ChlVPP--an effective and well-tolerated alternative to MOPP therapy for Hodgkin's disease

Treatment Strategies for Advanced Classical Hodgkin Lymphoma in the Times of Dacarbazine Shortage

The shortage of dacarbazine (DTIC) has created an acute and unprecedented crisis in the management of patients with classical Hodgkin lymphoma, with DTIC being an essential component of doxorubicin, bleomycin, vinblastine, and DTIC (ABVD) and prior attempts at omitting DTIC from ABVD leading to substantial loss of efficacy. In this review, we discuss the strategies to manage classical Hodgkin lymphoma during the DTIC shortage and propose a treatment algorithm on the basis of fitness and ability to receive anthracyclines safely.

The emerging role of reactive oxygen species in cancer therapy

The generation of reactive oxygen species (ROS) can be exploited therapeutically in the treatment of cancer. One of the first drugs to be developed that generates ROS was procarbazine. It is oxidised readily in an oxic environment to its azo derivative, generating ROS. Forty years ago, Berneis reported a synergistic effect in DNA degradation when procarbazine was combined with radiation; this was confirmed in preclinical in vivo modes. Early uncontrolled clinical trials suggested an enhancement of the radiation effect with procarbazine, but two randomised trials failed to confirm this. The role of ROS in cancer treatments and in the development of resistance to chemotherapy is now better understood. The possibility of exploiting ROS as a cancer treatment is re-emerging as a promising therapeutic option with the development of agents such as buthionine sulfoximine and motexafin gadolinium.

Hodgkin's disease in elderly patients (> or =60): clinical outcome and treatment strategies

PURPOSE

Older age is an adverse prognostic factor for survival for patients with Hodgkin's disease. This study assessed the outcome of elderly patients (>or=60 years) with Hodgkin's disease treated with curative intent in an attempt to identify the optimal treatment strategies for this group of patients.

METHODS AND MATERIALS

Eighty-six patients, 60-93 years old at the time of diagnosis, were treated for Hodgkin's disease with radical intent between 1969 and 1995. All patients underwent radiographic staging of the chest, abdomen, and pelvis, and 17 patients underwent staging laparotomy. Fifty-two patients had early-stage disease (Stage IA-IIA) and 34 had Stage IIB-IV Hodgkin's disease. The median follow-up time was 75 months (range 24-267) for surviving patients.

RESULTS

The 10-year actuarial freedom from treatment failure (FFTF) rate for all patients was 62%. The 10-year FFTF rate for patients with Stage IA-IIA and Stage IIB-IV disease was 71% and 49%, respectively (p = 0.03). Patients with early-stage disease treated with chemoradiotherapy had a lower crude rate of treatment failure (20%) than patients treated with either chemotherapy alone (33%) or radiotherapy alone (46%). However, no statistically significant difference was found between the treatment groups in terms of actuarial FFTF or overall survival. The 5- and 10-year overall survival rate (all causes) for all patients was 48% and 30%, respectively. The 10-year survival rate for patients with Stage IA-IIA and Stage IIB-IV disease was 31% and 26%, respectively (p = 0.07). On multiple regression analysis, including age, treatment, and stage in the Cox regression model with respect to overall survival, age was a marginally significant factor (p = 0.08). For FFTF, age was not a significant factor in the model (p = 0.11). We analyzed the subsequent outcome of patients who developed a first recurrence after initial treatment; the 5-year survival rate was only 20% after recurrence of Hodgkin's disease. Initial treatment was reasonably well tolerated.

CONCLUSION

Although more patients died of other causes than Hodgkin's disease, the recurrence of Hodgkin's disease had a significant impact on survival. Thus, we favor the use of chemoradiotherapy in early-stage patients >60 years to minimize the risk of relapse.

Current treatment of Hodgkin's disease

In spite of the fact that Hodgkin's disease (HD) remains still an enigma its management and treatment yield a cure rate of about 80% of all patients. However, this management has two limits: on one side favourable cases which should not be overtreated because of unacceptable side-effects, and on the other side very unfavourable cases which should be treated differently because of a very high rate of failure and/or relapse. Then it becomes necessary to precise as thoroughly as possible these two limits in order to choose the adequate treatment for the patient. Prognostic factors based on patient and disease characteristics allow a relatively exact classification of favourable and unfavourable cases. This distinction in two prognostic groups has therapeutic implications in terms of chemotherapy (regimen, duration) and radiotherapy (extension, doses). Other specific situations have to be considered, e.g. pediatric cases, pregnancy, old age and HIV-infected patients who need an adapted management according to very different situations.

Hodgkin's Lymphoma

This review focuses on the different treatment options available for the treatment of Hodgkin's disease, with an emphasis on the importance of the long-term sequelae of these therapies.

In Section I, Dr. Linch reviews the current status of Hodgkin's disease treatment. Survival rates have improved over the last three decades due both to better initial therapies and associated supportive care and to the success of salvage therapy. Unlike most other malignancies, a similar survival endpoint can be achieved by different means, e.g., intensive initial therapy resulting in a low relapse rate or less intensive initial therapy and more reliance on salvage therapy. Overall survival has thus become a difficult end-point for clinical trials of primary therapy, and the value of disease-free survival as an end-point can also be questioned. Quality-of-life issues are to the fore of clinical decision and include the psychological trauma of relapse and fertility status. Patient choice is increasingly important. The high level of success in treating Hodgkin's disease also means that attention must be focused on the very long term results and in this context the occurrence of second malignancies is a major issue.

In Section II, Dr. Gosden with Dr. Tulandi and Dr. Tan review the risks of infertility following radio-therapy and chemotherapy and address the actions that can be taken to overcome this problem, particularly for females and prepubertal boys and girls. Particular attention is paid to the recent developments in ovarian cryopreservation and harvesting immature germ cells.

In Section III, Dr. Hancock gives a comprehensive update of the incidence of secondary acute leukemia, non-Hodgkin's lymphoma and solid tumors in a large population of patients treated for Hodgkin's disease. The roles of radiotherapy, chemotherapy and combined modality treatment as risk factors contributing to the development of these secondary malignancies are reviewed. The importance of efforts to prevent late-occurring solid tumors such as lung cancer through smoking cessation programs and early detection by screening for cancers of the breast, thyroid and skin are emphasized.

Hodgkin's Lymphoma

This review focuses on the different treatment options available for the treatment of Hodgkin's disease, with an emphasis on the importance of the long-term sequelae of these therapies.

In Section I, Dr. Linch reviews the current status of Hodgkin's disease treatment. Survival rates have improved over the last three decades due both to better initial therapies and associated supportive care and to the success of salvage therapy. Unlike most other malignancies, a similar survival endpoint can be achieved by different means, e.g., intensive initial therapy resulting in a low relapse rate or less intensive initial therapy and more reliance on salvage therapy. Overall survival has thus become a difficult end-point for clinical trials of primary therapy, and the value of disease-free survival as an end-point can also be questioned. Quality-of-life issues are to the fore of clinical decision and include the psychological trauma of relapse and fertility status. Patient choice is increasingly important. The high level of success in treating Hodgkin's disease also means that attention must be focused on the very long term results and in this context the occurrence of second malignancies is a major issue.

In Section II, Dr. Gosden with Dr. Tulandi and Dr. Tan review the risks of infertility following radio-therapy and chemotherapy and address the actions that can be taken to overcome this problem, particularly for females and prepubertal boys and girls. Particular attention is paid to the recent developments in ovarian cryopreservation and harvesting immature germ cells.

In Section III, Dr. Hancock gives a comprehensive update of the incidence of secondary acute leukemia, non-Hodgkin's lymphoma and solid tumors in a large population of patients treated for Hodgkin's disease. The roles of radiotherapy, chemotherapy and combined modality treatment as risk factors contributing to the development of these secondary malignancies are reviewed. The importance of efforts to prevent late-occurring solid tumors such as lung cancer through smoking cessation programs and early detection by screening for cancers of the breast, thyroid and skin are emphasized.

Histologic grade does not predict prognosis in optimally treated, advanced-stage nodular sclerosing Hodgkin's disease

Forty-two patients with advanced-stage nodular sclerosing Hodgkin's disease (NSHD) were treated uniformly with combination chemotherapy and radiation therapy at the University of Nebraska Medical Center between 1982 and 1987. The cases were subclassified into low-grade (13 cases) and high-grade (29 cases) categories using the British National Lymphoma Investigation (BNLI) histologic criteria. After a median follow-up interval of 48 months, no significant differences with regard to the complete remission rate (100% versus 90%), remission durability (85% versus 96%), or predicted 4-year actuarial survival (92% versus 86%) were observed between the two groups, respectively. It was concluded that the BNLI grading scheme for NSHD does not predict the clinical outcome of patients with advanced-stage NSHD who receive optimal therapy.