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Baues C, Goergen H, Fuchs M, Rosenbrock J, Celik E, Eich H, Kobe C, Voltin CA, Engert A, Borchmann P, Marnitz S. Involved-Field Radiation Therapy Prevents Recurrences in the Early Stages of Hodgkin Lymphoma in PET-Negative Patients After ABVD Chemotherapy: Relapse Analysis of GHSG Phase 3 HD16 Trial. Int J Radiat Oncol Biol Phys 2021; 111:900-906. [PMID: 34389407 DOI: 10.1016/j.ijrobp.2021.07.1697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE The HD16 trial of the German Hodgkin Study Group (NCT00736320) demonstrated that radiation therapy in early-stage Hodgkin lymphoma without risk factors cannot be safely omitted, and therefore combined modality therapy (CMT) remains the standard treatment. To demonstrate the local effect of consolidating involved-field radiation therapy (IF-RT), we performed an analysis of the recurrence pattern of positron emission tomography (PET)-negative HD16 patients. METHODS AND MATERIALS Between 2009 and 2015, 1150 patients with early-stage Hodgkin lymphoma without risk factors were randomly assigned to PET guided to 20 Gy IF-RT after 2 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy in the HD16 study of the German Hodgkin Study Group. The study was designed as a prospective randomized controlled trial. We correlated the localization of recurrence with the panel-based IF-RT plan, which was drawn up for all patients prospectively, blinded to treatment allocation. Accordingly, we were able to identify recurrences that occurred at least in part inside or outside of the (potential) radiation field (in-field and out-field, respectively). RESULTS There were 328 and 300 PET-negative patients assigned to CMT and PET-guided treatment (ie, chemotherapy alone), respectively. Within a median 47-month follow-up, disease progression or recurrence was documented for 15 and 29 patients treated with and without IF-RT, respectively. Relapse localization was unknown in 1 CMT patient. Without IF-RT, 5-year incidence of in-field relapses was 10.5% (95% confidence interval, 6.5-14.6) compared with 2.4% (0.5-4.3) with CMT (P = .0008). There were no relevant differences in out-field recurrences (5-year incidence 4.1% [1.7-6.6] vs 6.6% [3.0-10.3], P = .54). There was no grade 4 toxicity observed during IF-RT, and incidence of second primary malignancies was similar in both groups. CONCLUSIONS PET-negative patients of the HD16 study showed no significant toxicity after 20 Gy IF-RT, and we demonstrated that omission of IF-RT resulted in more, particularly local, recurrences. Therefore, consolidation IF-RT should still be considered as standard therapy in this setting.
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Affiliation(s)
- Christian Baues
- Department of Radiooncology, Radiotherapy and Cyberknife Center; German Hodgkin Study Group (GHSG).
| | | | - Michael Fuchs
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Johannes Rosenbrock
- Department of Radiooncology, Radiotherapy and Cyberknife Center; German Hodgkin Study Group (GHSG)
| | - Eren Celik
- Department of Radiooncology, Radiotherapy and Cyberknife Center
| | - Hans Eich
- German Hodgkin Study Group (GHSG); Department of Radiotherapy, University Hospital of Muenster, Muenster, Germany
| | - Carsten Kobe
- German Hodgkin Study Group (GHSG); Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Conrad-Amadeus Voltin
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG); Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Simone Marnitz
- Department of Radiooncology, Radiotherapy and Cyberknife Center; German Hodgkin Study Group (GHSG)
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2
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Gerhard-Hartmann E, Goergen H, Bröckelmann PJ, Mottok A, Steinmüller T, Grund J, Zamò A, Ben-Neriah S, Sasse S, Borchmann S, Fuchs M, Borchmann P, Reinke S, Engert A, Veldman J, Diepstra A, Klapper W, Rosenwald A. 9p24.1 alterations and programmed cell death 1 ligand 1 expression in early stage unfavourable classical Hodgkin lymphoma: an analysis from the German Hodgkin Study Group NIVAHL trial. Br J Haematol 2021; 196:116-126. [PMID: 34520052 DOI: 10.1111/bjh.17793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/10/2021] [Indexed: 12/29/2022]
Abstract
High programmed cell death 1 ligand 1 (PD-L1) protein expression and copy number alterations (CNAs) of the corresponding genomic locus 9p24.1 in Hodgkin- and Reed-Sternberg cells (HRSC) have been shown to be associated with favourable response to anti-PD-1 checkpoint inhibition in relapsed/refractory (r/r) classical Hodgkin lymphoma (cHL). In the present study, we investigated baseline 9p24.1 status as well as PD-L1 and major histocompatibility complex (MHC) class I and II protein expression in 82 biopsies from patients with early stage unfavourable cHL treated with anti-PD-1-based first-line treatment in the German Hodgkin Study Group (GHSG) NIVAHL trial (ClinicalTrials.gov Identifier: NCT03004833). All evaluated specimens showed 9p24.1 CNA in HRSC to some extent, but with high intratumoral heterogeneity and an overall smaller range of alterations than reported in advanced-stage or r/r cHL. All but two cases (97%) showed PD-L1 expression by the tumour cells in variable amounts. While MHC-I was rarely expressed in >50% of HRSC, MHC-II expression in >50% of HRSC was found more frequently. No obvious impact of 9p24.1 CNA or PD-L1 and MHC-I/II expression on early response to the highly effective anti-PD-1-based NIVAHL first-line treatment was observed. Further studies evaluating an expanded panel of potential biomarkers are needed to optimally stratify anti-PD-1 first-line cHL treatment.
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Affiliation(s)
- Elena Gerhard-Hartmann
- Institute of Pathology, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Helen Goergen
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
| | - Paul J Bröckelmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany.,Faculty of Medicine and University Hospital of Cologne, Mildred Scheel School of Oncology Aachen Bonn Cologne Düsseldorf (MSSO ABCD), Cologne, Germany
| | - Anja Mottok
- Department of Pathology, University Hospital Gießen and Marburg GmbH, Gießen, Germany
| | - Tabea Steinmüller
- Institute of Pathology, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Johanna Grund
- Hematopathology Section and Lymph Node Registry, Department of Pathology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Alberto Zamò
- Institute of Pathology, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Susana Ben-Neriah
- Department for Lymphoid Cancer Research and Center for Lymphoid Cancer, BC Cancer, Vancouver, BC, Canada
| | - Stephanie Sasse
- Department IV of Internal Medicine, University Hospital of Aachen, University of Aachen, Aachen, Germany
| | - Sven Borchmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
| | - Michael Fuchs
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
| | - Peter Borchmann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
| | - Sarah Reinke
- Hematopathology Section and Lymph Node Registry, Department of Pathology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andreas Engert
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and German Hodgkin Study Group (GHSG), University of Cologne, Cologne, Germany
| | - Johanna Veldman
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Arjan Diepstra
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wolfram Klapper
- Hematopathology Section and Lymph Node Registry, Department of Pathology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andreas Rosenwald
- Institute of Pathology, University of Würzburg, Würzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
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3
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Damaschin C, Goergen H, Kreissl S, Plütschow A, Breywisch F, Mathas S, Meissner J, Sökler M, Topp MS, Vucinic V, Zimmermann A, von Tresckow B, Fuchs M, Engert A, Borchmann P, Eichenauer DA. Brentuximab vedotin-containing escalated BEACOPP variants for newly diagnosed advanced-stage classical Hodgkin lymphoma: follow-up analysis of a randomized phase II study from the German Hodgkin Study Group. Leukemia 2021; 36:580-582. [PMID: 34408266 PMCID: PMC8807388 DOI: 10.1038/s41375-021-01386-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Carla Damaschin
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Helen Goergen
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Stefanie Kreissl
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Annette Plütschow
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Frank Breywisch
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Stephan Mathas
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Max-Delbrück-Center for Molecular Medicine, Berlin, and Experimental and Clinical Research Center (ECRC), Berlin, Germany
| | - Julia Meissner
- Fifth Department of Internal Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Sökler
- Second Department of Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Max S Topp
- Second Department of Internal Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Vladan Vucinic
- Department of Hematology and Cell Therapy, Medical Oncology, Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Andreas Zimmermann
- Department of Internal Medicine III, University Hospital Munich, Munich, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany.,Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Michael Fuchs
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Andreas Engert
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Peter Borchmann
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- First Department of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany. .,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany.
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4
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Eichenauer DA, Bühnen I, Kreissl S, Goergen H, Fuchs M, von Tresckow B, Rosenwald A, Klapper W, Hansmann ML, Möller P, Bernd HW, Feller AC, Engert A, Borchmann P, Hartmann S. Histopathological growth patterns in patients with advanced nodular lymphocyte-predominant Hodgkin lymphoma treated within the randomized HD18 study: a report from the German Hodgkin Study Group. Br J Haematol 2021; 196:99-104. [PMID: 34396513 DOI: 10.1111/bjh.17770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
We retrospectively investigated histopathological growth patterns in individuals with advanced nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) treated within the randomized HD18 study. In all, 35/60 patients (58%) presented with atypical growth patterns. Patients with atypical growth patterns more often had stage IV disease (P = 0·0354) and splenic involvement (P = 0·0048) than patients with typical growth patterns; a positive positron emission tomography after two cycles of chemotherapy (PET-2) tended to be more common (P = 0·1078). Five-year progression-free survival [hazard ratio (HR) = 0·86; 95% confidence interval (CI) = 0·49-1·47] and overall survival (HR = 0·85; 95% CI = 0·49-1·51) did not differ between the groups after study treatment with PET-2-guided escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone). Thus, advanced NLPHL is often associated with atypical growth patterns but their prognostic impact is compensated by PET-2-guided escalated BEACOPP.
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Affiliation(s)
- Dennis A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Ina Bühnen
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Stefanie Kreissl
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Helen Goergen
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Michael Fuchs
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany.,Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Rosenwald
- Institute of Pathology, University of Würzburg and Comprehensive Cancer Center (CCC) Mainfranken, Würzburg, Germany
| | - Wolfram Klapper
- Institute of Pathology, Hematopathology Section and Lymph Node Registry, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Martin-Leo Hansmann
- Dr. Senckenberg Institute of Pathology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Peter Möller
- Institute of Pathology, University Hospital Ulm, Ulm, Germany
| | | | | | - Andreas Engert
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Peter Borchmann
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - Sylvia Hartmann
- Dr. Senckenberg Institute of Pathology, Goethe University Frankfurt, Frankfurt am Main, Germany
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5
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Kreissl S, Goergen H, Buehnen I, Kobe C, Moccia A, Greil R, Eichenauer DA, Zijlstra JM, Markova J, Meissner J, Feuring-Buske M, Soekler M, Beck HJ, Willenbacher W, Ludwig WD, Pabst T, Topp MS, Hitz F, Bentz M, Keller UB, Kühnhardt D, Ostermann H, Hertenstein B, Aulitzky W, Maschmeyer G, Vieler T, Eich H, Baues C, Stein H, Fuchs M, Diehl V, Dietlein M, Engert A, Borchmann P. PET-guided eBEACOPP treatment of advanced-stage Hodgkin lymphoma (HD18): follow-up analysis of an international, open-label, randomised, phase 3 trial. Lancet Haematol 2021; 8:e398-e409. [PMID: 34048679 DOI: 10.1016/s2352-3026(21)00101-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The German Hodgkin Study Group's HD18 trial established the safety and efficacy of PET-guided eBEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone in escalated doses) for the treatment of advanced-stage Hodgkin lymphoma. However, because of a protocol amendment during the enrolment period (June 1, 2011) that changed standard treatment from eight to six cycles, the results of the HD18 trial have been partially immature. We report a prespecified 5-year follow-up analysis of the completed HD18 trial. METHODS HD18 was an international, open-label, randomised, phase 3 trial done in 301 hospitals and private practices in five European countries. Patients aged 18-60 years with newly diagnosed, advanced-stage Hodgkin lymphoma and an Eastern Cooperative Oncology Group performance status of 0-2 were recruited. After receiving an initial two cycles of eBEACOPP (1250 mg/m2 intravenous cyclophosphamide [day 1], 35 mg/m2 intravenous doxorubicin [day 1], 200 mg/m2 intravenous etoposide [day 1-3], 100 mg/m2 oral procarbazine [day 1-7], 40 mg/m2 oral prednisone [day 1-14], 1·4 mg/m2 intravenous vincristine [day 8], and 10 mg/m2 intravenous bleomycin [day 8]), patients underwent a contrast-enhanced CT and PET scan (PET-2). Patients with positive PET-2 were randomly assigned to receive standard therapy (an additional six cycles of eBEACOPP; ie, eight cycles in total) or experimental therapy (an additional six cycles of eBEACOPP plus 375 mg/m2 intravenous rituximab; ie, eight cycles in total) until June 1, 2011. After June 1, 2011, all patients with positive PET-2 were assigned to the updated standard therapy with an additional four cycles of eBEACOPP (ie, six cycles in total). Patients with negative PET-2 were randomly assigned (1:1) to receive standard therapy (an additional six cycles of eBEACOPP [ie, eight cycles in total] until June 1, 2011; an additional four cycles of eBEACOPP [ie, six cycles in total] after June 1, 2011) or experimental therapy (an additional two cycles of eBEACOPP; ie, four cycles in total). Randomisation was done centrally with the minimisation method, including a random component, stratified by centre, age, stage, international prognostic score, and sex. The primary endpoint was progression-free survival. HD18 aimed to improve 5-year progression-free survival by 15% in the PET-2-positive intention-to-treat cohort and to exclude inferiority of 6% or more in 5-year progression-free survival in the PET-2-negative per-protocol population. This study is registered with ClinicalTrials.gov, NCT00515554, and is completed. FINDINGS Between May 14, 2008, and July 18, 2014, 2101 patients were enrolled and 1945 were assigned to a treatment group according to their PET-2 result. In the PET-2-positive cohort, with a median follow-up of 73 months (IQR 59 to 94), 5-year progression-free survival was 89·9% (95% CI 85·7 to 94·1) in 217 patients assigned to eight cycles of eBEACOPP before the protocol amendment and 87·7% (83·1 to 92·4) in 217 patients assigned to eight cycles of rituximab plus eBEACOPP (p=0·40). Among 506 patients who received six cycles of eBEACOPP after the protocol amendment, 5-year progression-free survival was 90·1% (95% CI 87·2 to 92·9), with a median follow-up of 58 months (IQR 39 to 66). In the PET-2-negative cohort, with a median follow-up of 66 months (IQR 54 to 85) in the combined pre-amendment and post-amendment groups, 5-year progression-free survival was 91·2% (95% CI 88·4 to 93·9) in 446 patients who received eight or six cycles of eBEACOPP and 93·0% (90·6 to 95·4) in 474 patients who received four cycles of eBEACOPP (difference 1·9% [95% CI -1·8 to 5·5]). In the subgroup of PET-2-negative patients randomly assigned after protocol amendment, 5-year progression-free survival was 90·9% (95% CI 86·8 to 95·1) in 202 patients assigned to receive six cycles of eBEACOPP and 91·0% (86·6 to 95·5) in 200 patients assigned to receive four cycles of eBEACOPP (difference 0·1% [-5·9 to 6·2]). INTERPRETATION Long-term follow-up confirms the efficacy and safety of PET-2-guided eBEACOPP in patients with advanced-stage Hodgkin lymphoma. The reduction from eight to four cycles of eBEACOPP represents a benchmark in the treatment of early-responding patients, who can now be potentially cured with a short and safe treatment approach. FUNDING Deutsche Krebshilfe, Swiss State Secretariat for Education, Research and Innovation SERI (Switzerland), and Roche Pharma. TRANSLATION For the German translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Stefanie Kreissl
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Ina Buehnen
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Carsten Kobe
- Department of Nuclear Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Alden Moccia
- Department of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - Richard Greil
- IIIrd Medical Department, Paracelsus Medical University and Salzburg Cancer Research Institute, Salzburg, Austria; Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria
| | - Dennis A Eichenauer
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | | | - Jana Markova
- Department of Internal Medicine - Hematology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | | | | | - Wolfgang Willenbacher
- Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; Medical University Innsbruck, Internal Medicine V: Hematology & Oncology, Innsbruck, Austria; Oncotyrol, Center for Personalized Cancer Medicine, Innsbruck, Austria
| | | | - Thomas Pabst
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; Department of Medical Oncology, Inselspital Bern, Bern, Switzerland
| | - Max S Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | | | - Martin Bentz
- Department of Internal Medicine III, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Ulrich Bernd Keller
- Medical Department, Division of Hematology and Oncology at Campus Benjamin Franklin, Berlin, Germany
| | - Dagmar Kühnhardt
- Department of Hematology and Oncology, Charité University of Medicine, Berlin, Germany
| | - Helmut Ostermann
- Department of Hematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Bernd Hertenstein
- Department of Internal Medicine I, Klinikum Bremen Mitte, Bremen, Germany
| | - Walter Aulitzky
- Department of Haematology and Oncology, Robert Bosch Hospital, Stuttgart, Germany
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Tom Vieler
- Karl Lennert-Cancer Center, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hans Eich
- Department of Radiotherapy, University Hospital of Münster, Münster, Germany
| | - Christian Baues
- Department of Radiotherapy, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Harald Stein
- Berlin Reference Center for Lymphoma and Haematopathology, Berlin, Germany
| | - Michael Fuchs
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Markus Dietlein
- Department of Nuclear Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group, Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German Hodgkin Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.
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6
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Eichenauer DA, Kreissl S, Bühnen I, Baues C, Kobe C, van Heek L, Goergen H, Fuchs M, Hartmann S, von Tresckow B, Engert A, Borchmann P. PET-2-guided escalated BEACOPP for advanced nodular lymphocyte-predominant Hodgkin lymphoma: a subgroup analysis of the randomized German Hodgkin Study Group HD18 study. Ann Oncol 2021; 32:807-810. [PMID: 33667668 DOI: 10.1016/j.annonc.2021.02.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- D A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany.
| | - S Kreissl
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - I Bühnen
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - C Baues
- German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany; Department of Radiation Oncology, University of Cologne, Cologne, Germany
| | - C Kobe
- German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany; Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - L van Heek
- German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany; Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - H Goergen
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - M Fuchs
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - S Hartmann
- Senckenberg Institute of Pathology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - B von Tresckow
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany; Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - A Engert
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
| | - P Borchmann
- First Department of Internal Medicine, Center for Integrated Oncology Aachen, Bonn, Cologne and Dusseldorf, University of Cologne, Cologne, Germany; German Hodgkin Study Group (GHSG), University Hospital Cologne, Cologne, Germany
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7
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Eichenauer DA, Müller H, Elger L, Goergen H, Fuchs M, Kreissl S, Böll B, Diehl V, von Tresckow B, Borchmann P, Engert A. Non-Hodgkin lymphoma after treatment for classical Hodgkin lymphoma: a report from the German Hodgkin Study Group. Br J Haematol 2021; 193:515-519. [PMID: 33486762 DOI: 10.1111/bjh.17327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Abstract
Data on non-Hodgkin lymphoma (NHL) after classical Hodgkin lymphoma (cHL) are scarce. We therefore performed a retrospective analysis comprising 11·841 cHL patients who had first-line treatment within the randomized German Hodgkin Study Group (GHSG) HD7-HD15 studies. After a median follow-up of 106 months, 175 patients (1·5%) had developed NHL. The median time to NHL was 44 months, the median age at NHL diagnosis was 54 years. The five-year event-free survival and overall survival estimates from the diagnosis of NHL were 36·9% and 44·2%, respectively. Thus, NHL after cHL is a rare event primarily affecting older individuals and often resulting in the patient´s death.
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Affiliation(s)
- Dennis A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Horst Müller
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Leonard Elger
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Helen Goergen
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Michael Fuchs
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Stefanie Kreissl
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Boris Böll
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany.,Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Peter Borchmann
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Andreas Engert
- First Department of Internal Medicine, Center for Integrated Oncology, Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group (GHSG), First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
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8
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Bröckelmann PJ, Goergen H, Keller U, Meissner J, Ordemann R, Halbsguth TV, Sasse S, Sökler M, Kerkhoff A, Mathas S, Hüttmann A, Bormann M, Zimmermann A, Mettler J, Fuchs M, von Tresckow B, Baues C, Rosenwald A, Klapper W, Kobe C, Borchmann P, Engert A. Efficacy of Nivolumab and AVD in Early-Stage Unfavorable Classic Hodgkin Lymphoma: The Randomized Phase 2 German Hodgkin Study Group NIVAHL Trial. JAMA Oncol 2021; 6:872-880. [PMID: 32352505 DOI: 10.1001/jamaoncol.2020.0750] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance In early-stage unfavorable classic Hodgkin lymphoma (cHL), conventional therapy induces high cure rates but also relevant acute and long-term toxic effects. Nivolumab is well tolerated and highly effective in relapsed/refractory cHL but has not been adequately studied in first-line treatment of early-stage cHL. The NIVAHL trial evaluated nivolumab in this setting with the aim to develop a highly effective yet tolerable systemic therapy to ultimately mitigate morbidity in patients who survive cHL. Objective To evaluate efficacy of 2 experimental nivolumab-based first-line treatment strategies in patients with early-stage unfavorable cHL. Design, Setting, and Participants This was an open-label, multicenter, phase 2 randomized clinical trial, open between April 2017 and October 2018. The trial took place at 35 trial centers across Germany, ranging from academic centers to private offices. Eligibility was defined by age 18 to 60 years, cHL confirmed by expert pathology review, early-stage unfavorable disease by German Hodgkin Study Group criteria (stage I to II with risk factor[s]), and absence of serious concomitant disease or organ dysfunction. Among 110 enrolled patients, 109 were eligible. Interventions Systemic therapy, per random assignment (1:1) to either concomitant treatment with 4 cycles of nivolumab and doxorubicin, vinblastine, and dacarbazine (N-AVD) or sequential treatment with 4 doses of nivolumab, 2 cycles of N-AVD, and 2 cycles of AVD at standard doses, followed by 30-Gy involved-site radiotherapy. Main Outcomes and Measures Complete remission (CR) rate after study treatment, aiming at excluding a CR rate of 80% or lower via a 2-sided 95% CI for each treatment group. Results Of 109 patients included in this study, 65 (59.6%) were women, and the median (range) age was 27 (18-60) years. At interim staging after 2 cycles of N-AVD or 4 doses of nivolumab monotherapy, 54 of 54 (100%) and 49 of 51 (96%) response-eligible patients, respectively, achieved an objective response, with CR in 47 (87%) and 26 (51%) patients, respectively. Among 101 patients eligible for primary end point analysis, 46 of 51 (90%; 95% CI, 79%-97%) patients receiving concomitant therapy and 47 of 50 (94%; 95% CI, 84%-99%) patients receiving sequential therapy achieved CR after study treatment. With a median follow-up of 13 months, 12-month progression-free survival was 100% for patients receiving concomitant treatment and 98% (95% CI, 95%-100%) for patients receiving sequential therapy. Conclusions and Relevance Both strategies combining nivolumab and AVD are feasible and resulted in high remission rates. Despite narrowly missing the efficacy benchmark in the concomitant group, the excellent 12-month progression-free survival and the unexpectedly high CR rate after 4 doses of nivolumab monotherapy warrant further evaluation of this approach in the first-line treatment of patients with early-stage cHL. Trial Registration ClinicalTrials.gov Identifier: NCT03004833.
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Affiliation(s)
- Paul J Bröckelmann
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
| | - Helen Goergen
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
| | - Ulrich Keller
- Klinikum Rechts der Isar der TU München, Internal Medicine III, Munich, Germany
| | - Julia Meissner
- Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Rainer Ordemann
- University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Teresa V Halbsguth
- Division of Hematology/Oncology, Department of Medicine II, Goethe University Hospital Frankfurt, Frankfurt, Germany
| | - Stephanie Sasse
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
| | | | - Andrea Kerkhoff
- Medizinische Klinik A, University Hospital Muenster, Muenster, Germany
| | - Stephan Mathas
- Division of Hematology, Oncology, and Tumor Immunology, Charité-Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
| | - Andreas Hüttmann
- Department of Hematology, University Hospital of Essen, Essen, Germany
| | | | - Andreas Zimmermann
- Department of Medicine III, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jasmin Mettler
- Department of Nuclear Medicine, University Hospital Cologne, Cologne, Germany
| | - Michael Fuchs
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
| | - Bastian von Tresckow
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
| | - Christian Baues
- German Hodgkin Study Group, Cologne, Germany.,Department of Radiooncology and Cyberknife Center, Faculty of Medicine, University Hospital Cologne, University Hospital Cologne, Cologne, Germany
| | | | - Wolfram Klapper
- Department of Hematopathology, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Carsten Kobe
- German Hodgkin Study Group, Cologne, Germany.,Department of Nuclear Medicine, University Hospital Cologne, Cologne, Germany
| | - Peter Borchmann
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
| | - Andreas Engert
- Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University of Cologne, Cologne, Germany.,German Hodgkin Study Group, Cologne, Germany
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Kreissl S, Müller H, Goergen H, Meissner J, Topp M, Sökler M, Markova J, Bernhard J, Greil R, von Tresckow B, Behringer K, Rüffer JU, Flechtner HH, Möstl M, Fuchs M, Engert A, Diehl V, Borchmann P. Health-Related Quality of Life in Patients With Hodgkin Lymphoma: A Longitudinal Analysis of the German Hodgkin Study Group. J Clin Oncol 2020; 38:2839-2848. [PMID: 32574114 DOI: 10.1200/jco.19.03160] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Many important details of health-related quality of life (HRQoL) after diagnosis and treatment of Hodgkin lymphoma (HL) are still unknown because large longitudinal studies of HRQoL are rare. Therefore, we analyzed a systematically assessed, comprehensive range of HRQoL domains in patients with HL of all stages from diagnosis up to 5 years of survivorship. PATIENTS AND METHODS We included patients with HL age 18-60 years at diagnosis from the German Hodgkin Study Group trials HD13, HD14, and HD15. We analyzed HRQoL using all functional and symptom scales of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 including deviations from reference values. We estimated the effect of different disease, patient, and treatment characteristics using multiple regression and repeated measures analysis and computed correlations of HRQoL scores. RESULTS We analyzed 4,215 patients with any HRQoL assessment within 5 years after treatment. Higher tumor burden at diagnosis was associated with impaired baseline scores in many HRQoL domains. During survivorship, cognitive, emotional, role, and social functioning and fatigue, dyspnea, sleep, and financial problems were severely and persistently affected. From year 2 on, mean deviations from reference values ranged between 12 and 29 points, with 10 points being a commonly used margin of clinical relevance. In all 3 trials, HRQoL domains 2 and 5 years after therapy were significantly influenced by baseline scores and age but not by randomized treatments. Fatigue was most closely correlated with other symptoms and scales. CONCLUSION Our results show a high and persistent amount of different HRQoL deficits in survivors of HL that are largely independent of the applied chemotherapies. Our analysis underscores the high, unmet medical need of these rather young survivors of HL regarding the psychosocial adverse effects of the cancer experience.
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Affiliation(s)
- Stefanie Kreissl
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Horst Müller
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | | | - Max Topp
- University Hospital of Würzburg, Würzburg
| | - Martin Sökler
- Hematology Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Jana Markova
- Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jürg Bernhard
- Department of Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Swiss Group for Clinical Cancer Research, Berne, Switzerland
| | - Richard Greil
- Third Medical Department, Paracelsus Medical University, Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria
| | - Bastian von Tresckow
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Karolin Behringer
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | | | - Hans-Henning Flechtner
- Department of Child and Adolescent Psychiatry and Psychotherapy, Otto von Guericke University, Magdeburg, Germany
| | - Michaela Möstl
- Third Medical Department, Hanusch Krankenhaus, Vienna, Austria
| | - Michael Fuchs
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
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Stadtbaeumer N, Müller H, Goergen H, Kreissl S, Borchmann P, Mayer A. The interplay between cancer-related fatigue and functional health in Hodgkin lymphoma survivors. Health Psychol 2020; 39:905-911. [PMID: 32496079 DOI: 10.1037/hea0000921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cancer-related fatigue (CRF) is among the most distressing symptoms reported by cancer survivors as compromising their quality of life. This study investigates the complex interplay between CRF and functional health (FH) in survivors of Hodgkin lymphoma by using longitudinal data to clarify the etiology of CRF. METHODS Data from N = 3596 survivors (HD13-15) from the German Hodgkin Study Group was analyzed using bivariate latent curve models with structured residuals to model how the interplay between CRF and FH unfolds over time across and within individuals. CRF and FH were measured with the EORTC QLQ-C30. Assessed FH domains were physical, cognitive, emotional, social, and role functioning. Age at diagnosis, gender, country, baseline fatigue, and cancer stage were included as covariates. RESULTS The latent curve models with structured residuals had an adequate model fit (χ² = 416.63-548.28, df = 114, p < .001, root mean square error of approximation = .03, comparative fit index = .98-.99, Tucker-Lewis index = .97-.98). On the between-person level, CRF and all FH domains were strongly negatively correlated (r = -.72 to r = -.84). On the within-person level, earlier CRF (ρF = -.05 to ρF = -.12) and FH deviations (ρFH = -.05 to ρFH = -.13) negatively predicted subsequent deviations of the respective other variable. Time-specific within-person improvements in physical, cognitive, and emotional functioning reduced CRF more than vice versa, whereas the effect of CRF was stronger for social functioning. Role functioning had a balanced relation with CRF. CONCLUSIONS This analysis reveals a complex reciprocal relation between CRF and FH with distinct between- and within-person effects. The results contribute to a better understanding of CRF in survivors of Hodgkin lymphoma and could inform the development of much-needed targeted interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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11
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Fuchs M, Goergen H, Kobe C, Borchmann P, Engert A. Reply to H.J.A. Adams et al. J Clin Oncol 2020; 38:1116-1117. [DOI: 10.1200/jco.19.03081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Michael Fuchs
- Michael Fuchs, MD and Helen Goergen, Dipl-Math, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Carsten Kobe, MD, Department of Nuclear Medicine, University of Cologne, Cologne, Germany; and Peter Borchmann, MD, PhD and Andreas Engert, MD, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne,
| | - Helen Goergen
- Michael Fuchs, MD and Helen Goergen, Dipl-Math, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Carsten Kobe, MD, Department of Nuclear Medicine, University of Cologne, Cologne, Germany; and Peter Borchmann, MD, PhD and Andreas Engert, MD, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne,
| | - Carsten Kobe
- Michael Fuchs, MD and Helen Goergen, Dipl-Math, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Carsten Kobe, MD, Department of Nuclear Medicine, University of Cologne, Cologne, Germany; and Peter Borchmann, MD, PhD and Andreas Engert, MD, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne,
| | - Peter Borchmann
- Michael Fuchs, MD and Helen Goergen, Dipl-Math, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Carsten Kobe, MD, Department of Nuclear Medicine, University of Cologne, Cologne, Germany; and Peter Borchmann, MD, PhD and Andreas Engert, MD, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne,
| | - Andreas Engert
- Michael Fuchs, MD and Helen Goergen, Dipl-Math, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Carsten Kobe, MD, Department of Nuclear Medicine, University of Cologne, Cologne, Germany; and Peter Borchmann, MD, PhD and Andreas Engert, MD, German Hodgkin Study Group, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne,
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12
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Voltin CA, Goergen H, Baues C, Fuchs M, Mettler J, Kreissl S, Oertl J, Klaeser B, Moccia A, Drzezga A, Engert A, Borchmann P, Dietlein M, Kobe C. Value of bone marrow biopsy in Hodgkin lymphoma patients staged by FDG PET: results from the German Hodgkin Study Group trials HD16, HD17, and HD18. Ann Oncol 2019; 29:1926-1931. [PMID: 30010775 DOI: 10.1093/annonc/mdy250] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Bone marrow (BM) involvement defines advanced-stage Hodgkin lymphoma and thus has impact on the assignment to treatment. Our aim was to evaluate whether the established BM biopsy may be omitted in patients if 18F-fluorodeoxyglucose positron emission tomography (PET) scanning is carried out during staging. Patients and methods Our analysis set consisted of 832 Hodgkin lymphoma patients from the German Hodgkin Study Group trials HD16, HD17, and HD18 who underwent both PET scanning and BM biopsy before treatment. All PET studies were centrally reviewed and BM was categorized as showing focal involvement or not. Results Taking BM biopsy as reference standard, baseline PET showed a negative predictive value of 99.9% [95% confidence interval (CI) 99.2% to 100%] with true-negative results in 702 of 703 cases. The sensitivity of PET for detecting BM involvement was 95.0% (95% CI 75.1% to 99.9%) as it could identify 19 out of 20 patients with positive BM biopsy. Moreover, PET found 110 additional subjects with focal BM lesions who would have been considered negative by biopsy. Conclusions When compared with BM biopsy, PET was able to detect focal BM lesions in a large number of additional patients. This indicates that conventional BM biopsy may substantially underestimate the actual incidence of BM involvement. Given the high negative predictive value, baseline PET scanning can safely be used to exclude BM involvement in Hodgkin lymphoma. BM biopsy should be considered only in such patients in whom PET-detected lesions lead to a change of treatment protocol. Registered trials The trials included in this analysis were registered at ClinicalTrials.gov: HD16-NCT00736320, HD17-NCT01356680, and HD18-NCT00515554.
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Affiliation(s)
- C-A Voltin
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - H Goergen
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - C Baues
- Departments of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - M Fuchs
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - J Mettler
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - S Kreissl
- Departments of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - J Oertl
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - B Klaeser
- Department of Nuclear Medicine, Inselspital, Bern University Hospital and University of Bern, Bern; Swiss Group for Clinical Cancer Research (SAKK), Bern
| | - A Moccia
- Swiss Group for Clinical Cancer Research (SAKK), Bern; Department of Medical Oncology, Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland
| | - A Drzezga
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - A Engert
- Departments of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - P Borchmann
- Departments of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - M Dietlein
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - C Kobe
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany.
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Kobe C, Goergen H, Fuchs M, Müller H, Baues C, Engert A, Dietlein M, von Tresckow B, Borchmann P. Predictive Value of Positron Emission Tomography/Computed Tomography After ABVD-Based Chemotherapy in Early-Stage Hodgkin Lymphoma. J Clin Oncol 2019; 37:3324-3325. [DOI: 10.1200/jco.19.01761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Carsten Kobe
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Helen Goergen
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Michael Fuchs
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Horst Müller
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Christan Baues
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Andreas Engert
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Markus Dietlein
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Bastian von Tresckow
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
| | - Peter Borchmann
- Carsten Kobe, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Helen Goergen, Dipl-Math, Michael Fuchs, MD, and Horst Müller, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany; Christan Baues, MD, University Hospital of Cologne, University of Cologne, Cologne, Germany; Andreas Engert, MD, German Hodgkin Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of
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Borchmann S, Cirillo M, Goergen H, Meder L, Sasse S, Kreissl S, Bröckelmann PJ, von Tresckow B, Fuchs M, Ullrich RT, Engert A. Pretreatment Vitamin D Deficiency Is Associated With Impaired Progression-Free and Overall Survival in Hodgkin Lymphoma. J Clin Oncol 2019; 37:3528-3537. [PMID: 31622132 DOI: 10.1200/jco.19.00985] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Vitamin D deficiency is described as a modifiable risk factor for the incidence of and mortality in many common cancers; however, data in Hodgkin lymphoma (HL) are lacking. PATIENTS AND METHODS We thus performed a study measuring pretreatment vitamin D levels in prospectively treated patients with HL and correlated this with clinical outcomes. A total of 351 patients from the German Hodgkin Study Group clinical trials (HD7, HD8, and HD9) were included. RESULTS Fifty percent of patients were vitamin D deficient (< 30 nmol/L) before planned chemotherapy. Pretreatment vitamin D deficiency was more common in relapsed/refractory patients than matched relapse-free controls (median baseline vitamin D, 21.4 nmol/L v 35.5 nmol/L; proportion with vitamin D deficiency, 68% v 41%; P < .001). Vitamin D-deficient patients had impaired progression-free survival (10-year difference, 17.6%; 95% CI, 6.9% to 28.4%; hazard ratio, 2.13; 95% CI, 1.84 to 2.48; P < .001) and overall survival (10-year difference, 11.1%; 95% CI, 2.1% to 20.2%; hazard ratio, 1.82; 95% CI, 1.53 to 2.15; P < .001), consistent across trials and treatment groups. We demonstrated that vitamin D status is an independent predictor of outcome and hypothesized that vitamin D status might be important for the chemosensitivity of HL. We subsequently performed experiments supplementing physiologic doses of vitamin D (calcitriol) to cultured HL cell lines and demonstrated increased antiproliferative effects in combination with chemotherapy. In an HL-xenograft animal model, we showed that supplemental vitamin D (dietary supplement, cholecalciferol) improves the chemosensitivity of tumors by reducing the rate of tumor growth compared with vitamin D or chemotherapy alone. CONCLUSION On the basis of our clinical and preclinical findings, we encourage that vitamin D screening and replacement be incorporated into future randomized clinical trials to properly clarify the role of vitamin D replacement therapy in HL.
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Affiliation(s)
- Sven Borchmann
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital of Cologne, Center for Molecular Medicine, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital of Cologne, Else Kröner Forschungskolleg Clonal Evolution in Cancer, Cologne, Germany
| | - Melita Cirillo
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Helen Goergen
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Lydia Meder
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital of Cologne, Center for Molecular Medicine, Cologne, Germany
| | - Stephanie Sasse
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Stefanie Kreissl
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Paul Jan Bröckelmann
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Bastian von Tresckow
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Michael Fuchs
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
| | - Roland Tillmann Ullrich
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany.,University of Cologne, Faculty of Medicine and University Hospital of Cologne, Center for Molecular Medicine, Cologne, Germany
| | - Andreas Engert
- University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Hodgkin Study Group, Cologne, Germany
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Fuchs M, Goergen H, Kobe C, Kuhnert G, Lohri A, Greil R, Sasse S, Topp MS, Schäfer E, Hertenstein B, Soekler M, Vogelhuber M, Zijlstra JM, Keller UB, Krause SW, Wilhelm M, Maschmeyer G, Thiemer J, Dührsen U, Meissner J, Viardot A, Eich H, Baues C, Diehl V, Rosenwald A, von Tresckow B, Dietlein M, Borchmann P, Engert A. Positron Emission Tomography-Guided Treatment in Early-Stage Favorable Hodgkin Lymphoma: Final Results of the International, Randomized Phase III HD16 Trial by the German Hodgkin Study Group. J Clin Oncol 2019; 37:2835-2845. [PMID: 31498753 DOI: 10.1200/jco.19.00964] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Combined-modality treatment (CMT) with 2× ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) and small-field radiotherapy is standard of care for patients with early-stage favorable Hodgkin lymphoma (HL). However, the role of radiotherapy has been challenged. Positron emission tomography (PET) after 2× ABVD (PET-2) might help to predict individual outcomes and guide treatment. METHODS Between November 2009 and December 2015, we recruited patients age 18 to 75 years with newly diagnosed, early-stage favorable HL for this international randomized phase III trial. Patients were assigned to standard CMT of 2× ABVD and 20-Gy involved-field radiotherapy or PET-guided treatment, omitting involved-field radiotherapy after negative PET-2 (Deauville score < 3). Primary objectives were to exclude inferiority of 10% or more in 5-year progression-free survival (PFS) of ABVD alone compared with CMT in a per-protocol analysis among PET-2-negative patients (noninferiority margin for hazard ratio, 3.01) and to confirm PET-2 positivity (Deauville score ≥ 3) as a risk factor for PFS among CMT-treated patients. RESULTS We enrolled 1,150 patients. Median follow-up was 45 months. Among 628 PET-2-negative, per-protocol-treated patients, 5-year PFS was 93.4% (95% CI, 90.4% to 96.5%) with CMT and 86.1% (95% CI, 81.4% to 90.9%) with ABVD (difference 7.3% [95% CI, 1.6% to 13.0%]; hazard ratio, 1.78 [95% CI, 1.02 to 3.12]). Five-year overall survival was 98.1% (95% CI, 96.5% to 99.8%) with CMT and 98.4% (95% CI, 96.5% to 100.0%) with ABVD. Among 693 patients who were assigned to CMT, 5-year PFS was 93.2% (95% CI, 90.2% to 96.2%) among PET-2-negative patients and 88.4% (95% CI, 84.2% to 92.6%) in PET-2-positive patients (P = .047). When using the more common liver cutoff (Deauville score, 4) for PET-2 positivity, the difference was more pronounced (5-year PFS, 93.1% [95% CI, 90.7% to 95.5%] v 80.9% [95% CI, 72.2% to 89.7%]; P = .0011). CONCLUSION In early-stage favorable HL, a positive PET after two cycles ABVD indicates a high risk for treatment failure, particularly when a Deauville score of 4 is used as a cutoff for positivity. In PET-2-negative patients, radiotherapy cannot be omitted from CMT without clinically relevant loss of tumor control.
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Affiliation(s)
- Michael Fuchs
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Carsten Kobe
- Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Georg Kuhnert
- Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Andreas Lohri
- Cantonal Hospital Baselland, Liestal, Switzerland.,Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland
| | - Richard Greil
- IIIrd Medical Department, Paracelcus Medical University and Salzburg Cancer Research Institute, Salzburg, Austria.,Salzburg Cancer Research Institute and AGMT (Arbeitsgemeinschaft Medikamentöse Tumortherapie), Salzburg, Austria
| | - Stephanie Sasse
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Max S Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Erhardt Schäfer
- Dres. med. Just/Düwel/Riesenberg/Steinke/Schäfer, Studiengesellschaft, Bielefeld, Germany
| | - Bernd Hertenstein
- Department of Internal Medicine I, Klinikum Bremen Mitte, Bremen, Germany
| | | | - Martin Vogelhuber
- Medizinische Klinik III, Universitätsklinik Regensburg, Regensburg, Germany
| | - Josée M Zijlstra
- Amsterdam University Medical Center, Vrije Universiteit, Department of Hematology, Amsterdam, Netherlands
| | - Ulrich Bernd Keller
- Department of Internal Medicine III, Klinikum "Rechts der Isar", Munich, Germany
| | - Stefan W Krause
- Department of Internal Medicine 5, Haematology/Oncology, University of Erlangen, Erlangen, Germany
| | - Martin Wilhelm
- Department of Medical Oncology, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Georg Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Julia Thiemer
- Clinic for Hematology, Oncology and Immunology, Philipps University, Marburg, Germany
| | - Ulrich Dührsen
- Department of Haematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Andreas Viardot
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Hans Eich
- Department of Radiotherapy, University Hospital of Muenster, Muenster, Germany
| | - Christian Baues
- Department of Radiotherapy, University of Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Andreas Rosenwald
- Institute of Pathology, Julius Maximilian University of Würzburg and Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Markus Dietlein
- Department of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG), Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
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Baues C, Goergen H, Fuchs M, Kobe C, Dietlein M, Rosenbrock J, Celik E, Eich H, Kriz J, Semrau R, Borchmann P, Engert A, Marnitz S. Consolidating Involved Field Radiotherapy Prevents Early and Local Recurrences in Early Stage Hodgkin Lymphoma. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kreissl S, Goergen H, Müller H, Meissner J, Mehnert A, Bürkle C, Fuchs M, Engert A, Behringer K, Borchmann P. Survivors’ perspectives on risks and benefits of Hodgkin lymphoma treatment: results of a survey by the German Hodgkin Study Group. Leuk Lymphoma 2018; 60:1389-1398. [DOI: 10.1080/10428194.2018.1540781] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Stefanie Kreissl
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Horst Müller
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | | | - Anja Mehnert
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
| | - Carolin Bürkle
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Michael Fuchs
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Karolin Behringer
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
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von Tresckow B, Kreissl S, Goergen H, Bröckelmann PJ, Pabst T, Fridrik M, Rummel M, Jung W, Thiemer J, Sasse S, Bürkle C, Baues C, Diehl V, Engert A, Borchmann P. Intensive treatment strategies in advanced-stage Hodgkin's lymphoma (HD9 and HD12): analysis of long-term survival in two randomised trials. Lancet Haematol 2018; 5:e462-e473. [PMID: 30290903 DOI: 10.1016/s2352-3026(18)30140-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although intensified chemotherapy regimens have improved tumour control and survival in advanced-stage Hodgkin's lymphoma, data on the long-term sequelae are scarce. We did preplanned follow-up analyses of the German Hodgkin Study Group (GHSG) trials HD9 and HD12 to assess whether the primary results of these trials-which had shown that intensive initial therapy in advanced-stage Hodgkin's lymphoma has a beneficial effect on treatment outcomes-would continue with longer follow-up. METHODS In HD9 (Feb 1, 1993, to March 10, 1998), 1282 patients with newly diagnosed, histology-proven, advanced-stage Hodgkin's lymphoma received eight alternating cycles of COPP and ABVD (COPP/ABVD), eight cycles of bBEACOPP, or eight cycles of eBEACOPP. In HD12 (Jan 4, 1999, to Jan 13, 2003; registered with ClinicalTrials.gov [NCT00265031]), 1670 patients with newly diagnosed, histology-proven, advanced-stage Hodgkin's lymphoma received eight cycles of eBEACOPP or four cycles of eBEACOPP plus four cycles of bBEACOPP (4 + 4), plus consolidation radiotherapy to initial bulk and residual disease or no radiotherapy, to analyse two non-inferiority objectives. In both trials, randomisation was done centrally in the GHSG trial coordination centre using the minimisation method including a random component, stratified according to centre, age, stage, international prognostic score, the presence or absence of a large mediastinal mass, and bulky disease. Patients and investigators were not masked to treatment allocation. All analyses were done on the intention-to-treat principle. The primary endpoint of this follow-up analysis was progression-free survival (time from first diagnosis to progressive disease, relapse, or death from any cause or censoring at the date of last information on disease status). To assess whether long-term outcome might be impaired by long-term sequelae, we analysed overall survival and second primary malignant neoplasm incidence as key secondary endpoints. FINDINGS Median observation time was 141 months (IQR 101-204) in HD9 and 97 months (69-143) in HD12. For HD9 trial patients, 15-year progression-free survival was 57·0% (95% CI 50·0-64·0) for COPP/ABVD, 66·8% (61·9-71·8) for bBEACOPP, and 74·0% (69·0-79·0) for eBEACOPP, 15-year overall survival was 72·3% (95% CI 66·5-78·1), 74·5% (70·1-78·9), and 80·9% (76·7-85·0), respectively. Progression-free survival and overall survival in the eBEACOPP group remained significantly better than in the COPP/ABVD group (hazard ratio [HR] 0·53, 95% CI 0·41-0·69, p<0·0001, and 0·68, 0·50-0·93, p=0·015, respectively). The 15-year cumulative incidence of second primary malignant neoplasms was 7·2% (95% CI 3·7-10·7) after COPP/ABVD, 13·0% (9·1-16·9) after bBEACOPP, and 11·4% (7·6-15·1) after eBEACOPP. For HD12 trial patients, non-inferiority of 4 + 4 was shown, with 10-year progression-free survival of 82·6% (95% CI 79·6-85·6) for eBEACOPP and 80·6% (77·4-83·7) for 4 + 4 (HR 1·13 [0·89-1·43], within non-inferiority margin of 1·50), and 10-year overall survival of 87·3% (95% CI 84·7-89·9) and 86·8% (84·2-89·4), respectively (HR 1·02 [95% CI 0·77-1·36]). Among 555 (37%) patients with residual disease after chemotherapy, omission of radiotherapy was associated with significantly worse 10-year progression-free survival (89·7% [95% CI 85·8-93·6] radiotherapy vs 83·4% [78·2-88·5] for no radiotherapy; p=0·027) and 10-year overall survival (94·4% [91·4-97·3] vs 88·4% [83·8-93·0]; p=0·025). 10-year cumulative second primary malignant neoplasms incidence was 6·4% (95% CI 3·3-9·5) for 4 + 4 and 8·8% (5·2-12·4) for eBEACOPP. INTERPRETATION Long-term follow-up of HD9 and HD12 shows an ongoing benefit of intensive first-line treatment and consolidation radiotherapy to residual disease in terms of progression-free survival and overall survival. Our results support the use of eBEACOPP in advanced-stage Hodgkin's lymphoma. However, because late toxicities such as second primary malignant neoplasms contribute to mortality, less toxic but equally effective treatments need to be developed to further improve overall survival. FUNDING Deutsche Krebshilfe e.V.
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Affiliation(s)
- Bastian von Tresckow
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Stefanie Kreissl
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Paul J Bröckelmann
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Thomas Pabst
- Swiss Group for Clinical Cancer Research, Bern, Switzerland; Department of Medical Oncology, University Hospital, Bern, Switzerland
| | - Michael Fridrik
- Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; Department of Internal Medicine III, Kepler Universitätsklinikum, Linz, Austria
| | - Mathias Rummel
- Department of Hematology/Oncology, Klinikum der Justus-Liebig-Universität, Gießen, Germany
| | - Wolfram Jung
- Department of Haematology and Medical Oncology, University Hospital Göttingen, Göttingen, Germany
| | - Julia Thiemer
- Clinic for Hematology, Oncology and Immunology, Philipps University, Marburg, Germany
| | - Stephanie Sasse
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Carolin Bürkle
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Christian Baues
- Department of Radiotherapy, University Hospital of Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany.
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Sasse S, Goergen H, Plütschow A, Böll B, Eichenauer DA, Fuchs M, Behringer K, Zijlstra JM, Greil R, Markova J, Topp MS, Meissner J, Neubauer A, Baues C, Engert A, Borchmann P, von Tresckow B. Outcome of Patients With Early-Stage Infradiaphragmatic Hodgkin Lymphoma: A Comprehensive Analysis From the German Hodgkin Study Group. J Clin Oncol 2018; 36:2603-2611. [PMID: 29989855 DOI: 10.1200/jco.2018.78.7192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The prognostic effect of isolated infradiaphragmatic involvement in Hodgkin lymphoma (HL) is controversial, and there are little data about patients treated with current therapies. Therefore, we performed a risk factor analysis to focus on isolated nodal infradiaphragmatic disease in patients treated within the German Hodgkin Study Group trials HD13 (clinical trial information: ISRCTN63474366) and HD14 (clinical trial information: ISRCTN04761296) for early-stage HL. Patients and Methods Characteristics and outcomes of patients who had infradiaphragmatic HL were compared with patients who had supradiaphragmatic disease. Progression-free survival (PFS) and overall survival (OS) were estimated according to Kaplan-Meier methods and were compared between groups using the log-rank test and Cox proportional hazards regression, which was also applied for multivariable analyses that adjusted for relevant baseline characteristics. Results Of 2,903 qualified patients, 223 (7.7%) were diagnosed with isolated nodal infradiaphragmatic disease. In general, these patients were older, had a poorer performance status, were more often male, and had the nodular sclerosis subtype less often than those with supradiaphragmatic disease. After a median follow-up time of 51 months, PFS and OS were significantly worse in patients with infradiaphragmatic disease (5-year PFS and OS, 80.1% and 91.5% v 91.2% and 97.6% in patients with supradiaphragmatic disease; each P < .001). In multivariable analyses, infradiaphragmatic HL remained a significant risk factor in terms of PFS (hazard ratio [HR], 1.5; 95% CI, 1.04 to 2.2; P = .03) and OS (HR, 2.0; 95% CI, 1.2 to 3.5; P = .01). However, inferior PFS and OS could not be observed among those patients treated with the more intensive chemotherapy (two cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine [ABVD] in HD13, and two cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone [BEACOPPescalated] plus two cycles of ABVD in HD14; all patients received 30 Gy of involved-field radiotherapy). Conclusion Early-stage HL that presents with infradiaphragmatic disease only represents a distinct patient group with an inferior outcome. However, this adverse outcome can be outweighed by appropriate combined modality treatment.
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Affiliation(s)
- Stephanie Sasse
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Helen Goergen
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Annette Plütschow
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Boris Böll
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Dennis A Eichenauer
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michael Fuchs
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Karolin Behringer
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Joseé M Zijlstra
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Richard Greil
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jana Markova
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Max S Topp
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Julia Meissner
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Andreas Neubauer
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Christian Baues
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Andreas Engert
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Peter Borchmann
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Bastian von Tresckow
- Stephanie Sasse, Helen Goergen, Annette Plütschow, Boris Böll, Dennis A. Eichenauer, Michael Fuchs, Karolin Behringer, Christian Baues, Andreas Engert, Peter Borchmann, and Bastian von Tresckow, University Hospital of Cologne, Cologne; Max S. Topp, University Hospital of Würzburg, Würzburg; Julia Meissner, University of Heidelberg, Heidelberg; Andreas Neubauer, Philipps University, Marburg, Germany; Joseé M. Zijlstra, VU University Medical Center, Amsterdam, the Netherlands; Richard Greil, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute and Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria; and Jana Markova, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
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Borchmann P, Goergen H, Kobe C, Lohri A, Greil R, Eichenauer DA, Zijlstra JM, Markova J, Meissner J, Feuring-Buske M, Hüttmann A, Dierlamm J, Soekler M, Beck HJ, Willenbacher W, Ludwig WD, Pabst T, Topp MS, Hitz F, Bentz M, Keller UB, Kühnhardt D, Ostermann H, Schmitz N, Hertenstein B, Aulitzky W, Maschmeyer G, Vieler T, Eich H, Baues C, Stein H, Fuchs M, Kuhnert G, Diehl V, Dietlein M, Engert A. PET-guided treatment in patients with advanced-stage Hodgkin's lymphoma (HD18): final results of an open-label, international, randomised phase 3 trial by the German Hodgkin Study Group. Lancet 2017; 390:2790-2802. [PMID: 29061295 DOI: 10.1016/s0140-6736(17)32134-7] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The intensive polychemotherapy regimen eBEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone in escalated doses) is very active in patients with advanced-stage Hodgkin's lymphoma, albeit at the expense of severe toxicities. Individual patients might be cured with less burdensome therapy. We investigated whether metabolic response determined by PET after two cycles of standard regimen eBEACOPP (PET-2) would allow adaption of treatment intensity, increasing it for PET-2-positive patients and reducing it for PET-2-negative patients. METHODS In this open-label, randomised, parallel-group phase 3 trial, we recruited patients aged 18-60 years with newly diagnosed, advanced-stage Hodgkin's lymphoma in 301 hospitals and private practices in Germany, Switzerland, Austria, the Netherlands, and the Czech Republic. After central review of PET-2, patients were assigned (1:1) to one of two parallel treatment groups on the basis of their PET-2 result. Patients with positive PET-2 were randomised to receive six additional cycles of either standard eBEACOPP (8 × eBEACOPP in total) or eBEACOPP with rituximab (8 × R-eBEACOPP). Those with negative PET-2 were randomised between standard treatment with six additional cycles of eBEACOPP (8 × eBEACOPP) or experimental treatment with two additional cycles (4 × eBEACOPP). A protocol amendment in June, 2011, introduced a reduction of standard therapy to 6 × eBEACOPP; after this point, patients with positive PET-2 were no longer randomised and were all assigned to receive 6 × eBEACOPP and patients with negative PET-2 were randomly assigned to 6 × eBEACOPP (standard) or 4 × eBEACOPP (experimental). Randomisation was done centrally using the minimisation method including a random component, stratified according to centre, age (<45 vs ≥45 years), stage (IIB, IIIA vs IIIB, IV), international prognostic score (0-2 vs 3-7), and sex. eBEACOPP was given as previously described; rituximab was given intravenously at a dose of 375 mg/m2 (maximum total dose 700 mg). The primary objectives were to show superiority of the experimental treatment in the PET-2-positive cohort, and to show non-inferiority of the experimental treatment in the PET-2-negative cohort in terms of the primary endpoint, progression-free survival. We defined non-inferiority as an absolute difference of 6% in the 5-year progression-free survival estimates. Primary analyses in the PET-2-negative cohort were per protocol; all other analyses were by intention to treat. This trial was registered with ClinicalTrials.gov, number NCT00515554. FINDINGS Between May 14, 2008, and July 18, 2014, we recruited 2101 patients, of whom 137 were found ineligible before randomisation and a further 19 were found ineligible after randomisation. Among 434 randomised patients (217 per arm) with positive PET-2, 5-year progression-free survival was 89·7% (95% CI 85·4-94·0) with eBEACOPP and 88·1% (83·5-92·7) with R-eBEACOPP (log-rank p=0·46). Patients with negative PET-2 randomly assigned to either 8 × eBEACOPP or 6 × eBEACOPP (n=504) or 4 × eBEACOPP (n=501) had 5-year progression-free survival of 90·8% (95% CI 87·9-93·7) and 92·2% (89·4-95·0), respectively (difference 1·4%, 95% CI -2·7 to 5·4). 4 × eBEACOPP was associated with fewer severe infections (40 [8%] of 498 vs 75 [15%] of 502) and organ toxicities (38 [8%] of 498 vs 91 [18%] of 502) than were 8 × eBEACOPP or 6 × eBEACOPP in PET-2-negative patients. Ten treatment-related deaths occurred: four in the PET-2-positive cohort (one [<1%] in the 8 × eBEACOPP group, three [1%] in the 8 × R-eBEACOPP group) and six in the PET-2-negative group (six [1%] in the 8 × eBEACOPP or 6 × eBEACOPP group). INTERPRETATION The favourable outcome of patients treated with eBEACOPP could not be improved by adding rituximab after positive PET-2. PET-2 negativity allows reduction to only four cycles of eBEACOPP without loss of tumour control. PET-2-guided eBEACOPP provides outstanding efficacy for all patients and increases overall survival by reducing treatment-related risks for patients with negative PET-2. We recommend this PET-2-guided treatment strategy for patients with advanced-stage Hodgkin's lymphoma. FUNDING Deutsche Krebshilfe, Swiss State Secretariat for Education and Research, and Roche Pharma AG.
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Affiliation(s)
- Peter Borchmann
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany.
| | - Helen Goergen
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Carsten Kobe
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - Andreas Lohri
- Cantonal Hospital Baselland, Liestal, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Richard Greil
- IIIrd Medical Department, Paracelcus Medical University and Salzburg Cancer Research Institute, Salzburg, Austria; Salzburg Cancer Research Institute and AGMT (Arbeitsgemeinschaft Medikamentöse Tumortherapie), Salzburg, Austria
| | - Dennis A Eichenauer
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | | | - Jana Markova
- Department of Internal Medicine-Hematology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Julia Meissner
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | | | - Andreas Hüttmann
- Department of Haematology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Judith Dierlamm
- Department of Oncology and Haematology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Soekler
- Department of Oncology and Haematology, University of Tübingen, Tübingen, Germany
| | - Hans-Joachim Beck
- Department of Oncology and Haematology, University Hospital Mainz, Mainz, Germany
| | - Wolfgang Willenbacher
- Salzburg Cancer Research Institute and AGMT (Arbeitsgemeinschaft Medikamentöse Tumortherapie), Salzburg, Austria; Medical University Innsbruck, Internal Medicine V: Hematology & Oncology, Innsbruck, Austria; Oncotyrol, Center for Personalized Cancer Medicine, Innsbruck, Austria
| | | | - Thomas Pabst
- Swiss Group for Clinical Cancer Research, Bern, Switzerland; Department of Medical Oncology, Inselspital Bern, Bern, Switzerland
| | - Max S Topp
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Felicitas Hitz
- Swiss Group for Clinical Cancer Research, Bern, Switzerland; Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Martin Bentz
- Department of Internal Medicine III, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Ulrich Bernd Keller
- Department of Internal Medicine III, Klinikum "Rechts der Isar", Munich, Germany
| | - Dagmar Kühnhardt
- Department of Hematology and Oncology, Charité University of Medicine, Berlin, Germany
| | - Helmut Ostermann
- Department of Hematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Norbert Schmitz
- Department of Haematology, Asklepios Hospital St Georg, Hamburg, Germany
| | - Bernd Hertenstein
- Department of Internal Medicine I, Klinikum Bremen Mitte, Bremen, Germany
| | - Walter Aulitzky
- Department of Haematology and Oncology, Robert Bosch Hospital, Stuttgart, Germany
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Ernst von Bergmann Hospital, Potsdam, Germany
| | - Tom Vieler
- Karl Lennert-Cancer Center, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hans Eich
- Department of Radiotherapy, University Hospital of Muenster, Muenster, Germany
| | - Christian Baues
- Department of Radiotherapy, University Hospital of Cologne, Cologne, Germany
| | - Harald Stein
- Berlin Reference Center for Lymphoma and Haematopathology, Berlin, Germany
| | - Michael Fuchs
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Georg Kuhnert
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
| | - Markus Dietlein
- Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group, Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
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Sasse S, Bröckelmann PJ, Goergen H, Plütschow A, Müller H, Kreissl S, Buerkle C, Borchmann S, Fuchs M, Borchmann P, Diehl V, Engert A. Long-Term Follow-Up of Contemporary Treatment in Early-Stage Hodgkin Lymphoma: Updated Analyses of the German Hodgkin Study Group HD7, HD8, HD10, and HD11 Trials. J Clin Oncol 2017; 35:1999-2007. [DOI: 10.1200/jco.2016.70.9410] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Purpose Combined-modality treatment is widely considered the standard of care in early-stage Hodgkin lymphoma (HL), and treatment intensity has been reduced over the last years. Long-term follow-up is important to judge both efficacy and safety of the different therapies used. Patients and Methods We analyzed updated follow-up data on 4,276 patients treated within the German Hodgkin Study Group trials HD7 and HD10 for early-stage favorable HL and HD8 and HD11 for early-stage unfavorable HL between 1993 and 2003. Results In HD7 (N = 627; median follow-up, 120 months), combined-modality treatment was superior to extended-field radiotherapy (RT), with 15-year progression-free survival (PFS) of 73% versus 52% (hazard ratio [HR], 0.5; 95% CI, 0.3 to 0.6; P < .001), without differences in overall survival (OS). In HD10 (N = 1,190; median follow-up, 98 months), noninferiority of two cycles of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) plus 20 Gy involved-field (IF)–RT to more intensive four cycles of ABVD plus 30 Gy IF-RT was confirmed with 10-year PFS of 87% each (HR, 1.0; 95%, 0.6 to 1.5) and OS of 94% each (HR, 0.9; 95% CI, 0.5 to 1.6), respectively. In both trials, no differences in second neoplasias were observed. In HD8 (N = 1,064; median follow-up, 153 months), noninferiority of involved-field RT to extended-field RT regarding PFS was confirmed (HR, 1.0; 95% CI, 0.8 to 1.2). In HD11 (N = 1,395; median follow-up, 106 months), superiority of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone at baseline over ABVD was not observed. After BEACOPPbaseline, 20 Gy IF-RT was noninferior to 30 Gy (10-year PFS, 84% v 84%; HR, 1.0; 95% CI, 0.7 to 1.5). In contrast, PFS was inferior in ABVD-treated patients receiving 20 Gy instead of 30 Gy IF-RT (10-year PFS, 76% v 84%; HR, 1.5; 95% CI, 1.0 to 2.1). No differences in OS or second neoplasias were observed in in both trials. Conclusion Long-term follow-up data of the four randomized trials largely support the current risk-adapted therapeutic strategies in early-stage HL. Nevertheless, continued follow-up is necessary to assess the long-term safety of currently applied therapeutic strategies.
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Affiliation(s)
- Stephanie Sasse
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Paul J. Bröckelmann
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Helen Goergen
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Annette Plütschow
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Horst Müller
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Stefanie Kreissl
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Carolin Buerkle
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Sven Borchmann
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Michael Fuchs
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Peter Borchmann
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Volker Diehl
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Andreas Engert
- All authors: German Hodgkin Study Group (GHSG), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
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Borchmann P, Goergen H, Kobe C, Eichenauer D, Greil R, Lohri A, Novak U, Markova J, Beck H, Meissner J, Zijlstra J, Ostermann H, Feuring-Buske M, Dierlamm J, Eich H, Baues C, Rosenwald A, Fuchs M, Diehl V, Kuhnert G, Dietlein M, Engert A. EBEACOPP WITH OR WITHOUT RITUXIMAB IN INTERIM-PET-POSITIVE ADVANCED-STAGE HODGKIN LYMPHOMA: UPDATED RESULTS OF THE INTERNATIONAL, RANDOMIZED PHASE 3 GHSG HD18 TRIAL. Hematol Oncol 2017. [DOI: 10.1002/hon.2437_52] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- P. Borchmann
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG); University Hospital of Cologne; Cologne Germany
| | - H. Goergen
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG); University Hospital of Cologne; Cologne Germany
| | - C. Kobe
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - D. Eichenauer
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG); University Hospital of Cologne; Cologne Germany
| | - R. Greil
- IIIrd Medical Department; Paracelsus Medical University and Salzburg Cancer Research Institute and AGMT (Arbeitsgemeinschaft Medikamentöse Tumortherapie); Salzburg Austria
| | - A. Lohri
- Oncology; Cantonal Hospital Baselland; Liestal Switzerland
| | - U. Novak
- Swiss Group for Clinical Cancer Research (SAKK); Inselspital Bern; Bern Switzerland
| | - J. Markova
- Third Faculty of Medicine; Charles University, University Hospital Kralovske Vinohrady; Prague Czech Republic
| | - H. Beck
- IIIrd Medical Department; University Hospital Mainz; Mainz Germany
| | - J. Meissner
- Center for Internal Medicine; University of Heidelberg; Heidelberg Germany
| | - J.M. Zijlstra
- Oncology; VU University Medical Center; Amsterdam The Netherlands
| | - H. Ostermann
- Department of Internal Medicine III; University Hospital of Munich; Munich Germany
| | - M. Feuring-Buske
- Department of Internal Medicine III; University Hospital of Ulm; Ulm Germany
| | - J. Dierlamm
- Department II; University Hospital Hamburg-Eppendorf; Hamburg Germany
| | - H. Eich
- Department of Radiotherapy; University Hospital of Muenster; Muenster Germany
| | - C. Baues
- Department of Radiotherapy, Germany x Berlin Reference Center for Lymphoma and 17 Berlin; University Hospital of Cologne; Cologne Germany
| | - A. Rosenwald
- 1Institute of Pathology; University of Wuerzburg; Wuerzburg Germany
| | - M. Fuchs
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG); University Hospital of Cologne; Cologne Germany
| | - V. Diehl
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG); University Hospital of Cologne; Cologne Germany
| | - G. Kuhnert
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - M. Dietlein
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - A. Engert
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG); University Hospital of Cologne; Cologne Germany
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23
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Bröckelmann PJ, Goergen H, Kohnhorst C, von Tresckow B, Moccia A, Markova J, Meissner J, Kerkhoff A, Ludwig WD, Fuchs M, Borchmann P, Engert A. Late Relapse of Classical Hodgkin Lymphoma: An Analysis of the German Hodgkin Study Group HD7 to HD12 Trials. J Clin Oncol 2017; 35:1444-1450. [DOI: 10.1200/jco.2016.71.3289] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Clinical characteristics, therapeutic approaches, and prognosis of late relapse (LR) in patients with classic Hodgkin lymphoma (cHL) are poorly understood. We performed a comprehensive analysis of LR of Hodgkin lymphoma (LR-HL). Methods To estimate the incidence of LR-HL, we retrospectively analyzed 6,840 patients with cHL included in the German Hodgkin Study Group trials HD7 to HD12. Patients who experienced a relapse > 5 years into remission were compared with patients in continued remission for > 5 years and with those who experienced a relapse ≤ 5 years after first diagnosis. Results With a median observation time of 10.3 years, 141 incidences of LR-HL were observed. Cumulative incidences at 10, 15, and 20 years rose linearly and were 2.5%, 4.3%, and 6.9%, respectively. The standardized incidence ratio for HL with respect to age- and sex-matched German reference data was 84.5 (95% CI, 71.2 to 99.7). LR-HL was more frequently observed in patients with early-stage favorable than unfavorable or advanced stage at first diagnosis (15-year cumulative incidence, 5.3% v 3.9% and 3.9%, respectively; P = .01). Overall survival from first diagnosis was worse after LR compared with nonrelapse survivors (10-year estimate, 95.8% v 86.1%; hazard ratio, 2.5; 95% CI, 1.7 to 3.5; P < .001). In patients with LR-HL, survival was better compared with 466 patients with earlier relapse (hazard ratio, 0.6; 95% CI, 0.4 to 0.9, P = .01). Forty-four percent and 49% of patients with LR-HL and earlier relapse, respectively, received stem cell transplantations. Conclusion Apart from treatment-associated adverse effects, survivors after initially successful therapy for cHL are at an 85-fold risk for recurrence of disease compared with the general German population. After risk-adapted treatment strategies, especially in early-stage favorable HL, regular clinical follow-up is recommended for timely detection of LR-HL. With adequate treatment, prognosis of LR-HL is better compared with early relapses.
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Affiliation(s)
- Paul J. Bröckelmann
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Helen Goergen
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Charlotte Kohnhorst
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Bastian von Tresckow
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Alden Moccia
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Jana Markova
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Julia Meissner
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Andrea Kerkhoff
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Wolf-Dieter Ludwig
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Michael Fuchs
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Peter Borchmann
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
| | - Andreas Engert
- Paul J. Bröckelmann, Helen Goergen, Charlotte Kohnhorst, Bastian von Tresckow, Michael Fuchs, Peter Borchmann, and Andreas Engert, University Hospital of Cologne, Cologne; Julia Meissner, University of Heidelberg, Heidelberg; Andrea Kerkhoff, University Hospital of Münster, Münster; Wolf-Dieter Ludwig, Helios Kinikum Berlin-Buch, Berlin, Germany; Alden Moccia, Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; and Jana Markova, University Hospital Kralovske Vinohrady, Prague, Czech
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24
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Behringer K, Goergen H, Müller H, Thielen I, Brillant C, Kreissl S, Halbsguth TV, Meissner J, Greil R, Moosmann P, Shonukan O, Rueffer JU, Flechtner HH, Fuchs M, Diehl V, Engert A, Borchmann P. Cancer-Related Fatigue in Patients With and Survivors of Hodgkin Lymphoma: The Impact on Treatment Outcome and Social Reintegration. J Clin Oncol 2016; 34:4329-4337. [DOI: 10.1200/jco.2016.67.7450] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Cancer-related fatigue occurs frequently in patients with Hodgkin lymphoma (HL) and has a major impact on their quality of life. We hypothesized that severe fatigue (sFA) might have an impact on patients’ treatment outcome and social reintegration. Methods Of 5,306 patients enrolled in the German Hodgkin Study Group’s fifth generation of clinical trials in HL (HD13, HD14, and HD15; nonqualified and older [> 60 years] patients excluded), 4,529 provided data on health-related quality of life. We describe sFA (defined as a score ≥ 50 on the 0 to 100 scale from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30) before and up to 9 years after therapy and analyze its impact on treatment outcome and social reintegration. Results The proportion of patients reporting sFA was 37% at baseline and ranged from 20% to 24% during follow-up. Baseline sFA was associated with significantly impaired progression-free survival and a trend to impaired overall survival, which can be overcome in patients receiving highly effective HL therapies as applied in our fifth-generation trials. Our analysis revealed a significant negative association of sFA and employment in survivors: 5 years after therapy, 51% and 63% of female and male survivors, respectively, with sFA were working or in professional education, compared with 78% and 90% without sFA, respectively ( P < .001 adjusted for age, sex, stage, baseline employment status, and treatment outcome). sFA was also associated with financial problems and the number of visits to a general practitioner and medical specialists. Conclusion sFA is an important factor preventing survivors from social reintegration during follow-up. This observation underscores the need to address fatigue as a significant diagnosis when treating patients with and survivors of cancer.
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Affiliation(s)
- Karolin Behringer
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Helen Goergen
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Horst Müller
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Indra Thielen
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Corinne Brillant
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Stefanie Kreissl
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Teresa Veronika Halbsguth
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Julia Meissner
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Richard Greil
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Peter Moosmann
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Oluwatoyin Shonukan
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Jens Ulrich Rueffer
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Hans-Henning Flechtner
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Michael Fuchs
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Volker Diehl
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Andreas Engert
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
| | - Peter Borchmann
- Karolin Behringer, Helen Goergen, Horst Müller, Indra Thielen, Corinne Brillant, Stefanie Kreissl, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jens Ulrich Rueffer, German Fatigue Society, Cologne; Teresa Veronika Halbsguth, University Hospital of Frankfurt, Frankfurt; Julia Meissner, University of Heidelberg, Heidelberg; Hans-Henning Flechtner, Otto von Guericke University, Magdeburg, Germany; Richard Greil, Paracelsus Medical University, Salzburg,
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25
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Kreissl S, Mueller H, Goergen H, Mayer A, Brillant C, Behringer K, Halbsguth TV, Hitz F, Soekler M, Shonukan O, Rueffer JU, Flechtner HH, Fuchs M, Diehl V, Engert A, Borchmann P. Cancer-related fatigue in patients with and survivors of Hodgkin's lymphoma: a longitudinal study of the German Hodgkin Study Group. Lancet Oncol 2016; 17:1453-1462. [PMID: 27612583 DOI: 10.1016/s1470-2045(16)30093-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/24/2016] [Accepted: 04/15/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with Hodgkin's lymphoma might have persistent fatigue even years after treatment. However, knowledge of the development of fatigue persisting long after completion of treatment is limited. Therefore, we did a detailed analysis of fatigue in our first-line clinical trials for early-stage favourable (HD13 trial), early-stage unfavourable (HD14 trial), and advanced-stage (HD15 trial) Hodgkin's lymphoma. Beyond the description of fatigue from diagnosis up to 5 years after treatment, we aimed to assess any effect of patient characteristics, disease characteristics, or treatment characteristics on persistent fatigue. METHODS In this longitudinal study, we included patients with early-stage favourable, early-stage unfavourable, and advanced-stage Hodgkin's lymphoma from the HD13, HD14, and HD15 trials, respectively, aged between 18 and 60 years. Eligible patients for these trials had newly diagnosed, histologically proven Hodgkin's lymphoma, an Eastern Cooperative Oncology Group performance status of 2 or lower, HIV negativity, and absence of comorbidity disallowing protocol treatment. We used the fatigue scale of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire to assess fatigue from diagnosis up to 5 years after the end of treatment. The primary outcomes of interest in this study were fatigue scores in the second and fifth year after end of treatment. We estimated the effect of different disease, patient, and treatment characteristics on fatigue with multiple regression analyses and identified fatigue trajectories with growth mixture models. The regression analyses and growth mixture models used robust and full information maximum likelihood estimates to account for missing data. The HD13, HD14, and HD15 trials are registered as international standard randomised controlled trials, ISRCTN63474366, ISRCTN04761296, and ISRCTN32443041, respectively. FINDINGS The HD13 trial enrolled patients with early-stage favourable disease from Jan 28, 2003, to Sept 30, 2009; the HD14 trial enrolled patients with early-stage unfavourable disease from Jan 28, 2003, to Dec 23, 2009; and the HD15 trial enrolled patients with advanced-stage disease from Jan 28, 2003, to April 18, 2008. 5306 patients were enrolled in these trials. We analysed 4215 patients with any valid fatigue assessment up to 5 years after the end of treatment. Patients with higher tumour burden at diagnosis had more fatigue at baseline (mean fatigue score in HD13: 30·8 [SD 28·0]; in HD14: 39·8 [29·4], and in HD15: 49·0 [30·2]). Fatigue scores (FA) in the second year after the end of treatment were 28·5 (24·7) in HD13, 28·8 (24·4) in HD14, and 30·7 (24·4) in HD15; in the fifth year after the end of treatment FA was 30·8 (26·0) in HD13, 27·1 (24·8) in HD14, and 28·2 (24·9) in HD15. Predictors of fatigue in the second and fifth year after end of treatment were baseline fatigue (p<0·0001) and age as a continuous variable (p<0·0001). In addition to preceding fatigue and age, patient sex and Hodgkin's lymphoma specific risk factors at baseline did not consistently and significantly improve the prognosis of fatigue in the first, second, and fifth year after end of treatment. There was no significant effect of treatment on fatigue scores in the second and fifth year after treatment. INTERPRETATION Our findings show a high incidence of severe acute and persistent fatigue in Hodgkin's lymphoma survivors, which is largely independent of tumour stage and treatment. Our results contribute to a better understanding of fatigue in patients with Hodgkin's lymphoma and Hodgkin's lymphoma survivors and could inform development of urgently needed intervention strategies. FUNDING Deutsche Krebshilfe.
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Affiliation(s)
- Stefanie Kreissl
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Horst Mueller
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Axel Mayer
- Department of Data Analysis, Ghent University, Ghent, Belgium
| | - Corinne Brillant
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Karolin Behringer
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | | | - Felicitas Hitz
- Cantonal Hospital of St Gallen, St Gallen, Switzerland; SAKK Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | | | | | - Hans-Henning Flechtner
- Department of Child and Adolescent Psychiatry and Psychotherapy, Otto von Guericke University, Magdeburg, Germany
| | - Michael Fuchs
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG), Department of Internal Medicine I, University Hospital of Cologne, Germany.
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Eichenauer DA, Goergen H, Plütschow A, Wongso D, Behringer K, Kreissl S, Thielen I, Halbsguth T, Bröckelmann PJ, Fuchs M, Böll B, von Tresckow B, Borchmann P, Engert A. Ofatumumab in relapsed nodular lymphocyte-predominant Hodgkin lymphoma: results of a phase II study from the German Hodgkin study group. Leukemia 2015; 30:1425-7. [DOI: 10.1038/leu.2015.321] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bröckelmann PJ, Goergen H, Fuchs M, Kriz J, Semrau R, Baues C, Kobe C, Behringer K, Eichenauer DA, von Tresckow B, Klimm B, Halbsguth T, Wongso D, Plütschow A, Haverkamp H, Dietlein M, Eich HT, Stein H, Diehl V, Borchmann P, Engert A. Impact of centralized diagnostic review on quality of initial staging in Hodgkin lymphoma: experience of the German Hodgkin Study Group. Br J Haematol 2015; 171:547-56. [DOI: 10.1111/bjh.13646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Paul J. Bröckelmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | - Michael Fuchs
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Jan Kriz
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Robert Semrau
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Christian Baues
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Carsten Kobe
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Karolin Behringer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Dennis A. Eichenauer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Bastian von Tresckow
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Beate Klimm
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department III of Internal Medicine; Krankenhaus Düren; Düren Germany
| | - Teresa Halbsguth
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department II of Internal Medicine; University Hospital of Frankfurt; Frankfurt Germany
| | - Diana Wongso
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | | | - Markus Dietlein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Hans T. Eich
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Harald Stein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Pathodiagnostik Berlin; Berlin Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Peter Borchmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Andreas Engert
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
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Behringer K, Goergen H, Hitz F, Zijlstra JM, Greil R, Markova J, Sasse S, Fuchs M, Topp MS, Soekler M, Mathas S, Meissner J, Wilhelm M, Koch P, Lindemann HW, Schalk E, Semrau R, Kriz J, Vieler T, Bentz M, Lange E, Mahlberg R, Hassler A, Vogelhuber M, Hahn D, Mezger J, Krause SW, Skoetz N, Böll B, von Tresckow B, Diehl V, Hallek M, Borchmann P, Stein H, Eich H, Engert A. Omission of dacarbazine or bleomycin, or both, from the ABVD regimen in treatment of early-stage favourable Hodgkin's lymphoma (GHSG HD13): an open-label, randomised, non-inferiority trial. Lancet 2015; 385:1418-27. [PMID: 25539730 DOI: 10.1016/s0140-6736(14)61469-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The role of bleomycin and dacarbazine in the ABVD regimen (ie, doxorubicin, bleomycin, vinblastine, and dacarbazine) has been questioned, especially for treatment of early-stage favourable Hodgkin's lymphoma, because of the drugs' toxicity. We aimed to investigate whether omission of either bleomycin or dacarbazine, or both, from ABVD reduced the efficacy of this regimen in treatment of Hodgkin's lymphoma. METHODS In this open-label, randomised, multicentre trial (HD13) we compared two cycles of ABVD with two cycles of the reduced-intensity regimen variants ABV (doxorubicin, bleomycin, and vinblastine), AVD (doxorubicin, vinblastine, and dacarbazine), and AV (doxorubicin and vinblastine), in patients with newly diagnosed, histologically proven, classic or nodular, lymphocyte predominant Hodgkin's lymphoma. In each treatment group, 30 Gy involved-field radiotherapy (IFRT) was given after both cycles of chemotherapy were completed. From Jan 28, 2003, patients were centrally randomly assigned (1:1:1:1) with a minimisation method to the four groups. Because of high event rates, assignment to the AV and ABV groups stopped early, on Sept 30, 2005, and Feb 10, 2006; assignment to ABVD and AVD continued (1:1) until Sept 30, 2009. Our primary objective was to show non-inferiority of the experimental variants compared with ABVD in terms of freedom from treatment failure (FFTF), by excluding a difference of 6% after 5 years corresponding to a hazard ratio (HR) of 1.72, via a 95% CI. Analyses reported here include qualified patients only, and between-group comparisons include only patients recruited during the same period. The trial was registered, number ISRCTN63474366. FINDINGS Of 1502 qualified patients, 566, 198, 571, and 167 were randomly assigned to receive ABVD, ABV, AVD, or AV, respectively. 5 year FFTF was 93.1%, 81.4%, 89.2%, and 77.1% with ABVD, ABV, AVD, and AV, respectively. Compared with ABVD, inferiority of the dacarbazine-deleted variants was detected with 5 year differences of -11.5% (95% CI -18.3 to -4.7; HR 2.06 [1.21 to 3.52]) for ABV and -15.2% (-23.0 to -7.4; HR 2.57 [1.51 to 4.40]) for AV. Non-inferiority of AVD compared with ABVD could also not be detected (5 year difference -3.9%, -7.7 to -0·1; HR 1.50, 1.00 to 2.26). 178 (33%) of 544 patients given ABVD had WHO grade III or IV toxicity, compared with 53 (28%) of 187 given ABV, 142 (26%) of 539 given AVD, and 40 (26%) of 151 given AV. Leucopenia was the most common event, and highest in the groups given bleomycin. INTERPRETATION Dacarbazine cannot be omitted from ABVD without a substantial loss of efficacy. With respect to our predefined non-inferiority margin, bleomycin cannot be safely omitted either, and the standard of care for patients with early-stage favourable Hodgkin's lymphoma should remain ABVD followed by IFRT. FUNDING Deutsche Krebshilfe and Swiss State Secretariat for Education and Research.
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Affiliation(s)
- Karolin Behringer
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Felicitas Hitz
- Cantonal Hospital of St Gallen, St Gallen, Switzerland and SAKK Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | - Richard Greil
- Third Medical Department, Paracelcus Medical University, Salzburg, Austria
| | - Jana Markova
- University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stephanie Sasse
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Michael Fuchs
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Max S Topp
- University Hospital Würzburg, Würzburg, Germany
| | | | - Stephan Mathas
- Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | | | | | - Peter Koch
- University Hospital Münster, Münster, Germany
| | | | - Enrico Schalk
- Department of Haematology and Oncology, Medical Centre, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Robert Semrau
- Department of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - Jan Kriz
- University Hospital Münster, Münster, Germany
| | - Tom Vieler
- Medizinische Klinik, Universitätsklinik Schleswig-Holstein, Kiel, Germany
| | - Martin Bentz
- Medizinische Klinik, Städtisches Klinikum Karlsruhe, Germany
| | - Elisabeth Lange
- Medizinische Klinik, Hämatologie/Onkologie, Evangelisches Krankenhaus, Hamm, Germany
| | - Rolf Mahlberg
- Medizinische Klinik, Krankenanstalt Mutterhaus d. Borromäerinnen, Trier, Germany
| | - Andre Hassler
- Zentrum für Innere Medizin, Hämatologie/Onkologie, Charité Campus Mitte, Berlin, Germany
| | - Martin Vogelhuber
- Medizinische Klinik, Universitätsklinik Regensburg, Regensburg, Germany
| | - Dennis Hahn
- Klinik für Onkologie, Katharinenhospital, Stuttgart, Germany
| | - Jörg Mezger
- Medizinische Klinik-Hämatologie, Onkologie, Immunologie, Palliativmedizin, St. Vincentius-Kliniken gAG, Karlsruhe, Germany
| | - Stefan W Krause
- Department of Internal Medicine 5, Haematology/Oncology, University of Erlangen, Germany
| | - Nicole Skoetz
- Cochrane Haematological Malignancies Group, Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Harald Stein
- Berlin Reference Center for Lymphoma and Haematopathology, Berlin, Germany
| | - Hans Eich
- University Hospital Münster, Münster, Germany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany.
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Böll B, Goergen H, Arndt N, Meissner J, Krause SW, Schnell R, von Tresckow B, Eichenauer DA, Sasse S, Fuchs M, Behringer K, Klimm BC, Naumann R, Diehl V, Engert A, Borchmann P. Relapsed hodgkin lymphoma in older patients: a comprehensive analysis from the German hodgkin study group. J Clin Oncol 2013; 31:4431-7. [PMID: 24190119 DOI: 10.1200/jco.2013.49.8246] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Progression or relapse of Hodgkin lymphoma (HL) is common among older patients. However, prognosis and effects of second-line treatment are thus far unknown. PATIENTS AND METHODS We investigated second-line treatment and survival in older patients with progressive or relapsed HL. Patients treated within German Hodgkin Study Group first-line studies between 1993 and 2007 were screened for refractory disease or relapse (RR-HL). Patients with RR-HL age ≥ 60 years at first-line treatment were included in this analysis. RESULTS We identified 105 patients (median age, 66 years); 28%, 31%, and 41% had progressive disease, early relapse, or late relapse, respectively. Second-line treatment strategies included intensified salvage regimens (22%), conventional polychemotherapy and/or salvage-radiotherapy with curative intent (42%), and palliative approaches (31%). Median overall survival (OS) for the entire cohort was 12 months; OS at 3 years was 31% (95% CI, 22% to 40%). A prognostic score with risk factors (RFs) of early relapse, clinical stage III/IV, and anemia identified patients with favorable and unfavorable prognosis (≤ one RF: 3-year OS, 59%; 95% CI, 44% to 74%; ≥ two RFs: 3-year OS, 9%; 95% CI, 1% to 18%). In low-risk patients, the impact of therapy on survival was significant in favor of the conventional polychemotherapy/salvage radiotherapy approach. In high-risk patients, OS was low overall and did not differ significantly among treatment strategies. CONCLUSION OS in older patients with RR-HL can be predicted using a simple prognostic score. Poor outcome in high-risk patients cannot be overcome by any of the applied treatment strategies. Our results might help to guide treatment decisions and evaluate new compounds in these patients.
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Affiliation(s)
- Boris Böll
- Boris Böll, Bastian von Tresckow, Dennis A. Eichenauer, Stephanie Sasse, Michael Fuchs, Karolin Behringer, Beate C. Klimm, Andreas Engert, and Peter Borchmann, University Hospital Cologne; Boris Böll, Helen Goergen, Bastian von Tresckow, Dennis A. Eichenauer, Stephanie Sasse, Michael Fuchs, Karolin Behringer, Beate C. Klimm, Volker Diehl, Andreas Engert, and Peter Borchmann, German Hodgkin Study Group, Cologne; Nils Arndt and Ralph Naumann, Stiftungsklinikum Mittelrhein, Koblenz; Julia Meissner, Heidelberg University Hospital, Heidelberg; Stefan W. Krause, Erlangen University Hospital, Erlangen; and Roland Schnell, Pioh Medical Oncology and Hematology, Frechen, Germany
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Klimm B, Goergen H, Fuchs M, von Tresckow B, Böll B, Meissner J, Glunz A, Diehl V, Eich HT, Engert A, Borchmann P. Impact of risk factors on outcomes in early-stage Hodgkin's lymphoma: an analysis of international staging definitions. Ann Oncol 2013; 24:3070-6. [PMID: 24148816 DOI: 10.1093/annonc/mdt413] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In early-stage Hodgkin's lymphoma (HL), treatment according to the early favorable or unfavorable subgroup is guided by staging definitions, which differ between various study groups worldwide. We analyzed risk factors used in different international staging systems and their impact on the outcome of early-stage HL patients. PATIENTS AND METHODS In 1173 early-stage HL patients treated homogenously within the German Hodgkin Study Group (GHSG) trials HD10 and HD11, the impact of three staging systems developed and used by the GHSG, the European Organization for Research and Treatment of Cancer (EORTC), and the National Comprehensive Cancer Network (NCCN) in discriminating risk groups for progression-free survival (PFS) and overall survival (OS) was assessed and the relevance of their single risk factors was investigated. RESULTS All the three staging systems defined an unfavorable risk group out of early-stage patients of comparable size (56%, 55%, and 57%), having a significantly poorer PFS and OS as compared with the corresponding favorable group; 5-year differences between early favorable and early unfavorable in terms of PFS were 9.4% (HR 2.61, 95% CI 1.74-3.91), 6.7% (HR 2.10, 95% CI 1.41-3.13), and 8.6% (HR 2.14, 95% CI 1.45-3.16) with the GHSG, EORTC, and NCCN definition, respectively. Sensitivity was high for all systems (84%, 79%, and 83%); however, there was a low specificity with high rates of false-positive results (1-specificity 54%, 53%, and 55%, respectively). Models of high sensitivity included risk factors associated with large tumor burden and high tumor activity. Most risk factors for tumor-specific end points were also predictive of OS. CONCLUSIONS Differentiating between a favorable and an unfavorable risk group has significant impact on PFS and OS in early-stage HL patients in the modern treatment era. Risk-adapted treatment strategies using new risk factors with higher specificity are needed.
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Affiliation(s)
- B Klimm
- Department I of Internal Medicine, German Hodgkin Study Group (GHSG), University Hospital Cologne
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Hay AE, Klimm B, Chen BE, Goergen H, Shepherd LE, Fuchs M, Gospodarowicz MK, Borchmann P, Connors JM, Markova J, Crump M, Lohri A, Winter JN, Dörken B, Pearcey RG, Diehl V, Horning SJ, Eich HT, Engert A, Meyer RM. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol 2013; 24:3065-9. [PMID: 24121121 DOI: 10.1093/annonc/mdt389] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment options for patients with nonbulky stage IA-IIA Hodgkin lymphoma include combined modality therapy (CMT) using doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) plus involved-field radiation therapy (IFRT), and chemotherapy with ABVD alone. There are no mature randomized data comparing ABVD with CMT using modern radiation techniques. PATIENTS AND METHODS Using German Hodgkin Study Group HD10/HD11 and NCIC Clinical Trials Group HD.6 databases, we identified 588 patients who met mutually inclusive eligibility criteria from the preferred arms of HD10 or 11 (n = 406) and HD.6 (n = 182). We evaluated time to progression (TTP), progression-free (PFS) and overall survival, including in three predefined exploratory subset analyses. RESULTS With median follow-up of 91 (HD10/11) and 134 (HD.6) months, respective 8-year outcomes were for TTP, 93% versus 87% [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.24-0.78]; for PFS, 89% versus 86% (HR 0.71, 95% CI 0.42-1.18) and for overall survival, 95% versus 95% (HR 1.09, 95% CI 0.49-2.40). In the exploratory subset analysis including HD10 eligible patients who achieved complete response (CR) or unconfirmed complete response (CRu) after two cycles of ABVD, 8-year PFS was 87% (HD10) versus 95% (HD.6) (HR 2.8; 95% CI 0.64-12.5) and overall survival 96% versus 100%. In contrast, among those without CR/CRu after two cycles of ABVD, 8-year PFS was 88% versus 74% (HR 0.35; 95% CI 0.16-0.79) and overall survival 95% versus 91%, respectively (HR 0.42; 95% CI 0.12-1.44). CONCLUSIONS In patients with nonbulky stage IA-IIA Hodgkin lymphoma, CMT provides better disease control than ABVD alone, especially among those not achieving complete response after two cycles of ABVD. Within the follow-up duration evaluated, overall survivals were similar. Longer follow-up is required to understand the implications of radiation and chemotherapy-related late effects. CLINICAL TRIALS The trials included in this analysis were registered at ClinicalTrials.gov: HD10 - NCT00265018, HD11 - NCT00264953, HD.6 - NCT00002561.
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Affiliation(s)
- A E Hay
- NCIC Clinical Trials Group and Queen's University, Kingston, Ontario, Canada
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Sasse S, Rothe A, Goergen H, Eichenauer DA, Lohri A, Kreher S, Jäger U, Bangard C, Kuhnert G, Böll B, von Tresckow B, Engert A. Brentuximab vedotin (SGN-35) in patients with transplant-naive relapsed/refractory Hodgkin lymphoma. Leuk Lymphoma 2013; 54:2144-8. [PMID: 23402268 DOI: 10.3109/10428194.2013.775434] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Only limited data are available on the role of brentuximab vedotin (SGN-35) in transplant-naive relapsed or refractory patients with Hodgkin lymphoma (HL). We thus retrospectively analyzed 14 patients with primary refractory or relapsed HL who were treated with brentuximab vedotin as single agent in a named patient program, who had not received prior high-dose chemotherapy (HDCT) and autologous stem cell transplant (ASCT) due to refractory disease (n = 9), comorbidity (n = 4) and unknown reasons (n = 1). Brentuximab vedotin resulted in an overall response rate of 71% (10/14) with five complete responses (CRs). Five of those patients with refractory disease and four patients with relevant comorbidity responded. Consolidating ASCT (n = 4) or allogeneic SCT (n = 1) was performed in five patients. Median progression-free survival (PFS) was 9 months and the median overall survival (OS) was not reached. These data indicate the therapeutic efficacy of brentuximab vedotin in chemotherapy-refractory transplant-naive patients with HL.
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Behringer K, Mueller H, Goergen H, Thielen I, Eibl AD, Stumpf V, Wessels C, Wiehlpütz M, Rosenbrock J, Halbsguth T, Reiners KS, Schober T, Renno JH, von Wolff M, van der Ven K, Kuehr M, Fuchs M, Diehl V, Engert A, Borchmann P. Gonadal Function and Fertility in Survivors After Hodgkin Lymphoma Treatment Within the German Hodgkin Study Group HD13 to HD15 Trials. J Clin Oncol 2013; 31:231-9. [DOI: 10.1200/jco.2012.44.3721] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To optimize fertility advice in patients with Hodgkin lymphoma (HL) before therapy and during survivorship, information on the impact of chemotherapy is needed. Therefore, we analyzed gonadal functions in survivors of HL. Patients and Methods Women younger than age 40 and men younger than 50 years at diagnosis in ongoing remission at least 1 year after therapy within the German Hodgkin Study Group HD13 to HD15 trials for early- and advanced-stage HL were included. Hormone parameters, menstrual cycle, symptoms of hypogonadism, and offspring were evaluated. Results A total of 1,323 (55%) of 2,412 contacted female and male survivors were evaluable for the current analysis (mean follow-up, 46 and 48 months, respectively). Follicle-stimulating hormone, anti-Müllerian hormone, and inhibin B levels correlated significantly with therapy intensity (P < .001). Low birth rates were observed in survivors after advanced-stage treatment within the observation time (women, 6.5%; men, 3.3%). Regular menstrual cycle was reported by more than 90% of female survivors of early-stage HL (recovery time mostly ≤ 12 months). After six to eight cycles of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone, menstrual activity was strongly related to age (< v ≥ 30 years: 82% v 45%, respectively; P < .001; prolonged recovery time). Thirty-four percent of women age ≥ 30 years suffered severe menopausal symptoms (three- to four-fold more frequently than expected). In contrast, male survivors had mean levels of testosterone within the normal range and reported no increased symptoms of hypogonadism. Conclusion The present analysis in a large group of survivors of HL provides well-grounded information on gonadal toxicity of currently used treatment regimens and allows risk-adapted fertility preservation and comprehensive support during therapy and follow-up.
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Affiliation(s)
- Karolin Behringer
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Horst Mueller
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Helen Goergen
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Indra Thielen
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Angelika Diana Eibl
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Volker Stumpf
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Carsten Wessels
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Martin Wiehlpütz
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Johannes Rosenbrock
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Teresa Halbsguth
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Katrin S. Reiners
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Thomas Schober
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Jorg H. Renno
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Michael von Wolff
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Katrin van der Ven
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Marietta Kuehr
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Michael Fuchs
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Volker Diehl
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Andreas Engert
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
| | - Peter Borchmann
- Karolin Behringer, Horst Mueller, Helen Goergen, Indra Thielen, Angelika Diana Eibl, Volker Stumpf, Carsten Wessels, Martin Wiehlpütz, Johannes Rosenbrock, Teresa Halbsguth, Katrin S. Reiners, Thomas Schober, Michael Fuchs, Volker Diehl, Andreas Engert, and Peter Borchmann, University Hospital of Cologne; Jorg H. Renno, Institute for Clinical Chemistry, University of Cologne, Cologne; Katrin van der Ven and Marietta Kuehr, University of Bonn, Bonn, Germany; Michael von Wolff, University Women's Hospital,
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Behringer K, Thielen I, Mueller H, Goergen H, Eibl AD, Rosenbrock J, Halbsguth T, Eichenauer DA, Fuchs M, Reiners KS, Renno JH, van der Ven K, Kuehr M, von Wolff M, Diehl V, Engert A, Borchmann P. Fertility and gonadal function in female survivors after treatment of early unfavorable Hodgkin lymphoma (HL) within the German Hodgkin Study Group HD14 trial. Ann Oncol 2012; 23:1818-25. [PMID: 22228451 DOI: 10.1093/annonc/mdr575] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the HD14 trial, 2×BEACOPPescalated+2×ABVD (2+2) has improved the primary outcome. Compared with 4×ABVD, this benefit might be compromised by more infertility in women. Therefore, we analyzed gonadal function and fertility. PATIENTS AND METHODS Women≤45 years in ongoing remission at least 1 year after therapy were included. Hormone parameters, menopausal symptoms, measures to preserve fertility, menstrual cycle, pregnancies, and offspring were evaluated. RESULTS Three hundred and thirty one of 579 women addressed participated (57.2%) and 263 per-protocol treated patients qualified (A=ABVD: 137, B=2+2: 126, mean time after therapy 42 and 43 months, respectively). Regular menstrual cycle after treatment (A: 87%, B: 83%) and time to recovery (≤12 months) were not different. Follicle-stimulating hormone and anti-Muellerian hormone were significantly better in arm A. However, pregnancies after therapy favored arm B (A: 15%, B: 26%, P=0.043) and motherhood rates were equivalent to the German normal population. Multivariate analysis revealed prophylactic use of gonadotropin-releasing hormone (GnRH) analogues as highly significant prognostic factor for preservation of fertility (odds ratio=12.87, P=0.001). Severe menopausal symptoms were frequent in women≥30 years (A: 21%, B: 25%). CONCLUSIONS Hormonal levels after 2+2 indicate a reduced ovarian reserve. However, 2+2 in combination with GnRH analogues does not compromise fertility within the evaluated observation time.
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Affiliation(s)
- K Behringer
- First Department of Internal Medicine, University Hospital of Cologne, and Institute for Clinical Chemistry, University of Cologne, Cologne, Germany
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