Nonmalignant Complications of Therapy for Hodgkin’s Disease

Hodgkin Lymphoma in Children and Adolescents: Advances in Pathology, Diagnosis, and Treatment Strategies

Strategies used for the treatment of children with Hodgkin lymphoma (HL) over the last four decades have resulted in excellent long-term survivals. However, the short- and long-term treatment-associated morbidities were high. In an attempt to reduce complications, the current treatment strategies apply initial risk stratification principles based on certain host and tumor risk factors to help assign patients to the appropriate risk group and tailor therapy based on response to chemotherapy (CTR). Radiotherapy (RT) was only given to certain groups of patients who show suboptimal response to CTR. Enrollment of patients in clinical trials allowed testing newer treatment strategies, which has improved the outcome significantly. High-dose CTR with stem cell support remains the mainstay of treatment for relapsed and refractory HL. Newer targeted medications are being increasingly used for the treatment of patients with relapsed and refractory HL, but results are variable. In this review report, we give extensive account about the pathophysiology, clinical presentation, histopathological diagnosis, modern investigation techniques, the most recent risk adapted treatment strategies, and the use and effect of novel medications. In addition, we discuss in details the short- and long-term therapy-related complications and future prospects in the management of HL.

Health profiles in 5836 long-term cancer survivors

Increasingly, prolonged survival follows the diagnosis of cancer. Cancer therapies result in complex and lasting health effects that create unique health-care needs for the survivors but are poorly understood (especially in survivors of adult cancers). Cancer survivors were asked to respond to a mailed health survey and provide medical and social information pertaining to their cancer experience. Information about demographics and perceived disease-related medical problems was analyzed. We analyzed the response of 5,836 survivors of adult cancers. Two-thirds of the responses came from women, and the response rate was 51% in both sexes. The mean interval since cancer diagnosis was 18.0 +/- 8.5 years. Younger survivors and men were more likely to report that cancer had affected their health. The health effect most commonly reported by survivors was arthritis/osteoporosis (26% of respondents). Survivors of Hodgkin's disease prominently reported thyroid and lung problems (33.8% of responders with the diagnosis). Prior diagnosis of lymphoma was associated with frequent mention of memory loss (14.7%). The passage of time decreased some perceived effects (memory loss) but increased others (arthritis/osteoporosis, cataracts). Compared with the general population, the incidence of several age- and gender-adjusted health conditions in cancer survivors is different. This group of cancer survivors reported generally good health but outlined multiple lasting medical problems. The health survey described represents 1 approach to the development of comprehensive information about the health needs of cancer survivors.

Effects of cancer treatment on reproduction and fertility

OBJECTIVE

(1) To review the effects of cancer treatment on reproduction and fertility in both women and men and (2) to review current and new techniques that could be used to preserve fertility and hormone production in women who have undergone cancer treatment.

DATA SOURCES

Entries to MEDLINE and CANCERLIT through to October 2001 were searched for evidence relevant to this article.

METHODS OF STUDY SELECTION

This document is primarily based on large retrospective cohort series and case reports, as no randomized trials were available.

TABULATION, INTEGRATION, AND RESULTS

The first part of this review article focuses on the effects of radiation and chemotherapy on reproductive function and innovative medical and surgical techniques employed to minimize these effects. The second part of this article describes conservative methods of managing cervical, endometrial, and ovarian cancer for women who wish to preserve their fertility.

CONCLUSIONS

Over the last decade, there has been a trend toward trying to preserve reproductive function in young patients with malignancy. Information acquired over the last century on the reproductive effects of radiation and chemo-therapy has enabled us to tailor our treatment of various malignancies affecting young patients. As we learn more about the biology and clinical behaviour of gynaecologic malignancies, we are able to modify surgical management to preserve fertility in select cases. All of these trends are in keeping with our goal to optimize quality of life in cancer care without compromising safety or survival.

Treatment of pediatric Hodgkin's disease with chemotherapy alone or combined modality therapy

Optimal treatment for Hodgkin's disease during childhood is unknown. We report the treatment outcome of patients with Hodgkin's disease <13 years of age seen at the American University of Beirut Medical Center (AUBMC) between 1980 and 1996. A retrospective review of the medical records of 24 children treated for HD at AUBMC was performed. Treatment consisted of chemotherapy alone (n = 15) or chemotherapy plus involved field radiotherapy (n = 9). Chemotherapy consisted of COPP, ABVD, or alternating cycles of each for a total of 6 to 12 cycles, depending on clinical and radiological response; three patients received MOPP. Five patients in the chemotherapy group had clinical stage (CS) I and II and 10 had CS III disease. In the combined modality group, eight patients had CS I and II and one had CS IV disease. At a median follow-up of 5 years, the event-free survival (EFS) for the combined modality group was 100% and the overall survival (OS) 100%. For the chemotherapy alone group, the EFS was 56% and the OS was 79%. Four patients (27%) in the chemotherapy alone group who had Stage IIIB disease relapsed. Mean time to relapse was 4.3 years. In our experience, six cycles of COPP or (COPP plus ABVD) alone were suboptimal for the treatment of Stage IIIB Hodgkin's disease patients, especially those with involvement of lower abdominal nodes (III2B), extensive pulmonary disease, or mixed cellularity histology. Radiation therapy or additional chemotherapy courses are required for these patients.

Hodgkin's disease. Diagnostic procedures

The current movement towards "minimal' staging may induce an unexpected movement, calling for "more intensive' treatments. Indeed, some of the changes, such as the renunciation of the staging laparotomy and the lymphangiogram, make the final stage less secure and require reassuring treatments, i.e. more extensive radiotherapy or chemotherapy. This is not surprising when one considers the importance of the information that was brought by the laparotomy and the fact that laparotomy could not be replaced by any other procedure with comparable yield. The use of powerful initial prognostic factors, together with objective biological parameters, either non-specific ones coupled with long-term and adequate testing such as the ESR, albumin, blood counts, or new and promising tests such as for the soluble CD30 antigen, should make up for the loss. In addition, a dynamic approach to the disease, i.e. the repetition at reasonable intervals of initially abnormal biological, functional or imaging tests may provide the most reliable information to ensure the patient's safety.

Late therapy-induced cardiac and pulmonary complications in cured patients with Hodgkin's disease treated with conventional combination chemo-radiotherapy

In recent years, with the advent of modern therapeutic approaches, patients with advanced Hodgkin's disease achieve high cure rates. Accordingly, more attention is now focused upon the late complications of chemotherapy and irradiation, occurring in cured patients many years after successful therapy for HD. In this report, we review the incidence and presentation of some of the cardiovascular and pulmonary complications which may appear in cured patients up to 20 years after therapy.

How relevant is secondary leukaemia for initial treatment selection in Hodgkin's disease?

Specific tools of decision analysis, a set of mathematical rules for simplifying complex decisions, were applied to evaluate the impact of secondary leukaemia on the selection of initial treatment in Hodgkin's disease (HD). For this purpose, a combined 'expected utility' considering survival, relapse free survival, and secondary leukaemia was determined for different treatment strategies. Our analysis revealed that considerations of secondary leukaemia for initial therapy should include the a priori estimation of all possible events which may occur after initial treatment, e.g. the probabilities of recurrence and success of salvage therapy. In early and intermediate stage HD, for example, the minimal risk of leukaemia after successful radiotherapy (RT) must be weighed against the increased risk after treatment failure and subsequent salvage therapy. Thus, the difference of expected risk of leukaemia between RT and combined modality treatment (CMT) is within 4% for HD, stage II B and near to 0% in stage III A. In advanced stage HD, the addition of RT to chemotherapy has no adverse effect on the expected utility of initial treatment. These conclusions are only marginally affected by reported differences in rates of recurrence, salvage success, and secondary leukaemia. Subjective quality of life considerations, such as the latency period between treatment and leukaemia and patients' attitudes towards the occurrence of leukaemia, did not significantly affect expected utilities. In summary, our results strongly suggest that presently there is no sound basis for reducing the intensity of initial treatment in HD to avoid secondary leukaemia.

Hodgkin's disease--I: Identification and classification

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Late cardiovascular and pulmonary complications of therapy in Hodgkin's disease: report of three unusual cases, with a review of relevant literature

With the advent of modern therapeutic approaches, even patients with advanced Hodgkin's disease have high cure rates today. Therefore, more attention is gradually being focused upon the late complications of chemotherapy and irradiation, appearing long after the patient is in remission and thought to be cured. In this report, we review the incidence and presentation of some of the cardiovascular and pulmonary complications which may appear later in the course of the disease. Cardiovascular mishaps reviewed include pericardial manifestations, conduction abnormalities, cardiomyopathy, and premature coronary artery disease. Pulmonary complications discussed are lung fibrosis, spontaneous pneumothorax, pulmonary veno-occlusive disease, and hyperlucent lung. Three instructive cases from our recent experience, are also presented. One fatal case was due to cardiac failure because of radiation-induced pericarditis and coronary artery disease. Another patient with an almost fatal complication required lung transplantation because of severe bilateral radiation fibrosis of the lung and pulmonary veno-occlusive disease. The third instance was also life-threatening in nature, with radiation-induced arterial changes in the major arteries of the chest and neck, resulting in recurrent cerebral and ophthalmic thromboembolic disease. It is suggested that potentially severe cardiopulmonary complications be considered during the planning of the initial and subsequent management of patients with Hodgkin's disease, particularly in an era employing autologous and allogeneic bone marrow transplantation as part of therapy in some cases.

Fertility following cancer therapy

This article reviews the literature relating to fertility following cancer therapy. Normal fertility clearly relies on normal gonadal and normal sexual function. Consideration is given here to the possible effects of surgery, radiotherapy and chemotherapy on fertility. Surgical techniques have now been described which in selected patients may allow normal erectile and ejaculatory function in the male, where previously impotence was inevitable. Maintaining radiation doses to the testes and ovaries to a minimum will reduce the incidence of radiation-induced sterility and may allow recovery of gonadal function. It is clear that cytotoxic chemotherapy does not inevitably result in permanent sterility. Some regimens are more toxic in this respect than others, and reducing the number of courses may improve the chances of retaining fertility. Hormonal manipulations designed to protect the gonad against cytotoxic damage have thus far been unsuccessful in the clinical situation.