Risk-adapted, combined-modality therapy with VAMP/COP and response-based, involved-field radiation for unfavorable pediatric Hodgkin's disease

Outcomes of proton therapy to infradiaphragmatic sites in pediatric patients with Hodgkin lymphoma

BACKGROUND

Proton therapy (PT) has potential advantages in pediatric Hodgkin lymphoma (pHL). However, there are limited data on PT, specifically to infradiaphragmatic targets. We report on PT planning details, doses achieved to organs at risk (OARs), and clinical and toxicity outcomes for patients with pHL who received PT to infradiaphragmatic regions.

METHODS

This is a retrospective study including patients treated between 2011 and 2022. Demographic and clinical factors were collected, and toxicity was reported using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Dosimetric and clinical factors associated with key outcomes were assessed via Cox regression. Photon plans were generated for all patients, and the paired t-tests or Wilcoxon signed rank sum tests were used for dosimetric comparisons.

RESULTS

Twenty-one patients comprising 22 PT courses were included. Median follow-up was 5.0 years, and mean age was 14.2 years. Median dose was 21 Gray equivalent (GyE) over 14 fractions. Top acute grade 1 (G1) toxicities included fatigue (59%) and anorexia (36%). Rates of acute G2 and G3+ toxicity were 18% and 0%, respectively. After PT, no local or marginal failures occurred. Five percent experienced disease progression, who were all successfully salvaged, and all patients were alive and disease-free at last follow-up. No secondary malignancies developed. Compared to photon radiotherapy, PT achieved significantly lower doses to the bowels, stomach, spleen, pancreatic tail, liver, kidneys, and pelvic bones.

CONCLUSIONS

PT is well-tolerated and leads to excellent oncologic and toxicity outcomes with long-term follow-up. PT confers dosimetric advantages when compared to photons.

Response-adapted consolidation therapy strategy for patients with metastatic high-risk neuroblastoma: Results of the SMC NB-2014 study

BACKGROUND

Tandem high-dose chemotherapy and autologous stem cell transplantation (HDCT/auto-SCT) and incorporation of 131I-metaiodobenzylguanidine (131I-MIBG) treatment have shown positive outcomes in high-risk neuroblastoma. However, more optimized treatment strategies are still needed.

PROCEDURE

The NB-2014 study was a nonrandomized, prospective trial that examined survival outcomes in metastatic high-risk neuroblastoma patients using response-adapted consolidation therapy. We used post-induction residual 123I-MIBG status at metastatic sites as a treatment response marker. Patients achieving complete resolution of MIBG uptake at metastatic sites underwent a reduced first HDCT/auto-SCT with a 20% dose reduction in HDCT. After the first HDCT/auto-SCT, patients with remaining MIBG uptake received dose-escalated (18 mCi/kg) 131I-MIBG treatment. In contrast, those with complete resolution of MIBG at metastatic sites received a standard dose (12 mCi/kg) of 131I-MIBG. We compared survival and toxicity outcomes with a historical control group from the NB-2009.

RESULTS

Of 65 patients treated, 63% achieved complete resolution of MIBG uptake at metastatic sites following induction chemotherapy, while 29% of patients still had MIBG uptake at metastatic sites after the first HDCT/auto-SCT. The 3-year event-free survival (EFS) and overall survival (OS) rates were 68.2% ± 6.0% and 86.5% ± 4.5%, respectively. Compared to NB-2009, EFS was similar (p = .855); however, NB-2014 had a higher OS (p = .031), a lower cumulative incidence of treatment-related mortality (p = .036), and fewer acute and late toxicities.

CONCLUSIONS

Our results suggest that response-adaptive consolidation therapy based on chemotherapy response at metastatic sites facilitates better treatment tailoring, and appears promising for patients with metastatic high-risk neuroblastoma.

Significance of E-lesions in Hodgkin lymphoma and the creation of a new consensus definition: a report from SEARCH

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.

"Per protocol" practice patterns for Children's Oncology Group trials within the radiation oncology community

Little is known about the prevalence of pediatric radiation oncologists treating patients off study according to Children's Oncology Group (COG) trials before data are available regarding toxicity and efficacy of novel radiotherapy regimens. We conducted a 12-question survey of 358 pediatric radiation oncologists to characterize practice patterns regarding ongoing and completed COG protocols off study. With 130 responses (40.3%), the prevalence of providing treatment per protocol, but off study, before data are available in abstract or peer-reviewed form varied from 9.1% (for ACNS1422) to 88.1% (for AHOD1331). Future studies are needed to understand the effects of these practice patterns on outcomes.

Relapse localization in Danish pediatric patients with Hodgkin lymphoma

BACKGROUND

Pediatric Hodgkin lymphoma (pHL) is highly curable. However, a minority experience relapse and are subjected to toxic salvage regimens. Investigating the patterns of relapse could help to select the patients and/or the involved sites that would benefit from consolidating radiotherapy.

MATERIAL AND METHODS

The Danish Childhood Cancer Registry was used to identify children <18 years with relapsed pHL from 1990-2018. The lymphoma volumes involved at diagnosis and at relapse were contoured on the patients' original scans. Rigid image co-registration was used to merge the scans enabling a visual assessment of the anatomical relapse localization relative to the initially involved lymph nodes, and if irradiated, to the radiotherapy field.

RESULTS

From 185 patients with pHL, 24 patients with relapse were available for analysis. All patients received combination chemotherapy and seven had consolidating radiotherapy. Relapses exclusively in initially involved sites occurred in 14 patients. Relapses exclusively in new sites were rare and only observed in three irradiated patients. Seven patients relapsed in both initially involved and new sites. The median time to relapse was 6 months (range 2-59 months), however, in-field relapses in irradiated patients occurred later (54 months, range 10-59 months). Neither risk group, initial bulky disease, early response, or metabolic activity seemed to be associated with the site of a later relapse.

CONCLUSION

The number of relapses were small, and conclusions regarding the selection of patients for radiotherapy could not be drawn. Relapse exclusively in initially involved sites were the most common, most often in the exact same initially involved lymph nodes. Hence, modern involved site radiotherapy, focusing on the initially involved lymphoma volume and minimizing the radiation doses to normal tissues, should be applied when consolidating radiotherapy is used in patients with pHL.

Late-onset cardiomyopathy among survivors of childhood lymphoma treated with anthracyclines: a systematic review

Medical advances in pediatric oncology have led to increases in survival but the long-term adverse effects of treatment in childhood cancer survivors have not yet been examined in depth. In this systematic review, we aimed to study the prevalence and risk factors of late-onset cardiomyopathy (LOCM) among survivors of childhood lymphoma treated with anthracyclines. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines we searched Pubmed/Medline, abstracted data and rated studies on quality regarding late-onset (>1 year following treatment) cardiotoxicity of anthracyclines in survivors of childhood lymphoma. Across 22 identified studies, the prevalence of anthracycline-induced LOCM among survivors of childhood lymphoma ranges from 0 to 40%. Anthracycline dose, administration and dose of mediastinal radiation, patient's age and era of diagnosis and evaluation, follow-up duration as well as disease relapse have been reported as risk factors for LOCM, whereas administration of dexrazoxane seems to act protectively. There was significant between-study heterogeneity with regards to lymphoma subtypes, follow-up duration, definition of outcomes, and anthracycline-based treatment protocols. The rates of anthracycline-induced LOCM among survivors of childhood lymphoma are high and dependent on study design. Future studies should explore whether modifying risk factors and suggested supportive care could decrease its prevalence among childhood lymphoma survivors. Until then, lifelong follow-up of these patients aiming to determinate the earliest signs of cardiac dysfunction is the most important measure towards primordial prevention of LOCM.

Long-Term Complications in Hodgkin's Lymphoma Survivors

Background

Although patients with Hodgkin's lymphoma (HL) achieve prolonged survival, long-term complications are a major cause of morbidity and mortality among long-term survivors of HL.

Methods

We retrospectively evaluated long-term complications in 336 HL survivors treated between January 1990 and January 2006 at the Department of Medical Oncology of the Hacettepe University Institute of Oncology who were >16 years old at presentation. All patients were regularly followed up every 3 months for the first 2 years after complete response, biannually for 3 years, and annually after 5 years.

Results

Median follow-up was 8.5 years. The mean age (±SD) of the patients at the time of diagnosis was 35.7 ± 13.1 years. The male to female ratio was 61%/39%. During follow-up, 29 second malignancies (8.6%) were diagnosed in 28 patients with HL; 22 were solid tumors and 7 were hematological malignancies. Forty-seven (14.0%) of all patients with HL were found to have thyroid abnormalities. During follow-up, 54 (16.1%) patients developed cardiovascular complications. Overall, 29 (8.6%) patients developed late pulmonary toxicities. The cumulative number of chronic viral infections was 13 (3.9%).

Conclusions

Long-term survivors of HL need to be properly followed up not only for disease control but also for evaluation of possible late morbidities to minimize the consequences.

Pediatric Hodgkin lymphoma: biomarkers, drugs, and clinical trials for translational science and medicine

Hodgkin lymphoma (HL) is a lymphoid malignancy that is typically derived from germinal-center B cells. EBV infection, mutations in NF-κB pathway genes, and genetic susceptibility are known risk factors for developing HL. CD30 and NF-κB have been identified as potential biomarkers in pediatric HL patients, and these molecules may represent therapeutic targets. Although current risk adapted and response based treatment approaches yield overall survival rates of >95%, treatment of relapse or refractory patients remains challenging. Targeted HL therapy with the antibody-drug conjugate Brentuximab vedotin (Bv) has proven to be superior to conventional salvage chemotherapy and clinical trials are being conducted to incorporate Bv into frontline therapy that substitutes Bv for alkylating agents to minimize secondary malignancies. The appearance of secondary malignancies has been a concern in pediatric HL, as these patients are at highest risk among all childhood cancer survivors. The risk of developing secondary leukemia following childhood HL treatment is 10.4 to 174.8 times greater than the risk in the general pediatric population and the prognosis is significantly poorer than the other hematological malignancies with a mortality rate of nearly 100%. Therefore, identifying clinically valuable biomarkers is of utmost importance to stratify and select patients who may or may not need intensive regimens to maintain optimal balance between maximal survival rates and averting late effects. Here we discuss epidemiology, risk factors, staging, molecular and genetic prognostic biomarkers, treatment for low and high-risk patients, and the late occurrence of secondary malignancies in pediatric HL.

Combined therapy in children and adolescents with classical Hodgkin's lymphoma: A report from the SFCE on MDH-03 national guidelines

Hodgkin's lymphoma (HL) in children and adolescents is highly curable, but children are at risk of long-term toxicity. The MDH-03 guidelines were established in order to decrease the burden of treatment in good-responder patients, and this report should be considered a step toward further optimization of treatment within large collaborative trials. We report the therapy and long-term outcomes of 417 children and adolescents treated according to the national guidelines, which were applied between 2003 and 2007 in France. The patients were stratified into three groups according to disease extension. Chemotherapy consisted of four cycles of VBVP (vinblastine, bleomycin, VP16, prednisone) in localized stages (G1/95 pts/23%), four cycles of COPP/ABV (cyclophosphamide, vincristine, procarbazine, prednisone, adriamycin, bleomycin, vinblastine) cycles in intermediate stages (G2/184 pts/44%) and three cycles of OPPA (vincristine, procarbazine, prednisone, adriamycin) plus three cycles of COPP in advanced stages (G3/138 pts/33%). Radiation therapy of the involved field was given to 97% of the patients, with the dose limited to 20 Gy in good responders (88%). With a median follow-up of 6.6 years, the 5-year event-free survival (EFS) and overall survival (OS) were 86.7% (83.1-89.7%) and 97% (94.5-98.1%), respectively. EFS and OS for G1, G2, and G3 were 98% and 100%, 81% and 97%, and 87% and 95%, respectively. Low-risk patients treated without alkylating agents and anthracycline had excellent outcomes and a low expected incidence of late effects. Intensification with a third OPPA cycle in high-risk group patients, including stage IV patients, allowed for very good outcomes, without increased toxicity.

The evolving role of radiation therapy in pediatric Hodgkin's disease

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.

Pediatric Hodgkin Lymphoma

Hodgkin lymphoma (HL) is one of the most curable pediatric and adult cancers, with long-term survival rates now exceeding 90% after treatment with chemotherapy alone or combined with radiotherapy (RT). Of note, global collaboration in clinical trials within cooperative pediatric HL study groups has resulted in continued progress; however, survivors of pediatric HL are at high risk of potentially life-limiting second cancers and treatment-associated cardiovascular disease. Over the last three decades, all major pediatric and several adult HL study groups have followed the paradigm of response-based treatment adaptation and toxicity sparing through the reduction or elimination of RT and tailoring of chemotherapy. High treatment efficacy is achieved using dose-dense chemotherapy. Refinement and reduction of RT have been implemented on the basis of results from collaborative group studies, such that radiation has been completely eliminated for certain subgroups of patients. Because pediatric staging and response criteria are not uniform, comparing the results of trial series among different pediatric and adult study groups remains difficult; thus, initiatives to harmonize criteria are desperately needed. A dynamic harmonization process is of utmost importance to standardize therapeutic risk stratification and response definitions as well as improve the care of children with HL in resource-restricted environments.

Hodgkin lymphoma in childhood: clinicopathological features and therapy outcome at 2 centers from a developing country

Hodgkin lymphoma (HL) accounts for 5% to 6% of all childhood cancer. It displays characteristic epidemiological, clinical, and pathological features according to various geographic areas. We aimed to assess the epidemiological aspects, clinicopathological features, and treatment outcome of pediatric HL treated at 2 Egyptian centers: Zagazig University Pediatric Oncology Unit and Benha Special Hospital Pediatric Oncology Unit. We carried a cross-sectional retrospective study by reviewing medical records for all patients admitted with the diagnosis of HL over 8 years in 2 oncology units during the period from January 2004 to January 2012. Age of the patients at presentation ranged from 3 to 14 years (median 6 years) and male: female ratio 1.7:1. Lymphadenopathy was the most common presentation (96.6%). Mixed cellularity subtype was dominant (50.8%), followed by nodular sclerosis (28.9%), lymphocyte-rich (18.6%) with lymphocyte depletion being the least dominant (1.7%). More than half of patients (55.9 %) had advanced disease (Ann Arbor stage III/IV disease). The duration of follow-up ranged from 5 to 87 months (mean 39.8 ± 24.1 months). The 5-year overall survival and event-free survival for patients were 96.6% and 84.7% respectively. In Egypt, HL occurs in young age group, with a higher incidence of mixed cellularity subtype and advanced disease. None of the clinical, epidemiological, or pathological characteristics had a significant association with the overall survival. The outcomes of HL in our 2 centers were satisfactory approaching the international percentage.

Stratification of treatment intensity in relapsed pediatric Hodgkin lymphoma

Risk-adapted, response-based therapies for pediatric Hodgkin lymphoma have resulted in 5-year survival exceeding 90%. Although high-dose chemotherapy and autologous hematopoietic stem cell transplantation (AHSCT) are considered standard for most patients with relapsed or refractory Hodgkin lymphoma, a subset of children with low risk relapse do not require AHSCT for cure. Currently there are no widely accepted criteria defining who should receive standard dose chemotherapy and/or radiotherapy, nor is there a standardized treatment regimen. We propose a risk-stratified, response-based algorithm for children with relapsed or refractory Hodgkin lymphoma that is based on a critical appraisal of published outcomes and prognostic factors.

Treatment outcome in children and adolescents with relapsed Hodgkin lymphoma--results of the UK HD3 relapse treatment strategy

The purpose of this national retrospective study was to evaluate the outcome in children with relapsed or primary refractory Hodgkin lymphoma [HL] after a primary chemotherapy alone treatment strategy. Between 2000 and 2005, 80 children with relapsed [n = 69] or primary refractory [n = 11] HL were treated on a standardized treatment protocol of 4-6 cycles of EPIC [etoposide, prednisolone, ifosfamide and cisplatin] chemotherapy. Radiotherapy was recommended to all relapsed sites. High dose therapy with stem cell rescue [SCT] was recommended for patients with poor response. The 5-year overall survival [OS] and progression-free survival from relapse was 75·8% [64·8-83·9] and 59·9% [48·3-69·7] respectively. Duration of first remission was strongly associated with OS; risk of death was decreased by 53% [Hazard ratio (HR): 0·47, 95% confidence interval (CI): 0·19-1·18] for those with a time from end of treatment to relapse of 3-12 months (compared to <3 months) and reduced by 80% (HR 0·20, 95% CI: 0·04-0·90) for those >12 months after end of treatment. Other poor prognostic factors included advanced stage disease at relapse and B symptoms at first diagnosis. The most important factor associated with salvage failure was time to relapse. Survival outcome in children with primary refractory HL is poor.

Relapse after treatment of pediatric Hodgkin lymphoma: outcome and role of surveillance after end of therapy

BACKGROUND

The outcome of treatment for pediatric Hodgkin lymphoma (HL) is excellent using chemotherapy and radiation. However, a minority of patients will relapse after treatment, but additional therapy achieves durable second remission in many cases. The optimal surveillance strategy after modern therapy for HL has not been well defined.

PROCEDURES

We reviewed the outcomes of pediatric patients with HL treated between 1990 and 2006 to determine the primary event that led to the detection of relapse. We determined the probability of relapse detection by routine follow-up procedures, including history, physical examination, laboratory tests, and imaging, and determined the impact of each of these screening methods on the likelihood of survival after relapse.

RESULTS

Relapse occurred in 64 of 402 evaluable patients (15.9%) at a median of 1.7 years from the time of diagnosis. The majority of relapses (60%) were diagnosed at a routine visit, and patient complaint was the most common initial finding that led to a diagnosis of relapse (47% of relapses). An abnormal finding on physical examination was the primary event in another 17% of relapses, and imaging abnormalities led to the diagnosis in the remaining 36%. Laboratory abnormalities were never the primary finding. The method of detection of relapse and timing (whether detected at a routine visit or an extra visit) did not impact survival.

CONCLUSIONS

In pediatric HL, most relapses are identified through history and physical examination. Frequent imaging of asymptomatic patients does not appear to impact survival and is probably not warranted.

Risk-adapted chemotherapy without procarbazine in treatment of children with Hodgkin lymphoma

BACKGROUND

Because procarbazine is not available in the mainland of China, a risk-adapted chemotherapy without the drug was adopted for children with Hodgkin lymphoma (HL) in two tertiary referral centers for childhood cancer in Shanghai. The objective of the present study was to obtain the results comparable with those of previous studies.

METHODS

From January 1998 to December 2009, patients below 18 years with newly diagnosed, untreated HL were enrolled in the study. The patients were stratified into risk groups R1 (early stage), R2 (intermediate stage) and R3 (advanced stage). All the patients who had attained a complete remission were not given involved field radiotherapy.

RESULTS

Fifty-six patients were eligible for the study. The 4-year event-free survival (EFS) rate was 100%, 80.3%±7.2%, and 62.5%±12.1% for the risk groups R1, R2, and R3, respectively. There was statistically significant difference in EFS between patients with and those without B symptoms (P<0.001). In group R2, the EFS rate was higher for patients treated with chemotherapy combined with radiation (100% vs. 75%±8.8%). But no statistical difference was observed (P=0.177). At the time of evaluation (December 31, 2010), secondary malignancy was not observed.

CONCLUSIONS

A significant fraction of children with early stage or intermediate stage HL can be cured with a chemotherapy regimen without procarbazine. Complete response to chemotherapy seems not to be a determinant to omit radiotherapy.

The management of children with lymphomas

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.

Association between radiotherapy vs no radiotherapy based on early response to VAMP chemotherapy and survival among children with favorable-risk Hodgkin lymphoma

CONTEXT

More than 90% of children with favorable-risk Hodgkin lymphoma can achieve long-term survival, yet many will experience toxic effects from radiation therapy. Pediatric oncologists strive for maintaining excellent cure rates while minimizing toxic effects.

OBJECTIVE

To evaluate the efficacy of 4 cycles of vinblastine, Adriamycin (doxorubicin), methotrexate, and prednisone (VAMP) in patients with favorable-risk Hodgkin lymphoma who achieve a complete response after 2 cycles and do not receive radiotherapy.

DESIGN, SETTING, AND PATIENTS

Multi-institutional, unblinded, nonrandomized single group phase 2 clinical trial to assess the need for radiotherapy based on early response to chemotherapy. Eighty-eight eligible patients with Hodgkin lymphoma stage I and II (<3 nodal sites, no B symptoms, mediastinal bulk, or extranodal extension) enrolled between March 3, 2000, and December 9, 2008. Follow-up data are current to March 12, 2012.

INTERVENTIONS

The 47 patients who achieved a complete response after 2 cycles received no radiotherapy, and the 41 with less than a complete response were given 25.5 Gy-involved-field radiotherapy.

MAIN OUTCOME MEASURES

Two-year event-free survival was the primary outcome measure. A 2-year event-free survival of greater than 90% was desired, and 80% was considered to be unacceptably low.

RESULTS

Two-year event-free survival was 90.8% (95% CI, 84.7%-96.9%). For patients who did not require radiotherapy, it was 89.4% (95% CI, 80.8%-98.0%) compared with 92.5% (95% CI, 84.5%-100%) for those who did (P = .61). Most common acute adverse effects were neuropathic pain (2% of patients), nausea or vomiting (3% of patients), neutropenia (32% of cycles), and febrile neutropenia (2% of patients). Nine patients (10%) were hospitalized 11 times (3% of cycles) for febrile neutropenia or nonneutropenic infection. Long-term adverse effects after radiotherapy were asymptomatic compensated hypothyroidism in 9 patients (10%), osteonecrosis and moderate osteopenia in 2 patients each (2%), subclinical pulmonary dysfunction in 12 patients (14%), and asymptomatic left ventricular dysfunction in 4 patients (5%). No second malignant neoplasms were observed.

CONCLUSIONS

Among patients with favorable-risk Hodgkin lymphoma and a complete early response to chemotherapy, the use of limited radiotherapy resulted in a high rate of 2-year event-free survival.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00145600.

Classical Hodgkin's lymphoma arising in different host's conditions: pathobiology parameters, therapeutic options, and outcome

Epidemiologic and molecular findings suggest that classical Hodgkin's lymphoma (CHL) is not a single disease but consists of more than one entity and may occur in different clinical settings. This review analyzes similarities and disparities among CHL entities arising in different host's conditions with respect to pathobiology parameters, therapeutic options, and outcome. For the purpose of this analysis, CHL entities have been subdivided according to the immune status of the host. In nonimmunosuppressed hosts, according to the age, CHL include pediatric, adult, and elderly forms, whereas, in immunosuppressed hosts, according to the type of immunosuppression, CHL include human immunodeficiency virus (HIV)-associated, iatrogenic, and post-transplant types. CHL entities in different settings are similar in morphology of neoplastic cells, expression of activation markers, and aberrations/activation of NFKB, JAK/STAT, and P13K/AKT pathways, but differ in the association with Epstein-Barr virus (EBV) infection, persistent B-cell phenotype, and cellular background composition. Large B-cell lymphomas resembling CHL may also be observed in the same clinical settings. These lesions, however, do not fulfill the diagnostic criteria of CHL and clinically display a very aggressive behavior. In this article, current treatment options for the CHL entities, especially for elderly CHL and HIV-associated CHL, are specifically reviewed. ABVD remains the gold standard both in nonimmunosuppressed or immunosuppressed hosts even if there are several data suggesting a possible improvement in outcome using the aggressive BEACOPP regimen in advanced stages. Refractory CHL, a clinical condition that may occur throughout the entire spectrum of CHL, is discussed separately.

BEACOPP chemotherapy is a highly effective regimen in children and adolescents with high-risk Hodgkin lymphoma: a report from the Children's Oncology Group

Dose-intensified treatment strategies for Hodgkin lymphoma (HL) have demonstrated improvements in cure but may increase risk for acute and long-term toxicities, particularly in children. The Children's Oncology Group assessed the feasibility of a dose-intensive regimen, BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) in children with high-risk HL (stage IIB or IIIB with bulk disease, stage IV). Rapidity of response was assessed after 4 cycles of BEACOPP. Rapid responders received consolidation therapy with guidelines to reduce the risk of sex-specific long-term toxicities of therapy. Females received 4 cycles of COPP/ABV (cyclophosphamide, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, vinblastine) without involved field radiation therapy (IFRT). Males received 2 cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) with IFRT. Slow responders received 4 cycles of BEACOPP and IFRT. Ninety-nine patients were enrolled. Myelosuppression was frequent. Rapid response was achieved by 74% of patients. Five-year event-free-survival is 94%, IFRT with median follow-up of 6.3 years. There were no disease progressions on study therapy. Secondary leukemias occurred in 2 patients. Overall survival is 97%. Early intensification followed by less intense response-based therapy for rapidly responding patients is an effective strategy for achieving high event-free survival in children with high-risk HL. This trial is registered at http://www.clinicaltrials.gov as #NCT00004010.

Initial response to salvage therapy determines prognosis in relapsed pediatric Hodgkin lymphoma patients

BACKGROUND

Pediatric Hodgkin lymphoma (HL) is a highly curable disease; however, prognostic factors for the survival of patients who develop recurrent disease have not been clearly defined.

METHODS

This was a retrospective analysis of 50 pediatric patients with HL who relapsed or progressed between 1990 and 2006 and who were retrieved with intense cytoreductive treatment regimens followed by autologous stem cell transplantation and radiation therapy. A Cox proportional hazards model was used to determine risk factors for second treatment failure and death.

RESULTS

The median patient age was 16.1 years (range, 4.9-22.1 years) at the time of HL diagnosis. Fifteen patients developed progressive disease during therapy, 14 patients relapsed early, and 21 patients relapsed late. Patients who remained alive at the time of this study had been followed for a median of 4.4 years (range, 1.2-16.6 years). The 5-year overall survival rate for patients who had an inadequate response (n = 14) to initial salvage therapy was only 17.9% (95% confidence interval [CI], 3.1%-42.5%) compared with 97.2% (95% CI, 81.9%-99.6%) for patients who responded (n = 36; P < .0001). In a multivariate Cox regression analysis of overall survival, an inadequate response to initial salvage therapy was the only significant variable (hazard ratio, 43.6; 95% CI, 5.4-354; P = .0004).

CONCLUSIONS

The current results indicated that pediatric patients with relapsed HL who have an inadequate response after initial primary salvage chemotherapy have a very poor prognosis and should be considered for novel therapies directed at biologic or immunologic targets.

Utility of bone marrow biopsy at diagnosis in pediatric Hodgkin's lymphoma

BACKGROUND

Bone marrow biopsy is considered essential for the staging and risk-adapted treatment of Hodgkin's lymphoma with unfavorable risk features. We reviewed the cases of pediatric Hodgkin's lymphoma in our institution to determine the impact of bone marrow involvement on treatment, relapse, and survival.

DESIGN AND METHODS

We reviewed the clinical characteristics and outcome of 383 patients treated for Hodgkin's lymphoma at St. Jude Children's Research Hospital between August 1990 and August 2008. The 5-year survival estimates for patients with and without bone marrow involvement were compared.

RESULTS

Of 228 patients who had a bone marrow biopsy at diagnosis, 21 had bone marrow involvement. Bone marrow findings changed the disease stage in only seven patients (3.1%): from IB to IVB (n=1), from IIA (with bulky disease) to IVA (n=1), from IIB to IVB (n=1), and from IIIB to IVB (n=4). One patient's risk assignment changed from intermediate to unfavorable risk without his chemotherapy being altered. No statistically significant difference was observed between patients with stage IV Hodgkin's lymphoma who did (n=21) and did not (n=61) have bone marrow involvement in 5-year relapse-free survival (89.6± 7% versus 73.9±6.1%; P=0.25) or 5-year overall survival (95.2±8.2% versus 87.3±4.9%; P=0.82).

CONCLUSIONS

Although bone marrow involvement changed the stage in 3.1% of pediatric Hodgkin's lymphoma patients, it did not change risk-adapted treatment or prognosis. We conclude that bone marrow biopsy need not be performed at diagnosis in patients who have unfavorable risk features, although this finding should be confirmed by larger prospective studies.

Current approaches to the management of pediatric Hodgkin lymphoma

Hodgkin lymphoma is one of the few cancers that affect both adults and children. Cure rates for Hodgkin lymphoma remain among the best for pediatric cancers. However, cure is often associated with significant delayed effects of therapy, including an elevated risk for second malignancies, cardiotoxicity, pulmonary toxicity, and gonadal and non-gonadal endocrine dysfunction. Therefore, the aim of current treatment strategies is to further improve outcomes while minimizing therapy-related complications. At diagnosis, patients are classified into risk groups based on disease stage, and the presence of clinical, biologic, and serologic risk factors. In general, the most recent trials have intensified therapy in those patients with high-risk disease to improve disease control, and have limited therapy in those patients with low-risk disease to avoid secondary effects. In low-risk patients, multiple studies have been conducted to investigate limiting either radiation therapy or chemotherapy to prevent long-term side effects without affecting the excellent cure rate. In intermediate- and high-risk patients, many studies have examined intensifying therapy to improve event-free survival rates. In addition, response assessment by fluorine-18-2-fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) may be particularly important in pediatric Hodgkin lymphoma; it may allow modification of treatment to maximize treatment efficacy and minimize late effects of chemotherapy and radiation therapy. Despite the improvements in treatment for all stages of Hodgkin lymphoma, there is still a subgroup of patients who do not enter remission with initial therapy or relapse after initial response to therapy. Unfortunately, standard-dose salvage chemotherapy for relapsed disease has disappointing results in terms of overall survival since patients have typically already received intensive therapy. While there is no standard of care in terms of salvage chemotherapy, high-dose chemotherapy with autologous stem cell transplant (ASCT) rescue has become the standard of care for the majority of children with relapsed Hodgkin lymphoma. The use of allogeneic transplantation is controversial in relapsed or refractory Hodgkin lymphoma; because of the high transplant-related mortality, allogeneic transplant has not been associated with improved overall survival over ASCT. As more has been learned about the biologic mechanisms involved in Hodgkin lymphoma, biologically-based therapies are being investigated for use in this disease, both at initial diagnosis and relapse. Both immunotherapy and small molecules are being studied as possible therapeutic agents in Hodgkin lymphoma. Unfortunately, the vast majority of investigations of novel agents have occurred exclusively in adult patients. However, since pediatric Hodgkin lymphoma and adult Hodgkin lymphoma are similar, these results may potentially be extrapolated to pediatric Hodgkin lymphoma.

Hodgkin's Lymphoma in Adolescents Treated With Adult Protocols: A Report From the German Hodgkin Study Group

Purpose

The standard of care for adolescent patients with Hodgkin's lymphoma (HL) is undefined, particularly the choice between pediatric and adult protocols. Thus, we compared risk factors and outcome of adolescents and young adults treated within study protocols of the German Hodgkin Study Group (GHSG).

Patients and Methods

Three thousand seven hundred eighty-five patients treated within the GHSG studies HD4 to HD9 were analyzed; 557 patients were adolescents age 15 to 20 years, and 3,228 patients were young adults age 21 to 45 years.

Results

Large mediastinal mass and involvement of three or more lymph node areas were more frequent in adolescents (P < .001). The incidence of other risk factors did not differ significantly between age groups. With a median observation time of 81 months for freedom from treatment failure (FFTF) and 85 months for overall survival (OS), log-rank test showed no significant differences between age groups regarding FFTF (P = .305) and a superior OS (P = .008) for adolescents. Six-year estimates for FFTF and OS were 80% and 94%, respectively, for adolescents and 80% and 91%, respectively, for young adults. After adjustment for other predictive factors, Cox regression analysis revealed age as a significant predictor for OS (P = .004), with a higher mortality risk for young adults. Secondary malignancies were more common in young adults (P = .037).

Conclusion

Outcome of adolescent and young adult patients treated within GHSG study protocols is comparable. These data suggest that adult treatment protocols exhibit a safe and effective treatment option for adolescent patients with HL. However, longer follow-up, including assessment of late toxicity, is necessary for final conclusions.

A risk-adapted, response-based approach using ABVE-PC for children and adolescents with intermediate- and high-risk Hodgkin lymphoma: the results of P9425

Current treatment strategies for Hodgkin lymphoma result in excellent survival but often confer significant long-term toxicity. We designed ABVE-PC (doxorubicin, bleomycin, vincristine, etoposide, prednisone, cyclophosphamide) to (1) enhance treatment efficacy by dose-dense drug delivery and (2) reduce risk of long-term sequelae by response-based reduction of cumulative chemotherapy. Efficient induction of early response by dose-dense drug delivery supported an early-response-adapted therapeutic paradigm. The 216 eligible patients were younger than 22 years with intermediate- or high-risk Hodgkin lymphoma. ABVE-PC was administered every 21 days. Rapid early responders (RERs) to 3 ABVE-PC cycles received 21 Gy radiation to involved regions; RER was documented in 63% of patients. Slow early responders received 2 additional ABVE-PC cycles before 21 Gy radiation. Five-year event-free-survival was 84%: 86% for the RER and 83% for the slow early responders (P = .85). Only 1% of patients had progressive disease. Five-year overall survival was 95%. With this regimen, cumulative doses of alkylators, anthracyclines, and epipodophyllotoxins are below thresholds usually associated with significant long-term toxicity. ABVE-PC is a dose-dense regimen that provides outstanding event-free survival/overall survival with short duration, early-response-adapted therapy.

Pediatric Hodgkin lymphoma survivors at negligible risk for significant bone mineral density deficits

BACKGROUND

We hypothesized that pediatric Hodgkin lymphoma (HL) survivors would have bone mineral density (BMD) deficits compared to their peers because of osteotoxic chemotherapy during the time of greatest BMD accretion.

METHODS

We retrospectively reviewed records of HL survivors returning for follow-up between 1990 and 2002. Of the 133 eligible survivors, 109 who underwent quantitative computed tomography (QCT) comprised the study group. QCT-determined BMD Z-scores were correlated with patient characteristics and therapeutic exposures by Wilcoxon rank sum or Chi-square tests. Logistic regression models were used to explore risk factors for diminished BMD.

RESULTS

The study cohort was half male (50.5%) and 85.3% reported their race as white. Participants were representative of all survivors potentially eligible for study, except that more study participants were female, had hypothyroidism, and had received cyclophosphamide. Median age at diagnosis was 15.1 years (range, 3.1-20.7 years); median time between diagnosis and QCT was 7.5 years (range, 5.0-12.4 years). The proportion of HL survivors with BMD below the mean did not significantly differ from the general population (P = 0.503). However, those with BMD -1.5 SD and BMD -2.0 SD or lower (14.7% and 7.3%, respectively) exceeded that in the general population (6.7% and 2.3%, respectively; P < 0.001 for both degrees of severity). Males, diagnosed at 14 years or older, were at 6.5 times higher risk than females (OR 95% CI: 1.24-34.14; P = 0.027) for BMD deficits.

CONCLUSIONS

Overall, pediatric HL survivors had negligible BMD deficits. Male gender was associated with an increased risk of developing BMD deficits.

The treatment of childhood Hodgkin lymphoma: improved survival in a developing country

BACKGROUND

To evaluate the clinical characteristics, treatment regimens, and outcome of children with Hodgkin lymphoma in a developing country over a period of 34 years.

METHODS

This paper retrospectively evaluates the treatment and prognosis of 614 children with Hodgkin lymphoma disease between 1971 and 2005. All patients were treated with chemotherapy, and also received radiotherapy.

RESULTS

There were 452 males and 162 females with a median age of 8 years (2 to 21); 183 patients had B symptoms. There were 165, 185, 145, and 119 patients in stage I, II, III, and IV, respectively. Histopathologic subtypes were mixed cellularity (344 patients), nodular sclerosis (90), lymphocytic predominance (62), lymphocytic depletion (46), unclassified types (69), and nodular lymphocyte predominant Hodgkin lymphoma (3). Overall (OS) and event-free survival (EFS) rates were 83 and 60%, though OS rates varied according to chemotherapy protocol; age; presence of B symptoms, leukocytosis, anemia, and extranodal involvement; and stage at diagnosis. Over the years, the median age of patients increased, as did the frequency of the nodular sclerosing type of disease.

CONCLUSIONS

This is one of the largest series in a single center. The increase in the median age and in the frequency of the nodular-sclerosing type are thought to be related to the development status of Turkey. The ABVD protocol yielded the best survival rates and should be used for treatment of patients with Hodgkin lymphoma.

Clinical characteristics and outcome of pediatric patients with stage IV Hodgkin lymphoma

BACKGROUND AND OBJECTIVES:

While treatment outcomes for patients with Hodgkin lymphoma (HL) have improved remarkably, patients with disseminated disease still have a poorer outcome. stage IV HL is often reported with other ‘advanced stage’ categories, confusing the specific contribution of disease dissemination to the outcome. This single-institution report looks at characteristics and outcomes of this specific category.

PATIENTS AND METHODS:

The medical records of pediatric HL patients (<14 years) from 1975 through 2003 were retrospectively reviewed and the data analyzed.

RESULTS:

Stage IV patients (n=67) had more poor-risk characteristics than patients in stages I-III (n=300) (B symptoms 86.6% vs. 19.3%, bulky disease 57.6% vs. 45.5% and mediastinal mass 77.6% vs. 29.7%; P<.001 for all characteristics). The liver was the most common extralymphatic site (in 51.5% of patients with stage IV disease. Stage IV patients received chemotherapy (CT) alone (n=55) or combined modality therapy (CMT) (n=12). Fifty-four patients (80.6%) achieved complete remission, 2 (3%) partial remission, 10 (14.9%) had progressive disease and 1 was lost to follow up. Overall survival was 79.4% and event-free survival (EFS) was 63.9% at 5 years. There was a non-significant benefit for CMT (OS=91.7% v. 77.1%, P=.3; EFS=70.7% v. 62.7%, p=.3). Ten of 12 relapsed and only 1 of 10 progressive disease patients were salvaged. On multivariate analysis, failure to achieve complete remission with CT was associated with a poorer outcome.

CONCLUSION:

Stage IV disease is associated with poor risk features and confers a worse outcome than stage I-III disease. Achievement of complete remission with CT is an important prognostic feature. Slow responders may require novel and/or aggressive therapy to achieve complete remission.

Treatment of pediatric hodgkin lymphoma

OPINION STATEMENT

We are increasingly successful in the treatment of Hodgkin lymphoma. Current risk adapted trials seek to maintain the excellent efficacy of older therapies, while simultaneously limiting their late toxicities. Current management of early stage/favorable disease involves the use of two to four cycles of tailored chemotherapy, often followed by low-dose, involved field radiation. Those with intermediate and advanced stage disease require more intense chemotherapy and radiation regimens. Functional imaging using [(18)F]-2 fluoro-D-2-deoxyglucose is increasingly used to determine complete vs. partial response and to detect relapse. Given the success of primary therapy, retrieval of patients remains a highly individualized challenge. The majority of children failing combined-modality treatment undergo high-dose chemotherapy followed by autologous hematopoietic stem cell rescue, oftentimes with consolidative radiotherapy.

Pericardial involvement at diagnosis in pediatric Hodgkin lymphoma patients

BACKGROUND

Because most cases are clinically silent, the incidence, clinical course, and outcome of pericardial involvement in Hodgkin lymphoma are unknown.

METHODS

Records of all patients with newly diagnosed Hodgkin lymphoma treated at our institution between 1991 and 2004 were reviewed. Pericardial involvement was identified by computerized tomography (CT) as focal thickening or nodularity present at the time of diagnosis, and by echocardiography as pericardial effusion. Outcomes measured were incidence of pericardial involvement, relapse-free survival, and overall survival.

RESULTS

Thirteen of 273 patients (5%) had pericardial involvement. All patients with pericardial involvement had nodular sclerosing tumors versus 183 of 260 patients without pericardial involvement (P = 0.02); 9 (67%) had a bulky mediastinal mass versus 27% (P = 0.002). Two patients required pericardial drainage to drain very large effusions (n = 2). Both patients were symptomatic with either shortness of breath or superior vena cava syndrome. In the 11 cases that did not undergo surgical drainage, the effusion resolved within days after starting chemotherapy. Two patients experienced distant relapse but underwent successful salvage therapy. All 13 patients remain alive and free of disease at a median follow-up of 9.7 years (range, 1.7-12.9 years) with normal cardiac function.

CONCLUSIONS

Pericardial involvement by lymphoma is usually asymptomatic unless accompanied by substantial pericardial effusion. In most cases, pericardial involvement resolves with treatment of the underlying malignancy, but close observation for hemodynamic complications is required. A symptomatic effusion, once treated, does not affect survival.

Comparison of treatment outcomes of childhood Hodgkin lymphoma in two US centers and a center in Recife, Brazil

BACKGROUND

Pediatric Hodgkin lymphoma (HL) has a cure rate of more than 80% in high-income countries (HIC). However, more than 80% of the world's children live in low-income countries (LIC), where the cure rate is often much lower.

PROCEDURE

We compared the outcome of HL of 371 patients treated at two pediatric oncology centers in the US to that of 62 patients treated at one center in Recife, Brazil (IMIP) to determine whether the same treatment strategy should be used in both high-income and LIC. The logrank test was used to compare event-free and overall survival.

RESULTS

The percentages of patients with unfavorable disease at each center were similar (P = 0.72). Patients with favorable disease at IMIP had estimated 5-year survival rates comparable to those of the US centers (100% and 99%, respectively). Among patients with unfavorable disease, those treated at IMIP had a 5-year event-free survival (EFS) rate of 60%, compared to 78% at the US centers; (P = 0.08). The 5-year survival estimate after relapse was 25% at IMIP versus 61% at the US centers (P = 0.08). The 5-year overall survival for patients with unfavorable disease was 72% at IMIP versus 90% at the US centers (P = 0.01).

CONCLUSIONS

Intensive frontline therapy should be considered for patients with unfavorable HL in LIC where the relapse rate is high and the salvage rate is low, provided that supportive care is adequate.

Pediatric Hodgkin Lymphoma: Maximizing Efficacy and Minimizing Toxicity

Historically, both adult and childhood Hodgkin lymphoma (HL) were treated with full-dose (35-45 Gy) extended-field radiation therapy (RT). Although this treatment was the first to produce reliable disease control, the resulting late toxicity led pediatric oncologists to pioneer the use of combined chemotherapy and low-dose (15-25 Gy) involved-field RT for all stages of HL. Currently, standard treatment of childhood HL is risk adapted; those with favorable risk disease typically receive 2 to 4 cycles of multi-agent chemotherapy with low-dose IFRT, whereas those with higher-risk disease receive more intensive chemotherapy before IFRT. This approach produces long-term survival rates >90% while limiting exposure to anthracyclines, alkylators, and radiation to normal tissues. In contrast to adult HL, IFRT remains an important component of the treatment of advanced-stage HL in pediatric patients. Current clinical trials for children with HL aim to further segregate patients into risk strata such that those who are highly curable can receive less toxic therapy, whereas high-risk patients can receive augmented therapy. Response-adapted therapy, in which overall treatment intensity is modified according to the initial response to chemotherapy, is emerging as a potential means of further reducing therapy for some while maintaining high cure rates. The challenge is to refine therapy in a rare disease in which long-time intervals are necessary to observe an adequate number of events (treatment failure or late effects) to answer judicious questions.

Outcome of a risk-related therapeutic strategy used prospectively in a population-based study of Hodgkin's lymphoma in adolescents

The aim was to assess outcome in a population-based cohort of adolescents with Hodgkin's lymphoma (HL) diagnosed in the UK's northern region over a 10-year period. Among a population of 3.09 million, 55 of 676 patients (8%) diagnosed with HL were aged 13–19. Seven had nodular lymphocyte-predominant HL, 48 classical HL (cHL). Of the latter, 36 were ⩾16 years. Application of the Scottish and Newcastle Lymphoma Group (SNLG) prognostic index meant 21 patients were considered high risk (index ⩾0.5). They received PVACEBOP multi-agent chemotherapy as primary therapy. Standard risk patients (SNLG index <0.5) were treated with standard ChlVPP or ABVD chemotherapy±radiotherapy. Scottish and Newcastle Lymphoma Group indexing is not valid for patients under 16. Twelve patients therefore received UKCCSG protocols (n=8), ABVD plus radiotherapy (n=2), or PVACEBOP (n=2). Forty-six patients with cHL (96%) achieved complete remission. Seven patients relapsed but all entered complete remission after salvage therapy. Five patients died: three of HL, one in an accident and one of disseminated varicella complicating cystic fibrosis. Five- and 10-year overall survival was 93 and 86%, respectively; disease-specific survival was 95 and 92%. The data suggest that older adolescents with high-risk HL require intensive protocols as primary therapy to secure optimal outcome.

Comparison of 18F-FDG-PET and standard procedures for the pretreatment staging of children and adolescents with Hodgkin's disease

PURPOSE

The aim of this study was to perform a prospective, blinded comparison of( 18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and conventional staging methods (CSMs) for initial staging of children and adolescents with Hodgkin's disease (HD).

METHODS

Over a period of 4 years, 55 children and adolescents with HD (mean age 15.5 years, range 3.9-18.9 years) were prospectively recruited into the study. They underwent 61 FDG-PET studies using a dedicated whole-body PET scanner as a part of their initial staging work-up. PET findings were correlated with the results of CSMs, including computed tomography (CT), ultrasound, bone scanning and bone marrow examination. Discordant findings were resolved by magnetic resonance imaging or clinical follow-up (range 2-47 months).

RESULTS

PET correctly changed the staging in 15% of patients (seven upstagings, two downstagings). Only two out of 61 patients (3%) were not accurately staged by PET; in these children, PET missed small lymphoma nodules detected on lung CT. The sensitivity of PET and CSMs for pretreatment staging was 96.5% and 87.5%, respectively; specificity was 100% and 60%, and accuracy, 96.7% and 85.2%, respectively. Upon combination of FDG-PET and lung CT, the diagnostic accuracy reached 100% in our series.

CONCLUSION

Our study showed that whole-body FDG-PET is an efficient and useful method for the initial staging of children with HD. FDG-PET in combination with lung CT should be recommended as a screening method prior to other conventional imaging modalities to plan a rational staging protocol. Large multicentre prospective studies are necessary to verify this conclusion.