The changing management of childhood Hodgkin's disease

Hodgkin's Disease in Children. Pathologic Study of 87 Cases

From 1963 to 1977 at the Istituto Nazionale Tumori at Milan, 112 patients below the age of 16 years with Hodgkin's disease (HD) were observed, representing 13.2 % of all the cases of this disease seen during the stated time interval. Eighty-seven of these cases are the subject of the present study. Fifty-nine patients were males and 28 females (2.1:1 ratio). The age range varied from 2 years 10 months to 15 years 10 months (median 10 years). Forty-three (49.4%) children, of whom 35 were males and 8 females, were below the age of 10 years at the onset of their disease. The clinical staging resulted in 34 patients as stage I, 33 as stage II, 13 as stage III and 7 as stage IV. The histologic type was nodular sclerosis (NS) in 49 cases (56.3 %), lymphocytic predominance (LP) in 15 cases (17.2 %), mixed cellularity (MC) type in 9 cases (10.3 %) and lymphocytic depletion (LD) in 8 cases (9.2 %). In the remaining 6 cases the histologic classification was not applicable. LP type in 15/15 (100 %) patients was associated with stages I and II, and NS in 38/49 (77 %) patients was related to stage I and stage II. The latter was also the istologic type most often encountered in patients with stage II disease (23/33 or 70 %). Eleven patients have died, and their survival varied from 6 to 47 months (median 30 months). The histologic type was LD in 4 cases, NS in 3 cases, MC in 1 case, and LP in 1 case. In the other 2 nonsurvivors, the histologic type was not identifiable. Of the 23 patients with more than a 5-year survival, 14 (60.8 %) had NS HD. As in adults, LP and NS were associated with early stages of the disease and with long survival.

Bilateral Bronchioloalveolar Carcinoma of the Lungs in a 7 Year Old Girl Treated for Hodgkin's Disease

In a 7 year old girl who had previously been given intensive treatment for Hodgkin's disease with numerous courses of multiagent therapy including MVPP (nitrogen mustard, vinblastine, prednisone, procarbazine) and who received radiotherapy in a total dose of 32 Gy to the sternal, and 24 Gy to the cervical (left and right) and axillary (left and right) regions, an autopsy revealed bilateral bronchioloalveolar carcinoma of the lungs.

Hodgkin's disease in the very young

PURPOSE

A retrospective review of patients with Hodgkin's disease treated at Stanford University Medical Center was undertaken to determine if, within the pediatric population, children < or = 10 years of age have a unique prognosis and response to treatment.

METHODS AND MATERIALS

Records of all patients treated for Hodgkin's disease at SUMC between 1961 and 1991 were reviewed.

RESULTS

Of 2238 patients with Hodgkin's disease, 91 (4%) were < or = 10 years of age. There is a predominance of male patients (80%) and a higher percentage of mixed cellularity (33%) and lymphocyte predominance (13%) histologies among the very young patients compared to adolescents and adults. The 5 and 10-year survival is 94 +/- 3% and 92 +/- 3%, respectively, for children < or = 10 vs. 93 +/- 2% and 86 +/- 3% for adolescents and 84 +/- 1% and 73 +/- 1% for adults. Five and 10-year freedom from relapse is also higher in the youngest children (88 +/- 4% and 85 +/- 4%, respectively) compared to adolescents (78 +/- 3% and 74 +/- 3%, respectively) and adults (70 +/- 1% and 67 +/- 1%, respectively). Actuarial survival at 25 years for children < or = 10 years is 78%, which is slightly better than for adolescents (67%) and significantly better than for adults (41%) (p = 0.001). Actuarial 25-year freedom from relapse is also significantly better for children < or = 10 (78%) compared to adolescents (74% [p = 0.05]) and adults (65% [p = 0.001]). For all stages of disease, children < or = 10 fare similarly to or slightly better than adolescents and substantially better than adults. For those with Stage I or II disease, survival at 5, 10, and 25 years is 98 +/- 2%, 93 +/- 4% and 73%, respectively, for children aged < or = 10; 98 +/- 1%, 91 +/- 3%, and 79%, respectively, for adolescents and 89 +/- 1%, 80 +/- 1%, and 45%, respectively, for adults. The greatest difference between age groups is seen for Stage III and IV patients. Those aged < or = 10 have an 89 +/- 5% 5 and 10-year survival, and 89% actuarial 25-year survival compared to 87 +/- 4%, 80 +/- 5%, and 28%, respectively, for adolescents and 77 +/- 2%, 64 +/- 2%, and 41%, respectively, for adults. Of patients < or = 10 years of age, 28 (31%) were treated with primary external beam radiotherapy, and 59 (65%) received combined modality therapy consisting of low-dose radiation and chemotherapy. With a median follow-up of 11 years, freedom from relapse is 64% and survival 75% for the radiotherapy group, compared to 97% (p = 0.000) and 93% (p = 0.21) for those treated with combined modality therapy.

CONCLUSION

Results indicate that young age is a favorable prognostic factor in Hodgkin's disease. Combined modality therapy has led to improved freedom from relapse and survival rates for all stages of disease and is currently the treatment of choice for the majority of very young children.

Hodgkin's disease in children 4 years of age or younger

The natural history of Hodgkin's disease in children younger than 4 years of age is unknown. Thirty-eight patients younger than 4 years of age at the time of diagnosis of Hodgkin's disease were treated at the member institutions of the Pediatric Oncology Group. They were found to be predominantly white and male with early-stage disease. Mixed cellularity and nodular sclerosing histologies were most commonly seen and occurred in equal frequency. They responded to therapy extremely well attaining a complete remission rate of 92% to 94%. Even after relapse, they can be successfully retrieved with salvaging therapy.

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

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

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

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

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

One hundred seventy-eight previously untreated children with biopsy-proven Hodgkin's disease of clinical Stages I and II were treated and followed between 1965 and 1978. Staging laparotomy was performed in 30 patients. Ninety-four percent of the patients obtained a complete remission; 24 patients have died. The actuarial survival rate for all patients was 90% at 5 years, and 81% at 10 years. The disease-free survival rate was 69% at 5 years, and 65% at 10 years. When nitrogen mustard, vincristine, procarbazine, and prednisone (MOPP) chemotherapy was added to either extended field or involved field irradiation, the relapse rate was significantly decreased as compared with the protocols without MOPP and prophylactic para-aortic irradiation. The authors believe that surgical staging may not be necessary as splenic involvement may be treated in some patients by MOPP chemotherapy alone or in association with splenic paraaortic radiotherapy. However, the side effects of MOPP need further study by other chemotherapy programs.

Multiple nevoid basal cell carcinoma syndrome and Hodgkin's disease

A patient with nodular sclerosing Hodgkin's disease and basal cell carcinoma syndrome is reported. Medulloblastoma and ovarian fibromas have already been associated with the syndrome and its coexistence with other malignant neoplasms has been described. The authors report here the first case of Hodgkin's disease with the multiple nevoid basal cell carcinoma syndrome. The fact that the patient's mother also has the syndrome, and the maternal grandfather had Hodgkin's disease seems to indicate more than a chance association of two independent events.

Involved field (IF) irradiation with or without chemotherapy in the management of children with Hodgkin's disease

The present policy at Memorial Sloan Kettering Cancer Center (MSKCC) of treating children with Hodgkin's disease [HD] is as follows: involved field (IF) irradiation only (3,600 rad) for Stages IA and IIA; IF irradiation (2,400 or 2,000 rad) combined with multidrug chemotherapy (MDP) protocol for all other stages. A somewhat higher recurrence rate is accepted for Stages IA and IIA in view of the good salvage rate for these recurrences and in view of side effects of more aggressive types of radiation treatment. One hundred forty-two patients with HD, 2-19 years of age, were treated at MSKCC between 1970 and 1981; 98 of these were treated according to the present policy (SP group), and 44 (NP group) were treated differently. All SP patients underwent staging laparotomy. The follow-up time was 12 to 146 months with a median of 65 months; two patients were lost to follow-up. For the SP group, all stages, 10-year disease-free survival is 77%, and 10-year survival is 93%. By comparison, in the NP group 10-year disease-free survival is 64%, and 10-year survival is 80%. The disease-free survival of SP patients in Stages IA and IIA treated with IF radiation alone is 72%, and survival is 95%. The disease-free survival of SP patients in advanced stages treated with combined radiation and chemotherapy is 87%; the salvage rate of recurrent disease in these stages is poor. The survival was apparently better (P = 0.07) in the SP group as compared to the NP group. All 6 patients of the SP group who died had a nodular sclerosing type of HD. None of the patients in the SP group have developed secondary malignancies, and no severe bone growth retardations or late effects to other organs were observed. In our opinion, IF irradiation alone might at present be suitable treatment for children in Stages IA and IIA of Hodgkin's disease, and addition of IF radiation with low doses of MPD improves the survival of patients in advanced stages.

Hodgkin's disease in children: seventeen years experience at the Instituto Português de Oncologia de Francisco Gentil

The experience of 52 children with Hodgkin's disease was reviewed. Compared with Hodgkin's disease in adults there was an increased incidence among boys. Mixed cellularity (MC) was the most common histologic type (60.5% in boys, and 64.4% in girls) as was also observed in adults (61.1% in men and 63.0% in women). The methods of therapy consisted of three main groups: extended-field radiotherapy (EFRT) + MOPP; involved-field radiotherapy (IVRT) + MOPP, 44.4% for IVRT + Monochemotherapy, and 80% for EFRT alone. The progressive improvement in results was associated with the change from IVRT to EFRT and the introduction of multiagent chemotherapy.

Management of neoplasms of the head and neck in children. II. Malignant tumors

The otolaryngologist who treats children must have knowledge of the neoplasms that can occur in childhood. Such tumors are usually mesenchymal in origin and may be benign or malignant. Diagnosis and management of the more common benign tumors are undertaken by the otolaryngologist because local excision is generally curative. The proper treatment of malignant lesions requires a more extensive, multidisciplinary team, which includes a pediatric oncologist, diagnostic and therapeutic radiologist, and pathologist, in addition to the otolaryngologist. This article outlines the types of malignant neoplasms that occur in childhood and discusses current approaches to therapy.

Skeletal lesions in Hodgkin's disease. Review of literature and case reports

Skeletal lesions in Hodgkin's disease can be due to different underlying causes. Reports on bone changes in Hodgkin's disease are reviewed and compared with two of our patients. The first patient, a fourteen year old girl with Hodgkin's disease, staged IV B, had skeletal involvement at the time of diagnosis. The other patient developed, three and a half years after the onset of the disease, bone lesions which might have been thought to be a manifestation of Hodgkin's disease. But by bacteriologic and histologic studies salmonella osteomyelitis could be proven.

CT scans of long-term survivors of various childhood malignancies

Forty-two children with various systemic malignancies in continuous remission for 1 to 3 years after the completion of chemotherapy had CT scans with normal ventricular dimensions, similar to a noncancer "control" population. Seventeen of these patients had acute lymphocytic leukemia (ALL) treated either with prophylactic cranial irradiation and intrathecal methotrexate [7] or intrathecal methotrexate alone [10] and the remaining 25 patients had soft tissue sarcomas. Sixteen other patients with sarcomatous meningitis had enlarged ventricles while on chemotherapy. Nine had ALL. Seven had soft tissue sarcomas, none of whom received any prior CNS irradiation or intrathecal chemotherapy. In this retrospective study no evidence of hydrocephalus or significant white matter hypodensity was detected in long-term survivors of childhood cancer, regardless of whether prophylactic intrathecal chemotherapy and/or cranial irradiation was given. Direct involvement of the CNS with meningeal cancer was the most important association with ventriculomegaly.

Management of stages I to III Hodgkin disease in children

Thirty-seven children, ages 4 through 16 years, presented with clinical stages I, II, or III Hodgkin disease. In nine (24%) patients, laparotomy and splenectomy resulted in a pathologic stage that varied from the clinical stage. Of 36 patients with pathologic stages I, II, and III, 26 have been followed for more than two years from diagnosis. Pathologic stages I and IIA disease were found in 21 patients, and 19 received radiation therapy alone (usually mantle-field), with 90% disease-free survival and 95% overall survival (median follow-up 46 months). Five patients had stage IIB disease; two had progression of disease while received combined modality therapy. Of ten patients with stage III disease, five have had relapses and five have remained in complete remission. All relapses occurred in patients receiving either irradiation or chemotherapy but not both. This experience supports extended-field irradiation alone as adequate treatment for stages 1 and IIA Hodgkin disease in children, but suggests that for stages IIB and III, single modality treatment is not adequate.

Serum immunoglobulin levels in childhood Hodgkin's disease. Effect of splenectomy and long-term follow-up

Children with Hodgkin's disease had significantly elevated serum IgG and IgA levels but normal IgM and IgD levels when compared with healthy age- and sex-matched controls. The increased serum IgG and IgA levels occurred in all four clinical stages of Hodgkin's disease but were not related to histologic cell type. Following staging splenectomy, serum IgG, IgA, and IgD levels fell by 20% in patients who recieved radiation therapy then returned to preoperative levels; by contrast, serum IgM levels fell by 50% and remained there for at least 36 months. Patients who received chemotherapy had a persistent decline in serum levels of all immunoglobulin classes by at least 40%. Thus, staging splenectomy per se appears to be at least partly responsible for the postoperative decline in serum IgM levels and this effect is enchanced by aggressive treatment of the Hodgkin's disease.

Influenza immunization of children with neoplastic diseases

During the National Influenza Immunization Program in 1976, 147 children with neoplastic diseases received Wyeth split-product bivalent influenza vaccine: A/New Jersey/8/76 (HSW1N1), A/Victoria/3/75 (H3N2). Thirteen normal siblings served as controls. Seventy-one patients received two doses of the vaccine four weeks apart. After the second injection of A/NJ/8/76, there was a difference between the response of the patients on chemotherapy and those off therapy greater than or equal to 30 days--38% vs. 76%, P less than 0.01 for four-fold rise and 26% vs. 57%, P less than 0.05 for the attainment of protective (greater than or equal to 32) hemagglutination inhibition (HI) titers. These differences were observed in both leukemia-lymphoma and solid tumor patients. There was a difference in HI titers to A/Vic/75 between patients on and off chemotherapy after a single injection, 34% vs. 71%, P less than 0.001 for a four-fold rise. After the second immunization, only 52% on, and 86% off therapy (P less than 0.05) had a four-fold rise in titers. Thirty-two percent of the patients on treatment who achieved "protective" titers did so only after the second immunization. Immunoglobulin levels and neutropenia did not correlate with the inability to obtain a four-fold rise in titers. Our findings suggest that patients on chemotherapy cannot be effectively vaccinated by a new antigen, and that single yearly boosters may be insufficient for recall of old antigens. Patients off chemotherapy greater than or equal to 30 days respond as normal controls.

Osteosarcoma and acute myeloblastic leukemia after therapy for childhood Hodgkin disease - a case report

A child diagnosed with Stage IVB Hodgkin disease at nine and one-half years of age subsequently developed osteosarcoma and acute myelogenous leukemia ten years after her initial diagnosis. She received multiple courses of radiotherapy and several single chemotherapeutic agents for her Hodgkin disease. Theraphy-induced multiple malignancies and intrinsic predisposition to carcinogenesis in this case is discussed.

Hodgkin's disease in children: treatment with low dose radiation and MOPP without staging laparotomy: a preliminary report

Twenty-seven children with previously untreated Hodgkin's disease (CS I-2, II-13, III-3, IV-9) were given three cycles of MOPP to induce a remission which was consolidated with extended field radiation (2000--3500 rad) and three cycles of MOPP. Surgical staging was discontinued. Twenty-five of 27 children have not relapsed (range 15+--64+ months; median 39+ months); two children have died, one of uncontrolled Hodgkin's disease and one of acute infection while in complete remission. Actuarial 3 and 5 year survival rates and relapse-free rates are 91%. The merits of this treatment approach are discussed.

MVPP chemotherapy combined with radiotherapy in the treatment of Hodgkin's disease in children

Thirty-four children with Hodgkin's disease were treated during the years 1969--75. After radiotherapy, 7--15 cycles of MVPP were given within 24--53 months. In order to avoid chronic leukopenia, leukocyte counts were made frequently during chemotherapy, and the drug doses adjusted accordingly. A complete remission was obtained in 32 of the 34 children. Two patients died because of progressive disease. Twelve of the 32 survivors have been followed for at least 5 years, and a further 12 for at least 3 years. Three children are still on chemotherapy, whereas the remaining 29 being followed are in continued complete remission.

Hodgkin's disease in children

Fifty-nine children with Hodgkin's disease were seen over a 34-year period. Compared with Hodgkin's disease in adults, there was an increased male incidence, especially in the younger children. This was associated with an increased male incidence of lymphocyte-predominant histology. Forty-six patients underwent lymphography as part of their staging, and 13 had staging laparotomies. The 5-year survival for the entire group was 85%, with a median survival of 10 years. Response to radiotherapy in children with Stages I-IIIA disease was: 12 children treated with involved-field radiotherapy after inadequate clinical staging had a 3-year remission rate of 13%, and a median length of remission of 18 months; 24 children treated with extended-field radiotherapy after adequate clinical staging, including lymphography, had a 3-year remission rate of 72%, and a median duration of remission not yet reached; 3 children treated with elective local radiotherapy for Stage IA disease after intensive clinical staging remain in complete remission for periods of up to 34 months. Eight out of 10 children with Stages IIIB-IV disease, treated with combination chemotherapy, achieved complete remission with a 3-year remission rate of 70%; 7 children treated with combination chemotherapy following relapse after radiotherapy all achieved complete remission with a 3-year complete remission rate of 66%. Thirteen children underwent laparotomy and splenectomy as a staging procedure. Five were found to have intra-abdominal disease, including 4 with splenic involvement. These results show that there is no place for involved-field radiotherapy after inadequate clinical staging, in the management of childhood Hodgkin's disease. Extended-field radiotherapy after adequate staging, and combination chemotherapy, produce results which are as good as those for adults, but the benefits of these treatments and of staging laparotomy must be balanced against the possible complications when they are used in children. These problems are discussed and a scheme of management is proposed.

Involved field radiation therapy for early stage Hodgkin's disease in children: preliminary results

Twenty Stage I and II children with Hodgkin's disease were treated with involved field radiation therapy. Twelve patients were Stage I. The histologic types were:nodular sclerosis(seven cases), mixed cellularity (two) and lymphocyte predominant (three). There were eight Stage II patients (six nodular sclerosis and two of mixed cellularity). One Stage I and 4 Stage II patients had class B disease. Involved field irradiation was used in these children after staging laparotomy showed no disease below the diaphragm. Eight of the 20 patients relapsed, five in lymph nodes adjacent to the primary site, two in areas across the diaphragm; the other had both local and distant extension. The median time to relapse after completion of radiation therapy for Stage I and II were 15 and 5 months, respectively. Two of the eight children with recurrent disease are dead. The other six were retreated and are alive and free of disease for periods ranging from 24 to 68 months after original treatment (median, 36 months). Two of the six survivors in this group received irradiation to the site of the recurrent disease only, one was given total nodal irradiation, and three had chemotherapy. The other 12 patients are in continuous first remission. They have been followed for a median time of 26 months. The actuarial relapse-free survival and survival rates at 3 years are 57 and 89%, respectively.

The multidiscipline team in a cancer center

To surgery, radiation, and chemotherapy for cancer has been added a fourth modality: multidisciplinary therapy, which is improving the survival and cure rate among children. Specialists working together in a coordinated effort suspect, confirm, then treat cancer; follow and rehabilitate the patient; analyze and report results. Prospective protocols for the different cancer types are written. Research discoveries are constantly introduced to refine diagnosis and treatment, minimize morbidity, and improve results. A series of confrontations and agreements concerning each individual patient takes place among representatives from the specialties to review submitted information, select research and diagnostic tests, plan and carry out precisely coordinated treatment and rehabilitation, modify protocols according to patients' tolerance, and categorize response. Personal and single therapeutic modality bias lessens, house staff education is provided, and competent and understanding professionals function in the child's best interest. Documentation of input leading to decisions at serial meetings and of the extent to which they were carried out during each patient's course provides a particular dimension of the case record which is needed by subsequent participants over months and year.