Patients classified as having stage I or IIA Hodgkin Lymphoma (HL) are considered to have early stage disease and are almost always curable. For the purpose of treatment selection patients can be segregated into two groups based on the presence of the following “higher risk” features.
- B symptoms (unexplained fever ≥38°C, soaking night sweats, unexplained weight loss ≥10% within 6 months)
- Extra-nodal disease
- Bulky disease (≥10 cm or >33% of the chest diameter on chest x-ray)
- Three or more sites of nodal involvement
- Sedimentation rate of 50 mm/h or higher
Individuals without these features are effectively treated with a shorter course of chemotherapy with ABVD (doxorubicin, bleomycin, Velban, and dacarbazine) followed by local radiation treatment which consistently cures over 95% of patients with stage I or IIA HL.2 Clinical trials have determined that ABVD for 4 cycles or ABVD for two cycles plus “involved field” radiation directly to areas of cancer cures the majority of early stage HL patients.3,4
Patients with “higher risk” features and symptoms are typically treated as though they have advanced stage disease and are still cured the majority of the time; they do however require more chemotherapy; 4 cycles of ABVD + radiation or 6 cycles of ABVD.
The goal of treatment for early stage HL is cure and to limit treatment-related side effects as much as possible. Historically, patients with stage I or IIA disease were successfully treated with radiation therapy alone. Radiation therapy is a “local” therapy and unable to kill cancer cells outside its field of delivery. Therefore, patients with HL had to undergo extensive staging with surgery, as well as removal of the spleen (staging laparotomy) to ensure that the cancer could be adequately treated with radiation therapy alone.
Full doses of radiation therapy cause significant long-term side effects to many patients.1 Chemotherapy is more capable of curing early and advanced stage HL because unlike radiation it kills cancer cells anywhere in the body. The long-term side effects of chemotherapy are also less severe than those caused by radiation therapy. Currently most patients with stage I or IIA disease are treated with a combination of chemotherapy and radiation therapy in reduced doses. By utilizing combination therapy, high cure rates can be achieved, and the long-term side effects of each treatment may be decreased. Additionally, the extensive surgical staging evaluation can be avoided.
Methods to Detect Residual Lymphoma: Doctors monitor the response to treatment by checking for residual HL on CT or MRI scans after initial treatment. The presence of a residual mass can create problems for management because the mass may represent active HL or merely be scar or dead tissue from chemotherapy damage. PET (positron emission tomography) scanning helps doctors more accurately determine the presence of residual HL following treatment.5,6
1 Dores GM, Metayer C, Curtis RE, et al.: Second malignant neoplasms among long-term survivors of Hodgkin’s disease: a population-based evaluation over 25 years. J Clin Oncol 20 (16): 3484-94, 2002.
2 Duggan D, Petroni G, Johnson J, et al. Randomized comparison of ABVD and MOPP/ABV hybrid for the treatment of advanced Hodgkin’s disease: report of an Intergroup trial.
3 Engert A, Franklin J, Eich HT, et al.: Two cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine plus extended-field radiotherapy is superior to radiotherapy alone in early favorable Hodgkin’s lymphoma: final results of the GHSG HD7 trial. J Clin Oncol 25 (23): 3495-502, 2007.
4 Meyer RM, Gospodarowicz MK, Connors JM, et al.: ABVD alone versus radiation-based therapy in limited-stage Hodgkin’s lymphoma. N Engl J Med 366 (5): 399-408, 2012.
5 Raemaekers JM, André MP, Federico M, et al.: Omitting radiotherapy in early positron emission tomography-negative stage I/II Hodgkin lymphoma is associated with an increased risk of early relapse: Clinical results of the preplanned interim analysis of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol 32 (12): 1188-94, 2014
6 Radford J, Illidge T, Counsell N, et al.: Results of a trial of PET-directed therapy for early-stage Hodgkin’s lymphoma. N Engl J Med 372 (17): 1598-607, 2015.