1
|
Zijtregtop EAM, Zeal J, Metzger ML, Kelly KM, Mauz-Koerholz C, Voss SD, McCarten K, Flerlage JE, Beishuizen A. Significance of E-lesions in Hodgkin lymphoma and the creation of a new consensus definition: a report from SEARCH. Blood Adv 2023; 7:6303-6319. [PMID: 37522740 PMCID: PMC10589789 DOI: 10.1182/bloodadvances.2023010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 08/01/2023] Open
Abstract
The International Staging Evaluation and Response Criteria Harmonization for Childhood, Adolescent, and Young Adult Hodgkin Lymphoma (SEARCH for CAYAHL) seeks to provide an appropriate, universal differentiation between E-lesions and stage IV extranodal disease in Hodgkin lymphoma (HL). A literature search was performed through the PubMed and Google Scholar databases using the terms "Hodgkin disease," and "extranodal," "extralymphatic," "E lesions," "E stage," or "E disease." Publications were reviewed for the number of participants; median age and age range; diagnostic modalities used for staging; and the definition, incidence, and prognostic significance of E-lesions. Thirty-six articles describing 12 640 patients met the inclusion criteria. Most articles reported staging per the Ann Arbor (72%, 26/36) or Cotswolds modification of the Ann Arbor staging criteria (25%, 9/36), and articles rarely defined E-lesions or disambiguated "extranodal disease." The overall incidence of E-lesions for patients with stage I-III HL was 11.5% (1330/11 602 unique patients). Available stage-specific incidence analysis of 3888 patients showed a similar incidence of E-lesions in stage II (21.2%) and stage III (21.9%), with E-lesions rarely seen with stage I disease (1.1%). E-lesions likely remain predictive, but we cannot unequivocally conclude that identifying E-lesions in HL imparts prognostic value in the modern era of the more selective use of targeted radiation therapy. A harmonized E-lesion definition was reached based on the available evidence and the consensus of the SEARCH working group. We recommend that this definition of E-lesion be applied in future clinical trials with explicit reporting to confirm the prognostic value of E-lesions.
Collapse
Affiliation(s)
- Eline A. M. Zijtregtop
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Jamie Zeal
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN
- Department of Medicine, University of Tennessee Health Sciences Center, Memphis, TN
| | - Monika L. Metzger
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Kara M. Kelly
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Christine Mauz-Koerholz
- Department of Pädiatrische Hämatologie und Onkologie, Zentrum für Kinderheilkunde der Justus-Liebig-Universität Giessen, Giessen, Germany
- Medical Faculty, Martin-Luther-University of Halle-Wittenberg, Halle, Germany
| | - Stephan D. Voss
- Department of Radiology, Boston Children’s Hospital Dana-Farber Cancer Institute, Boston, MA
| | | | - Jamie E. Flerlage
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Auke Beishuizen
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| |
Collapse
|
2
|
Kluge R, Kurch L, Georgi T, Metzger M. Current Role of FDG-PET in Pediatric Hodgkin's Lymphoma. Semin Nucl Med 2017; 47:242-257. [PMID: 28417854 DOI: 10.1053/j.semnuclmed.2017.01.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hodgkin's lymphoma is one of the most curable pediatric cancers with long-term survival rates exceeding 90% following intensive treatment. Collaborative group studies worldwide aim on reduction or elimination of radiotherapy to avoid potentially life-limiting late effects especially second cancers and cardiovascular diseases. Large prospective trials have integrated early response FDG-PET scans to identify adequate responders to chemotherapy in whom radiotherapy may safely be omitted. The criteria for interpretation of early response PET have changed during the past years and will be further refined based on trial results. FDG-PET is also systematically used to assess initial disease involvement of pediatric Hodgkin's lymphoma and could replace bone marrow biopsy. This article summarizes the role of FDG-PET in staging and response assessment focusing on large pediatric trials, the criteria for PET interpretation and pitfalls.
Collapse
Affiliation(s)
- Regine Kluge
- Department of Nuclear Medicine, University Hospital of Leipzig, Leipzig, Germany.
| | - L Kurch
- Department of Nuclear Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Georgi
- Department of Nuclear Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Monika Metzger
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| |
Collapse
|
3
|
Fredman E, Mansur DB, Russo S. The evolving role of radiation therapy in pediatric Hodgkin's disease. Expert Rev Anticancer Ther 2016; 16:605-13. [PMID: 27137877 DOI: 10.1080/14737140.2016.1182428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Identifying the optimal treatment of pediatric Hodgkin's disease has been at the forefront of clinical investigation in recent years. Results of a number of large clinical trials have driven paradigm shifts in how physicians approach this often curable disease. In an effort to balance the goals of maximizing survival while minimizing acute toxicities and late complications, the recommended indications, targets, doses and schedules of chemotherapy and radiation have and continue to evolve. Recent attempts to decrease the total volume of tissue receiving radiation without requiring a significant escalation in cytotoxic chemotherapy have shown promise in low, intermediate and high risk patients. Utilizing risk-adapted, response-based treatment, researchers hope to uncover a subpopulation that may not require previously considered standard treatment modalities.
Collapse
Affiliation(s)
- Elisha Fredman
- a Department of Radiation Oncology, Seidman Cancer Center , University Hospitals, Case Medical Center , Cleveland , OH , USA
| | - David B Mansur
- a Department of Radiation Oncology, Seidman Cancer Center , University Hospitals, Case Medical Center , Cleveland , OH , USA
| | - Suzanne Russo
- a Department of Radiation Oncology, Seidman Cancer Center , University Hospitals, Case Medical Center , Cleveland , OH , USA
| |
Collapse
|
4
|
Bröckelmann PJ, Goergen H, Fuchs M, Kriz J, Semrau R, Baues C, Kobe C, Behringer K, Eichenauer DA, von Tresckow B, Klimm B, Halbsguth T, Wongso D, Plütschow A, Haverkamp H, Dietlein M, Eich HT, Stein H, Diehl V, Borchmann P, Engert A. Impact of centralized diagnostic review on quality of initial staging in Hodgkin lymphoma: experience of the German Hodgkin Study Group. Br J Haematol 2015; 171:547-56. [DOI: 10.1111/bjh.13646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Paul J. Bröckelmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | - Michael Fuchs
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Jan Kriz
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Robert Semrau
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Christian Baues
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Carsten Kobe
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Karolin Behringer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Dennis A. Eichenauer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Bastian von Tresckow
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Beate Klimm
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department III of Internal Medicine; Krankenhaus Düren; Düren Germany
| | - Teresa Halbsguth
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department II of Internal Medicine; University Hospital of Frankfurt; Frankfurt Germany
| | - Diana Wongso
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | | | - Markus Dietlein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Hans T. Eich
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Harald Stein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Pathodiagnostik Berlin; Berlin Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Peter Borchmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Andreas Engert
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| |
Collapse
|
5
|
Kirisits C, Federico M, Nkiwane K, Fidarova E, Jürgenliemk-Schulz I, de Leeuw A, Lindegaard J, Pötter R, Tanderup K. Quality assurance in MR image guided adaptive brachytherapy for cervical cancer: Final results of the EMBRACE study dummy run. Radiother Oncol 2015; 117:548-54. [PMID: 26316396 DOI: 10.1016/j.radonc.2015.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 07/22/2015] [Accepted: 08/01/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Upfront quality assurance (QA) is considered essential when starting a multicenter clinical trial in radiotherapy. Despite the long experience gained for external beam radiotherapy (EBRT) trials, there are only limited audit QA methods for brachytherapy (BT) and none include the specific aspects of image guided adaptive brachytherapy (IGABT). METHODS AND MATERIALS EMBRACE is a prospective multicenter trial aiming to assess the impact of (MRI)-based IGABT in locally advanced cervical cancer. An EMBRACE dummy run was designed to identify sources and magnitude of uncertainties and errors considered important for the evaluation of clinical, and dosimetric parameters and their relation to outcome. Contouring, treatment planning and dose reporting was evaluated and scored with a categorical scale of 1-10. Active feedback to centers was provided to improve protocol compliance and reporting. A second dummy run was required in case of major deviations (score <7) for any item. RESULTS Overall 27/30 centers passed the dummy run. 16 centers had to repeat the dummy run in order to clarify major inconsistencies to the protocol. The most pronounced variations were related to contouring for both EBRT and BT. Centers with experience in IGABT (>30 cases) had better performance as compared to centers with limited experience. CONCLUSION The comprehensive dummy run designed for the EMBRACE trial has been a feasible tool for QA in IGABT of cervix cancer. It should be considered for future IGABT trials and could serve as the basis for continuous quality checks for brachytherapy centers.
Collapse
Affiliation(s)
- Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria.
| | - Mario Federico
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria; Radiation Oncology Department, HUGC Dr. Negrin, Las Palmas, Spain
| | - Karen Nkiwane
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Elena Fidarova
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | | | - Astrid de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | | | - Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
| |
Collapse
|
6
|
Lüders H, Rühl U, Marciniak H, Haerting J, Claviez A, Mann G, Schellong G, Wickmann L, Dörffel W. The impact of central review and central therapy planning on the treatment of children and adolescents with Hodgkin lymphoma. Eur J Cancer 2014; 50:425-33. [DOI: 10.1016/j.ejca.2013.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/16/2013] [Accepted: 09/25/2013] [Indexed: 11/17/2022]
|
7
|
Martin J, Frantzis J, Chung P, Langah I, Crain M, Cornes D, Plank A, Finch T, Jones M, Khoo E, Catton C. Prostate radiotherapy clinical trial quality assurance: how real should real time review be? (A TROG-OCOG Intergroup Project). Radiother Oncol 2013; 107:333-8. [PMID: 23751377 DOI: 10.1016/j.radonc.2013.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Review of plans early in treatment offers the potential to reduce the chance of sub-optimal treatment delivery. We compare the use of real time reviews (RTR) either before randomization (pre-rand 3D RTR) or following randomization (post-rand 2D RTR). MATERIALS AND METHODS PROFIT is an international randomised trial for men with prostate cancer which had credentialing via multiple dummy runs. In Australia, but not Canada, all plans were submitted for pre-rand 3D RTR using 3D software, and resubmission was requested if significant protocol deviations (PD) were seen. All plans from Canada and Australia then underwent post-rand 2D RTR using a 2D assessment. RESULTS For 147 Australian patients, pre-rand 3D RTR was fast (median 1 day, 95% range 0-4 days). 51 minor and 5 major PD were observed and 15 of the 147 cases (10%) required resubmission. Of the 5 major PD, 4 were remedied on resubmission and 1 was withdrawn from study. For the post-rand 2D RTR, reports from 147 Australian cases and 193 Canadian cases were reviewed. No major PD were reported from Australian cases, but 3 were seen in Canadian cases (0% versus 1.5%; p=0.26). There was also no difference in the rate of minor PD (14.3% versus 15.3%; p=NS). CONCLUSIONS In a study using relatively simple treatment volumes after comprehensive credentialing, pre-rand 3D RTR offers only modest benefits compared with post-rand 2D RTR. In the future the intensity of RTR may need to vary according to protocol and site specific factors.
Collapse
Affiliation(s)
- Jarad Martin
- Department of Radiation Oncology, Calvary Mater Hospital, Newcastle, Australia.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Dörffel W, Rühl U, Lüders H, Claviez A, Albrecht M, Bökkerink J, Holte H, Karlen J, Mann G, Marciniak H, Niggli F, Schmiegelow K, Schwarze EW, Pötter R, Wickmann L, Schellong G. Treatment of Children and Adolescents With Hodgkin Lymphoma Without Radiotherapy for Patients in Complete Remission After Chemotherapy: Final Results of the Multinational Trial GPOH-HD95. J Clin Oncol 2013; 31:1562-8. [DOI: 10.1200/jco.2012.45.3266] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To minimize the risk of late effects in pediatric Hodgkin lymphoma (HL) by omitting radiotherapy (RT) in patients in complete remission (CR) after chemotherapy and reducing the standard radiation dose to 20 Gy in patients in incomplete remission. Patients and Methods Between 1995 and 2001, 925 patients with classical HL (cHL) were registered from seven European countries in German Society of Pediatric Oncology and Hematology Hodgkin Lymphoma Trial 95. Patients in treatment group 1 (TG1; early stages) received two cycles of vincristine, prednisone, procarbazine, and doxorubicin or vincristine, prednisone, etoposide, and doxorubicin chemotherapy; additional two or four cycles of cyclophosphamide, vincristine, prednisone, and procarbazine were added in TG2 (intermediate stages) or TG3 (advanced stages), respectively. Patients in CR (assessed by computed tomography or magnetic resonance imaging) did not undergo RT. Those with tumor volume reduction more than 75% received reduced involved-field RT with 20 Gy and an additional 10- or 15-Gy boost only for larger residuals. Results Rates of overall survival, progression-free survival (PFS), and event-free survival at 10 years were (± SE) 96.3% ± 0.6%, 88.2% ± 1.1%, and 85.4% ± 1.3%, respectively. PFS for TG1 patients without or with RT was 97.0% ± 2.1% versus 92.2% ± 1.7% (P = .214) but was unsatisfactory for nonirradiated patients in TG2 (68.5% ± 7.4% v 91.4% ± 1.9%; P < .0001), with similar but not significant results in TG3 (82.6% ± 5.4% v 88.7% ± 2.0%, P = .259). Reduction of the standard radiation dose from 25 to 20 Gy did not increase failure rate. Conclusion RT can be omitted in early stage HL in so defined CR following this chemotherapy. RT with 20(−35) Gy proved to be sufficient in patients with incomplete remission following chemotherapy.
Collapse
Affiliation(s)
- Wolfgang Dörffel
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Ursula Rühl
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Heike Lüders
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Alexander Claviez
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Marion Albrecht
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Jos Bökkerink
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Harald Holte
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Jonas Karlen
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Georg Mann
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Heinz Marciniak
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Felix Niggli
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Kjeld Schmiegelow
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Ernst-Wilhelm Schwarze
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Richard Pötter
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Lutz Wickmann
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| | - Günther Schellong
- Wolfgang Dörffel, Heike Lüders, Heinz Marciniak, and Lutz Wickmann, HELIOS Hospital Berlin-Buch, Berlin-Buch; Ursula Rühl and Marion Albrecht, VIVANTES Hospital Berlin-Moabit, Berlin-Moabit; Alexander Claviez, University of Schleswig-Holstein, Kiel; Ernst-Wilhelm Schwarze, Municipal Clinic Dortmund, Dortmund; Günther Schellong, University Hospital of Münster, Münster, Germany; Jos Bökkerink, Academisch Ziekenhuis Nijmegen, the Netherlands; Harald Holte, Oslo University Hospital, Oslo, Norway; Jonas
| |
Collapse
|
9
|
Frew JA, Lewis J, Lucraft HH. The management of children with lymphomas. Clin Oncol (R Coll Radiol) 2012; 25:11-8. [PMID: 23231943 DOI: 10.1016/j.clon.2012.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 08/10/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
Abstract
Lymphomas account for 10-15% of all paediatric malignancies. They are highly curable with 5 year survival rates of up to 95% for Hodgkin lymphoma and 82% for non-Hodgkin lymphoma. These excellent results have focused recent attention on reducing the burden of treatment-related morbidity while maintaining the excellent outcomes. Lymphomas are highly radiosensitive and radiotherapy was used historically in the treatment of both paediatric Hodgkin and non-Hodgkin lymphomas. As the late effects of radiotherapy, including second tumours, were recognised, successive protocols seeking to minimise late effects were developed that reduced the use of radiotherapy. Current treatment protocols for non-Hodgkin lymphoma are chemotherapy based and radiotherapy has been virtually eliminated. In contrast, current paediatric Hodgkin lymphoma protocols continue to use radiotherapy as part of combined modality treatment, targeted according to risk factors and response and at the minimum effective dose. This article reviews the treatment of Hodgkin lymphoma in children with particular emphasis on the role of radiotherapy.
Collapse
Affiliation(s)
- J A Frew
- Northern Centre for Cancer Care, The Freeman Hospital, High Heaton, Newcastle-upon-Tyne, UK.
| | | | | |
Collapse
|
10
|
Kriz J, Bangard C, Haverkamp U, Bongartz R, Baues C, Engert A, Mueller RP, Eich HT. Quality control of involved-field radiotherapy for patients with early stage Hodgkin's lymphoma based on a central prospective review. Comparison of the results between two study generations of the German Hodgkin Study Group. Strahlenther Onkol 2012; 188:660-5. [PMID: 22692351 DOI: 10.1007/s00066-012-0103-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 03/08/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Based on experience in trials HD10 and HD11 (1998-2003), the radiotherapy reference center of the German Hodgkin Study Group (GHSG) continued their central prospective radiation oncological review in trials HD13 and HD14. The purpose of this analysis was to identify the impact of this procedure on radiotherapeutic management and to compare findings with former trials. METHODS Between 2003 and 2009, 1,710 patients were enrolled in the HD13 trial (early favorable stages) and 2,039 patients in the HD14 trial (early unfavorable stages). All patients received a total of 30 Gy involved-field (IF) radiotherapy within a combined modality approach. RESULTS For patients in HD13, there was a correction of disease involvement in 847/1,518 patients (56%), and for patients in HD14 in 1,370/1,905 patients (72%). Most discrepancies were observed in the lower mediastinum (19.2%), infraclavicular (31.7%), upper cervical (12.7%), and supraclavicular (10.8%) lymph nodes. This resulted in a change of disease stage in 241 (7%) patients and a shift into another study protocol in 66 (2%) patients. Due to the incorrect lymph node documentation of the participating study centers, the IF radiotherapy volume had to be enlarged in 1,063/3,423 patients (31%) and reduced in 244/3,423 patients (7.1%). These findings are comparable to the results of the quality control in the trials HD10 and HD11 (2,611 patients reviewed). CONCLUSION Central review of the diagnostic imaging and clinical findings of Hodgkin's lymphoma patients shows a considerable number of discrepancies compared with the local evaluation. Thus, meticulous evaluation of all imaging information in close collaboration between the radiation oncologist and diagnostic radiologist is mandatory.
Collapse
Affiliation(s)
- J Kriz
- Department of Radiation Oncology, University of Muenster, Albert-Schweitzer Campus 1, Gebäude 1A, 48419, Muenster, Germany
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Ehrlich PF, Friedman DL, Schwartz CL. Monitoring diagnostic accuracy and complications. A report from the Children's Oncology Group Hodgkin lymphoma study. J Pediatr Surg 2007; 42:788-91. [PMID: 17502184 DOI: 10.1016/j.jpedsurg.2006.12.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Cancer studies mandate quality assurance programs for clinical trials. Surgeons consistently play 2 roles early in the management of Hodgkin lymphoma in children and adolescents: obtaining a specimen for pathologic diagnosis and placing a central venous catheter to assist with therapy delivery. A surgical quality assurance program was embedded as part of the of the Hodgkin lymphoma study (AHODOOO31) to assess diagnostic accuracy and complications. METHODS Surgical checklists and operative and pathology reports were reviewed concurrently. Diagnostic technique, success rate, location of biopsy, combined procedures under one anesthetic, and complications are reported. RESULTS One hundred eighty-five cases were reviewed, with 169 having complete data. Diagnostic techniques included open biopsy (n = 148), computed tomography-guided core biopsy (n = 5), thoracoscopic/laparoscopic biopsy (n = 10) and fine-needle aspirations (n = 4). No staging laparotomies were performed. Biopsy sites included cervical (133), mediastinal (18), axillary (7), and others (11). Diagnostic accuracy was 145 of 148 (98.5%) for the open biopsy; 4 of 5, core biopsy (80%); 6 of 10 (60%), thoracoscopic/laparoscopic biopsy; and 1 of 4, fine-needle aspiration (25%). Eighteen had mediastinal disease only, 9 of whom had a thoracoscopic biopsy with a 55% diagnostic accuracy. Inadequate sample was the only reason for a lack of diagnosis. A second open operation was required in these cases for diagnosis. At biopsy, frozen section confirmed a malignancy in 68. In 38 of these 68 children, a central line was placed during the same anesthetic. The most common complication was inadequate sampling. Three wound infections were reported. CONCLUSIONS With an appropriate surgical approach to obtain an adequate tissue specimen, diagnostic accuracy is high and surgical complications are low in children with Hodgkin lymphoma. Diagnostic technique should ensure adequate tissue sampling especially when not using an open procedure. When possible, central line insertion should be performed under the same anesthetic. Fine-needle aspiration was not used enough to assess its role in the diagnosis of children with Hodgkin lymphoma.
Collapse
Affiliation(s)
- Peter F Ehrlich
- Department of Pediatric Surgery and University of Michigan Medical Center, Ann Arbor, MI 48104, USA.
| | | | | |
Collapse
|
12
|
Sittig DF. Potential impact of advanced clinical information technology on cancer care in 2015. Cancer Causes Control 2006; 17:813-20. [PMID: 16783609 DOI: 10.1007/s10552-006-0020-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 02/15/2006] [Indexed: 02/05/2023]
Abstract
New clinical information technologies now sporadically available will soon be in routine clinical use, bringing many changes to all phases of the cancer care continuum. For example, new technologies such as: (1) The next generation Internet; (2) Real-time clinical decision support systems; (3) Off-line, population-based systems; (4) Large, integrated, individual patient-level phenotypic and genotypic databases with intelligent data mining capabilities; (5) Wireless, invasive and non-invasive physiologic monitoring devices; (6) Natural Language Processing (NLP) systems; and (7) Mathematical models of complex biological systems all have the potential to impact significantly the provision of cancer care throughout its continuum. While new information management and communication techniques and technologies will reduce many of the inefficiencies and inaccuracies of our present systems, there will be an equal, and potentially far more dangerous, set of unintended consequences. Informatics investigators, cancer specialists, and health system administrators must focus on the study of what is working and what is not, as well as, on development and testing of the new clinical information management and communication technologies, if we are to be ready for the future.
Collapse
Affiliation(s)
- Dean F Sittig
- Center for Health Research, Northwest Permanente, PC, 3800 N. Interstate Ave. (CHR @ WIN), Portland, OR 97227, USA.
| |
Collapse
|
13
|
Ng AK, Li S, Neuberg D, Fisher DC, McMillan C, Silver B, Marcus KC, Stevenson MA, Mauch PM. Long-term results of a prospective trial of mantle irradiation alone for early-stage Hodgkin's disease. Ann Oncol 2006; 17:1693-7. [PMID: 17018702 DOI: 10.1093/annonc/mdl288] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To determine the long-term treatment outcome and late effects of mantle irradiation alone in selected patients with early-stage Hodgkin's disease. METHODS Between 1988 and 2000, 87 patients with pathologic stage (Ann Arbor) I-IIA or clinical stage IA Hodgkin's disease were entered on to a prospective trial of mantle irradiation alone. Patients with B symptoms, large mediastinal adenopathy, or subcarinal or hilar involvement were excluded. The median doses to the mantle field and mediastinum were 36 Gy (range 30.3-40) and 38.6 Gy (range 30.6-44), respectively. The actuarial freedom from treatment failure (FFTF) and overall survival (OS) rates were calculated using the Kaplan-Meier technique. RESULTS The median follow-up was 107 months (range 23-192). Thirteen of 87 patients (15%) relapsed at a median of 30 months (range 5-62). The 5- and 10-year actuarial FFTF rates were 86% and 84.7%, respectively. All 13 patients who relapsed are alive without evidence of disease at a median of 84 months (range 30-156) post-salvage therapy. Five patients developed a second malignancy at a median of 93 months (range 27-131). The 10-year actuarial risk of a second malignancy was 4.5%. There have been two deaths to date, both due to second malignancies. The 10-year OS rate was 98.2%. CONCLUSION In selected patients with early-stage Hodgkin's disease, mantle irradiation alone has an excellent long-term survival rate, comparing favorably with the previous standard treatment of extended-field radiation therapy and the current standard of combined modality therapy.
Collapse
Affiliation(s)
- A K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Mayer R, Handl-Zeller L, Quehenberger F, Hammer J, Kametriser G, Kolbabek H, Petrova-Schuman K, Raunik W, Rhomberg W, Schratter-Sehn A, Hackl A, Pötter R. Patterns of care in radiotherapy of breast cancer in Austria 1985: data acquisition and comparison with data of US-PCS 1983. Radiother Oncol 2004; 72:45-51. [PMID: 15236873 DOI: 10.1016/j.radonc.2004.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2003] [Revised: 03/26/2004] [Accepted: 04/26/2004] [Indexed: 11/17/2022]
Abstract
PURPOSE In Austria, a Patterns of Care Study (PCS) has been conducted to evaluate the standards of practice for breast cancer patients. The year 1985 was selected in order to establish a base data set. MATERIALS AND METHODS At all nine radiation therapy facilities active in patient treatment in 1985, ten patients charts were randomly selected and reviewed. Evaluation of the radiotherapeutic standards was the principal purpose, however, surgical and histopathological parameters were also considered. RESULTS Results of the Austrian PCS (including 90 patients) were compared with the "1983 Patterns of Care Process Survey for Definitive Breast Irradiation" performed in 1983 in the U.S. (including 191 patients). Documentation of pathologic tumour size (83% vs. 73%), histologic tumour subtype (99% vs. 97%) and microscopic margin analysis (60% vs. 51%) showed comparable results. Technical equipment was obviously quite different in the two countries, cobalt therapy was used in 25% in the US-PCS compared to 71% in the Austrian PCS. A clear difference also was obtained concerning the use of wedges for tangential breast/thoracic wall fields (64% vs. 21%) and the frequency of portal films (93% vs. 26%). CONCLUSIONS Comparing both PCS studies, we found overall many similarities. Differences could be obtained in the quality level of radiation treatment, as for example use of wedges for tangential fields and the number of portal films. In a next step, a further Austrian PCS is planned to compare the Austrian base data from 1985 with quality standards from 1993 and 2001.
Collapse
Affiliation(s)
- Ramona Mayer
- Department of Radiation Oncology, University Medical School of Graz, Auenbruggerplatz 32, A-8036 Graz, Austria
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Eich HT, Staar S, Gossmann A, Hansemann K, Skripnitchenko R, Kocher M, Semrau R, Engert A, Josting A, Franklin J, Krug B, Diehl V, Müller RP. Centralized radiation oncologic review of cross-sectional imaging of Hodgkin's disease leads to significant changes in required involved field-results of a quality assurance program of the German Hodgkin Study Group. Int J Radiat Oncol Biol Phys 2004; 58:1121-7. [PMID: 15001253 DOI: 10.1016/j.ijrobp.2003.08.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2003] [Revised: 08/12/2003] [Accepted: 08/15/2003] [Indexed: 11/25/2022]
Abstract
PURPOSE To guarantee the treatment quality of involved-field radiotherapy (IF-RT) of patients in the Hodgkin's disease (HD)10 and HD11 trials of the German Hodgkin Study Group, with 460 participating study centers, a quality assurance program was conducted. It was based on a central prospective radiation oncologic review of all patients' entire diagnostic imaging and clinical findings. An individual RT prescription was provided for every study patient. The purpose of the present investigation was to assess the feasibility of such a procedure and its impact on the final definition of disease extension and patient treatment. METHODS AND MATERIALS Between 1998 and 2002, 1371 patients were enrolled into the HD10 trial (early-stage disease) and 1570 patients into the HD11 trial (intermediate-stage disease). The HD10 trial tested four cycles of Adriamycin (doxorubicin), bleomycin, vinblastine, and dacarbazine (ABVD) against two cycles of ABVD followed by 20 Gy of IF-RT vs. 30 Gy of IF-RT (four study arms). The HD11 trial compared four cycles of ABVD with four cycles of BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) baseline followed by 20 Gy IF-RT vs. 30 Gy IF-RT in a four-arm design. All study centers were required to score disease involvement at a total of 34 possible anatomic sites on case report forms and send them, together with all diagnostic imaging, to the RT reference center in Cologne, Germany. Images were reviewed there by a panel of expert radiation oncologists and radiologists and compared with the case report form. Differences between the disease involvement documented by the participating center and the reference center were recorded. Subsequently, an individualized treatment proposal was compiled. Complete sets of documentation were submitted to the reference center for 89% of the patients in both HD10 and HD11. RESULTS A considerable proportion of involved sites were incorrectly recorded on the corresponding case report form by the participating center. For patients with early-stage HD (HD10), there was a correction of disease involvement in 49% (593 of 1214 patients) and for patients with intermediate-stage HD (HD11) in 67% (936 of 1397 patients). Most discrepancies were seen in the lower mediastinum (23%), infraclavicular (17%), upper cervical (16%), supraclavicular (13%), and pulmonary hilar region (13%). This resulted in a change of disease stage in 41 of those 1,529 patients whose documented disease involvement had to be corrected (2.7%). Ninety-three patients had to be treated in a different protocol, because of changes in stage and risk factors. Owing to incorrect lymph node documentation of the participating centers, the RT treatment volume had to be enlarged in 891 (34%) and reduced in 82 (3%) of 2,611 patients. CONCLUSION A central prospective review of patient data and consecutive prescription of individual RT treatment volume is feasible within large multicenter trials for HD. Such a procedure has a significant impact on the correctness of stage definition, allocation to treatment groups, and extent of the IF treatment volume.
Collapse
Affiliation(s)
- Hans Theodor Eich
- Department of Radiation Oncology, University of Cologne, Cologne, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Dieckmann K, Pötter R, Hofmann J, Heinzl H, Wagner W, Schellong G. Does bulky disease at diagnosis influence outcome in childhood Hodgkin's disease and require higher radiation doses? Results from the German-Austrian Pediatric Multicenter Trial DAL-HD-90. Int J Radiat Oncol Biol Phys 2003; 56:644-52. [PMID: 12788169 DOI: 10.1016/s0360-3016(03)00125-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The identification of risk factors is required for risk-adapted treatment strategies in the treatment of Hodgkin's disease. To assess the influence of bulky disease at diagnosis as compared with other risk factors on event-free survival (EFS) in pediatric Hodgkin's disease such as stage, B-symptoms, number of involved lymph node regions, histology, and remission status after chemotherapy, we analyzed the outcome of 552 patients treated with a risk-adapted treatment strategy consisting of OPPA(OEPA)/COPP (vincristine, procarbazine, etoposide, prednisone, adriamycin, cyclophosphamide) and involved-field radiotherapy. METHODS AND MATERIALS Between 1990 and 1995, 578 patients with primary Hodgkin's disease (HD) were enrolled in the German/Austrian Pediatric Hodgkin's Disease Study Group (DAL) Multicenter Study (HD-90). Patients were stratified into three treatment groups (TGs) for early, intermediate, and advanced stage. All patients received induction chemotherapy (CT) with two cycles of OEPA for boys and two cycles of OPPA for girls. Patients in TG2 and TG3 received another two or four cycles, respectively, of COPP. Chemotherapy was followed by involved-field radiotherapy. The radiation field, which was prescribed by the study center, was treated with a dose of 25 Gy/25 Gy/20 Gy (TG1/TG2/TG3), and in case of insufficient remission with a local boost of 5 Gy to 10 Gy. The following prognostic factors were analyzed with regard to their impact on EFS: bulky disease, mediastinal tumor, number of involved lymph node regions, histology, treatment group, B-symptoms, sex, age, and remission status after chemotherapy. RESULTS Significant univariate predictive factors for the EES were: nodular sclerosis type 2 (NS2) histology (relative risk [RR] 3.43; p = 0.0002), presence of B-symptoms (RR 2.70; p = 0.0014), number of involved regions (1.55; p = 0.019), and treatment groups (RR 1.33; p = 0.017). There was a higher risk (RR 1.92; p = 0.040) for patients with bulky compared with nonbulky disease (5-year EFS 89.6%/94.6%). In the multiple regression model, only NS2 and B-symptoms remained strong predictive factors. The remission status after chemotherapy did not correlate with EFS (p = 0.66). CONCLUSION Treatment strategies in Hodgkin's disease have an impact on different risk factors. In the risk-adapted treatment strategy of the HD-90 study, tumor burden indicated as bulky disease or as number of involved lymph nodes loses its importance, whereas NS2 histology and B-symptoms have a major impact on treatment outcome. Bulky disease at diagnosis might require higher radiation doses only in case of insufficient remission.
Collapse
Affiliation(s)
- Karin Dieckmann
- Department of Radiotherapy and Radiobiology, University of Vienna, General Hospital Vienna, Vienna, Austria.
| | | | | | | | | | | |
Collapse
|
17
|
Abstract
Although childhood Hodgkin disease is sensitive to the treatment regimens devised for Hodgkin disease in adults, long-term toxicity is enhanced in the developing individual. As a result, there have been dual goals in the design of clinical trials for pediatric Hodgkin disease: 1) to reduce long-term organ injury; and 2) to increase efficacy. Radiation dose and field has been reduced by enhanced reliance on chemotherapy, thus limiting the risks of hypoplasia, hypothyroidism, secondary cancers, and valvular and atherosclerotic heart disease. Multiagent, chemotherapeutic regimens for children have been developed to avoid the risks of sterility, leukemia, and cardiopulmonary toxicity. Newer approaches advocate for early dose intensity to limit cumulative therapy using response-based paradigms. Targeting molecular mechanisms specific for the Reed-Sternberg cell may allow for less toxic and more efficacious treatments in the future.
Collapse
Affiliation(s)
- Cindy L Schwartz
- Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, Maryland 21208, USA.
| |
Collapse
|