODS Patients were randomly assigned to receive bevacizumab on day 1 or temsirolimus on days 1, 8, and 15 of each 21-day treatment cycle, together with vinorelbine on days 1 and 8, and cyclophosphamide on day 1 for a maximum of 12 cycles. Local tumor control with surgery and/or radiation therapy was permitted after 6 weeks of treatment. The primary end point was event-free survival (EFS). Radiographic response was assessed at 6 weeks. The study had a phase II selection that was design to detect a 15% difference between the two regimens (α = .2; 1-β = 0.8; two sided test). RESULTS Eighty-seven of 100 planned patients were enrolled when the trial was closed after the second interim analysis after 46 events occurred in 68 patients with sufficient follow-up. The O'Brien Fleming boundary at this analysis corresponded to a two-sided P value of .058 with an observed two-sided P value of .003 favoring temsirolimus. The 6-month EFS for the bevacizumab arm was 54.6% (95% CI, 39.8% to 69.3%) and 69.1% (95% CI, 55.1% to 83%) for the temsirolimus arm. Objective response rates were 28% (95% CI, 13.7% to 41.3%) and 47% (95% CI, 31.5% to 63.2%) for the bevacizumab and temsirolimus arms, respectively (P = .12) and, 28% of patients on bevacizumab and 11% on temsirolimus had progressive disease at 6 weeks. CONCLUSION Patients who received temsirolimus had a superior EFS compared with bevacizumab. Temsirolimus has been selected for additional investigation in newly diagnosed patients with intermediate-risk RMS.
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Affiliation(s)
- Leo Mascarenhas
- Children's Hospital Los Angeles and University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | | | | | | | | | | | - Simon C Kao
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Roshni Dasgupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sheri L Spunt
- Stanford University School of Medicine, Stanford, CA
| | - William H Meyer
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
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9
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Kelly KM, Cole PD, Pei Q, Bush R, Roberts KB, Hodgson DC, McCarten KM, Cho SY, Schwartz C. Response-adapted therapy for the treatment of children with newly diagnosed high risk Hodgkin lymphoma (AHOD0831): a report from the Children's Oncology Group. Br J Haematol 2019; 187:39-48. [PMID: 31180135 DOI: 10.1111/bjh.16014] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/12/2019] [Indexed: 11/30/2022]
Abstract
The AHOD0831 study for paediatric patients with high risk Hodgkin lymphoma tested a response-based approach designed to limit cumulative alkylator exposure and reduce radiation volumes. Patients (Stage IIIB/IVB) received two cycles of ABVE-PC (doxorubicin, bleomycin, vincristine, etoposide, prednisone, cyclophosphamide). Rapid early responders [RER, no positron emission tomography (PET) activity above mediastinal blood pool] were consolidated with 2 cycles of ABVE-PC. Slow early responders (SER) received 2 cycles of ifosfamide/vinorelbine and 2 cycles of ABVE-PC. Radiotherapy was administered to sites of initial bulk and/or SER. By intent-to-treat analysis, 4-year second event-free survival (EFS; freedom from second relapse or malignancy) was 91·9% [95% confidence interval (CI): 86·1-95·3%], below the projected baseline of 95% (P = 0·038). Five-year first EFS and overall survival (OS) rates are 79·1% (95% CI: 71·5-84·8%) and 95% (95% CI: 88·8-97·8%). Eight of 11 SER patients with persistent PET positive lesions at the end of chemotherapy had clinical evidence of active disease (3 biopsy-proven, 5 with progressive disease or later relapses). Although this response-directed approach did not reach the ambitiously high pre-specified target for second EFS, EFS and OS rates are comparable with results of recent trials despite the reduction in radiotherapy volumes from historical involved fields. Persistent PET at end of chemotherapy identifies a cohort at an especially high risk for relapse/early progression.
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Affiliation(s)
- Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Peter D Cole
- Division of Pediatric Hematology/Oncology, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Qinglin Pei
- Department of Biostatistics, University of Florida, Children's Oncology Group, Statistics and Data Center, Gainesville, FL, USA
| | - Rizvan Bush
- Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | - Kenneth B Roberts
- Department of Therapeutic Radiology, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Kathleen M McCarten
- Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Steve Y Cho
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Cindy Schwartz
- Division of Pediatric Hematology, Oncology and BMT, Medical College of Wisconsin, Milwaukee, WI, USA
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10
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Tinkle CL, Williams NL, Wu H, Wu J, Kaste SC, Shulkin BL, Talleur AC, Flerlage JE, Hudson MM, Metzger ML, Krasin MJ. Treatment patterns and disease outcomes for pediatric patients with refractory or recurrent Hodgkin lymphoma treated with curative-intent salvage radiotherapy. Radiother Oncol 2019; 134:89-95. [PMID: 31005229 DOI: 10.1016/j.radonc.2019.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/14/2019] [Accepted: 01/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The use of radiotherapy (RT) for pediatric patients with Hodgkin lymphoma (HL) experiencing disease progression or recurrence (15%) is controversial. We report treatment patterns and outcomes for pediatric patients with refractory/recurrent HL (rrHL) treated with curative-intent RT. MATERIALS AND METHODS Forty-six patients with rrHL treated with salvage RT at our institution were identified. All received risk-adapted, response-based frontline therapy and were retrieved with cytoreductive regimens followed by RT to failure sites, with or without autologous hematopoietic cell transplantation (AHCT). Cumulative incidence (CIN) of local failure (LF) and survival were estimated after salvage RT and regression models determined predictors of LF after salvage RT. RESULTS RT was administered as part of frontline therapy in 70% of patients, omitted for early response assessment in 13%, or deferred for primary progression in 17%. AHCT was omitted in 20% of patients. Median initial and salvage dose/site were 25.5 Gy and 30.6 Gy, respectively. Eight patients experienced progression. Two died without progression (median follow-up from salvage RT = 3.8 years). The 5-year CIN of LF after salvage RT was 17.7% (95% confidence interval [CI], 8.2-30.2%). The 5-year freedom from subsequent treatment failure and overall survival (OS) was 80.1% (95% CI, 69.2-92.6%) and 88.5% (95% CI, 79.5-98.6%), respectively. Inadequate response to salvage systemic therapy (p = 0.048) and male sex (p = 0.049) were significantly associated with LF after salvage RT. CONCLUSION rrHL is responsive to salvage RT, with low LF rates after moderate doses. OS is excellent, despite refractory disease. Initial salvage therapy response predicts subsequent LF.
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Affiliation(s)
- Christopher L Tinkle
- Department of Radiation Oncology, St. Jude Children's Hospital, Memphis, United States.
| | - Noelle L Williams
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, United States
| | - Huiyun Wu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, United States
| | - Jianrong Wu
- Department of Biostatistics, University of Kentucky, Lexington, United States
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, United States; Department of Radiology, University of Tennessee Health Science Center, Memphis, United States; Department of Oncology, St. Jude Children's Research Hospital, Memphis, United States
| | - Barry L Shulkin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, United States; Department of Radiology, University of Tennessee Health Science Center, Memphis, United States
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, United States
| | - Jamie E Flerlage
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, United States
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, United States
| | - Monika L Metzger
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, United States
| | - Matthew J Krasin
- Department of Radiation Oncology, St. Jude Children's Hospital, Memphis, United States
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Locatelli F, Mauz-Koerholz C, Neville K, Llort A, Beishuizen A, Daw S, Pillon M, Aladjidi N, Klingebiel T, Landman-Parker J, Medina-Sanson A, August K, Sachs J, Hoffman K, Kinley J, Song S, Song G, Zhang S, Suri A, Gore L. Brentuximab vedotin for paediatric relapsed or refractory Hodgkin's lymphoma and anaplastic large-cell lymphoma: a multicentre, open-label, phase 1/2 study. LANCET HAEMATOLOGY 2018; 5:e450-e461. [DOI: 10.1016/s2352-3026(18)30153-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 12/13/2022]
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12
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Peripheral neuropathy in children and adolescents treated for cancer. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:744-754. [PMID: 30236383 DOI: 10.1016/s2352-4642(18)30236-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 12/22/2022]
Abstract
Peripheral neuropathy is a well recognised treatment-related toxicity in children with cancer, associated with exposure to neurotoxic chemotherapy agents. Acute damage can occur in sensory, motor, or autonomic neurons, with symptoms that are rarely life threatening, but often severe enough to interfere with function during therapy and after treatment ends. The type of neuropathy and specific symptoms are associated with multiple factors including age at time of therapy, genetic predisposition, chemotherapy type and cumulative dose, and exposure to other agents during therapy. In this Review, we describe the peripheral neuropathy phenotype in children during cancer therapy and among survivors who have completed therapy, to summarise genetic and treatment-related risk factors for neuropathy, and to outline strategies to monitor and detect neuropathy during and after therapy. Additionally, we outline strategies for medical management of neuropathy during treatment and potential rehabilitation interventions to prevent or remediate functional loss.
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13
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Cole PD, McCarten KM, Pei Q, Spira M, Metzger ML, Drachtman RA, Horton TM, Bush R, Blaney SM, Weigel BJ, Kelly KM. Brentuximab vedotin with gemcitabine for paediatric and young adult patients with relapsed or refractory Hodgkin's lymphoma (AHOD1221): a Children's Oncology Group, multicentre single-arm, phase 1-2 trial. Lancet Oncol 2018; 19:1229-1238. [PMID: 30122620 PMCID: PMC6487196 DOI: 10.1016/s1470-2045(18)30426-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with primary refractory Hodgkin's lymphoma or early relapse have a poor prognosis. Although many salvage regimens have been developed, there is no standard of care. Brentuximab vedotin and gemcitabine have been shown to be active in patients with relapsed or refractory Hodgkin's lymphoma when used as monotherapy, and each has been successfully used in combination with other agents. Preclinical data suggest that brentuximab vedotin can sensitise lymphoma cells to gemcitabine, supporting the use of the combination. We aimed to define the safety and efficacy of brentuximab vedotin with gemcitabine in children and young adults with primary refractory Hodgkin's lymphoma or early relapse. METHODS In this Children's Oncology Group, multicentre, single-arm, phase 1-2 trial, we recruited patients with Hodgkin's lymphoma from hospitals across the USA and Canada. Eligible patients were aged younger than 30 years, had no previous brentuximab vedotin exposure, and had primary refractory disease or relapse of less than 1 year from completion of initial treatment. Each 21-day cycle consisted of 1000 mg/m2 intravenous gemcitabine on days 1 and 8 and intravenous brentuximab vedotin on day 1 at 1·4 mg/kg or 1·8 mg/kg. The primary objectives were to establish the recommended phase 2 dose of brentuximab vedotin in this combination, the safety of the combination, and the proportion of patients who achieved a complete response among those treated at the recommended phase 2 level, within four cycles of treatment. This trial is registered with ClinicalTrials.gov, number NCT01780662. FINDINGS Between Feb 5, 2013, and Aug 19, 2016, 46 patients were enrolled, including one who was found to be ineligible, in the two phases of the study. The recommended phase 2 dose of brentuximab vedotin was 1·8 mg/kg in combination with gemcitabine 1000 mg/m2. 24 (57%) of 42 evaluable patients (95% CI 41-72) given this dose level had a complete response within the first four cycles of treatment. Four (31%) of 13 patients with a partial response or stable disease had all target lesions with Deauville scores of 3 or less after cycle 4. By modern response criteria, these were also complete responses (total number with complete response 28 [67%] of 42 [95% CI 51-80]). The most common grade 3-4 adverse events in all 42 participants treated at the recommended phase 2 dose were neutropenia (15 [36%]), rash (15 [36%]), transaminitis (9 [21%]), and pruritus (4 [10%]). There were no treatment-related deaths. INTERPRETATION Brentuximab vedotin with gemcitabine is a safe combination treatment with a tolerable toxicity profile for patients with primary refractory Hodgkin's lymphoma or high-risk relapse. The preliminary activity of this combination shown in this trial warrants further investigation in randomised controlled trials. FUNDING National Institutes of Health and the St. Baldrick's Foundation.
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Affiliation(s)
- Peter D Cole
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA; Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | | | - Qinglin Pei
- Department of Biostatistics, University of Florida, Gainesville, FL, USA; Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | | | | | - Richard A Drachtman
- Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Terzah M Horton
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Rizvan Bush
- Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | - Susan M Blaney
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Nagpal P, Akl MR, Ayoub NM, Tomiyama T, Cousins T, Tai B, Carroll N, Nyrenda T, Bhattacharyya P, Harris MB, Goy A, Pecora A, Suh KS. Pediatric Hodgkin lymphoma: biomarkers, drugs, and clinical trials for translational science and medicine. Oncotarget 2016; 7:67551-67573. [PMID: 27563824 PMCID: PMC5341896 DOI: 10.18632/oncotarget.11509] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 08/18/2016] [Indexed: 01/09/2023] Open
Abstract
Hodgkin lymphoma (HL) is a lymphoid malignancy that is typically derived from germinal-center B cells. EBV infection, mutations in NF-κB pathway genes, and genetic susceptibility are known risk factors for developing HL. CD30 and NF-κB have been identified as potential biomarkers in pediatric HL patients, and these molecules may represent therapeutic targets. Although current risk adapted and response based treatment approaches yield overall survival rates of >95%, treatment of relapse or refractory patients remains challenging. Targeted HL therapy with the antibody-drug conjugate Brentuximab vedotin (Bv) has proven to be superior to conventional salvage chemotherapy and clinical trials are being conducted to incorporate Bv into frontline therapy that substitutes Bv for alkylating agents to minimize secondary malignancies. The appearance of secondary malignancies has been a concern in pediatric HL, as these patients are at highest risk among all childhood cancer survivors. The risk of developing secondary leukemia following childhood HL treatment is 10.4 to 174.8 times greater than the risk in the general pediatric population and the prognosis is significantly poorer than the other hematological malignancies with a mortality rate of nearly 100%. Therefore, identifying clinically valuable biomarkers is of utmost importance to stratify and select patients who may or may not need intensive regimens to maintain optimal balance between maximal survival rates and averting late effects. Here we discuss epidemiology, risk factors, staging, molecular and genetic prognostic biomarkers, treatment for low and high-risk patients, and the late occurrence of secondary malignancies in pediatric HL.
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Affiliation(s)
- Poonam Nagpal
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mohamed R. Akl
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Nehad M. Ayoub
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Tatsunari Tomiyama
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tasheka Cousins
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Betty Tai
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Nicole Carroll
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Themba Nyrenda
- Department of Research, Hackensack University Medical Center, Hackensack, NJ, USA
| | | | - Michael B. Harris
- Department of Pediatrics, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Andre Goy
- Clinical Divisions, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Andrew Pecora
- Clinical Divisions, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - K. Stephen Suh
- The Genomics and Biomarkers Program, The John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
- Department of Research, Hackensack University Medical Center, Hackensack, NJ, USA
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15
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Horton TM, Drachtman RA, Chen L, Cole PD, McCarten K, Voss S, Guillerman RP, Buxton A, Howard SC, Hogan SM, Sheehan AM, López-Terrada D, Mrazek MD, Agrawal N, Wu MF, Liu H, De Alarcon PA, Trippet TM, Schwartz CL. A phase 2 study of bortezomib in combination with ifosfamide/vinorelbine in paediatric patients and young adults with refractory/recurrent Hodgkin lymphoma: a Children's Oncology Group study. Br J Haematol 2015; 170:118-22. [PMID: 25833390 DOI: 10.1111/bjh.13388] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/04/2015] [Indexed: 02/02/2023]
Abstract
A Children's Oncology Group clinical trial aimed to determine if bortezomib (B) increased the efficacy of ifosfamide and vinorelbine (IV) in paediatric Hodgkin lymphoma (HL). This study enrolled 26 relapsed HL patients (<30 years) treated with two to four cycles of IVB. The primary endpoint was anatomic complete response (CR) after two cycles. Secondary endpoints included overall response (OR: CR + partial response) at study completion compared to historical controls [72%; 95% confidence interval (CI): 59-83%]. Although few patients achieved the primary objective, OR with IVB improved to 83% (95% CI: 61-95%; p = 0.32). Although not statistically different, results suggest IVB may be a promising combination.
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Affiliation(s)
- Terzah M Horton
- Department of Pediatrics, Division of Pediatric Haematology-Oncology, Texas Children's Cancer Center and Baylor College of Medicine, Houston, TX, USA
| | | | - Lu Chen
- Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | - Peter D Cole
- Department of Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kathleen McCarten
- Quality Assurance Response Centre (QARC), Brown University, Providence, RI, USA
| | - Stephan Voss
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Guillerman
- Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Allen Buxton
- Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | - Scott C Howard
- Department of Oncology, St. Jude's Children's Research Hospital, Memphis, TN, USA
| | - Shirley M Hogan
- Department of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Andrea M Sheehan
- Department of Pathology, Texas Children's Hospital and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Dolores López-Terrada
- Department of Pathology, Texas Children's Hospital and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Matthew D Mrazek
- Department of Pediatrics, Division of Pediatric Haematology-Oncology, Texas Children's Cancer Center and Baylor College of Medicine, Houston, TX, USA
| | - Neeraj Agrawal
- Department of Pediatrics, Division of Pediatric Haematology-Oncology, Texas Children's Cancer Center and Baylor College of Medicine, Houston, TX, USA
| | - Meng-Fen Wu
- Division of Biostatistics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Hao Liu
- Division of Biostatistics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Cindy L Schwartz
- Department of Pediatrics, MD Anderson Cancer Center, Houston, TX, USA
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16
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Perales MA, Ceberio I, Armand P, Burns LJ, Chen R, Cole PD, Evens AM, Laport GG, Moskowitz CH, Popat U, Reddy NM, Shea TC, Vose JM, Schriber J, Savani BN, Carpenter PA. Role of cytotoxic therapy with hematopoietic cell transplantation in the treatment of Hodgkin lymphoma: guidelines from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2015; 21:971-83. [PMID: 25773017 DOI: 10.1016/j.bbmt.2015.02.022] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/25/2015] [Indexed: 12/22/2022]
Abstract
The role of hematopoietic cell transplantation (HCT) in the therapy of Hodgkin lymphoma (HL) in pediatric and adult patients is reviewed and critically evaluated in this systematic evidence-based review. Specific criteria were used for searching the published literature and for grading the quality and strength of the evidence and the strength of the treatment recommendations. Treatment recommendations based on the evidence are included and were reached unanimously by a panel of HL experts. Both autologous and allogeneic HCT offer a survival benefit in selected patients with advanced or relapsed HL and are currently part of standard clinical care. Relapse remains a significant cause of failure after both transplant approaches, and strategies to decrease the risk of relapse remain an important area of investigation.
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Affiliation(s)
- Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | - Izaskun Ceberio
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Hematology Department, Hospital Universitario Donostia, Donostia, Spain
| | - Philippe Armand
- Division of Hematological Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Linda J Burns
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Robert Chen
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California
| | - Peter D Cole
- Department of Pediatrics, Albert Einstein College of Medicine and Department of Pediatric Hematology/Oncology, The Children's Hospital at Montefiore, Bronx, New York
| | - Andrew M Evens
- Department of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Ginna G Laport
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Craig H Moskowitz
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nishitha M Reddy
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas C Shea
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Julie M Vose
- Division of Hematology/Oncology, The Nebraska Medical Center, Omaha, Nebraska
| | - Jeffrey Schriber
- Cancer Transplant Institute, Virginia G Piper Cancer Center, Scottsdale, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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