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Advanced Unfavorable Hodgkin Lymphoma

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    A prospective, randomized trial of 307 patients with advanced-stage disease, including IIB disease and advanced-favorable HL patients, compared ABVD, BEACOPP (four escalated courses plus two standard courses), and CEC.[6] With a median follow-up of 41 months, although progression-free survival (PFS) favored BEACOPP over ABVD (78% vs. 68%, P = .038), there was no significant difference in OS.[6][Level of evidence: 1iiDiii]

    A prospective, randomized study of 331 patients compared ABVD with escalated BEACOPP, along with a planned autologous stem cell transplantation after reinduction chemotherapy for relapsed or resistant disease. With 61 months' median follow-up, although 7-year freedom from first progression favored escalated BEACOPP (73% vs. 85%, P = .004), 7-year OS was not statistically different (84% vs. 89%, P = .39).[7][Level of evidence: 1iiA] Escalated BEACOPP is associated with increased rates of myelodysplasia and acute myelogenous leukemia (3%–4%).[8]

    Further follow-up is required to assess rates of secondary malignancies with these regimens. Stanford V is an alternative drug combination with mandated radiation therapy consolidation for most patients and survival rates comparable to those with ABVD.[9,10][Level of evidence: 1iiA]

    Three prospective, randomized trials did not show a benefit in OS from the addition of consolidative radiation therapy to chemotherapy for patients with advanced-stage disease.[11,12,13][Level of evidence: 1iiA] In a meta-analysis of 1,740 patients treated on 14 different trials, no improvement was observed in 10-years' OS for patients with advanced-stage HL who received combined modality therapy versus chemotherapy alone.[14][Level of evidence: 3iiiA] The German Hodgkin Lymphoma Study Group HD15 trial showed that a negative positive–emission tomographic (PET) scan after BEACOPP induction therapy was highly predictive for a good outcome even with omission of consolidative radiation therapy (negative predictive value for PET was 94% [95% confidence interval, 91%–97%]).[15] No survival advantage is known for the use of radiation consolidation for patients with massive mediastinal disease and advanced stage disease, though differences exist in sites of first relapse.[16]

    Clinical trials are addressing the role of more intensive regimens for patients with advanced-stage disease and poor prognostic factors. Early chemotherapy intensification resulting from an interim, PET-positive scan after two cycles of ABVD has also been proposed.[17] Controversy exists about whether the optimal strategy should involve early dose intensification, with subsequent risks of increased late toxic effects (such as leukemia) or whether ABVD should be employed and patients who relapse be salvaged with high-dose treatment and autografting. In a prospective, randomized trial of 163 patients with unfavorable advanced-stage disease who attained a complete or partial remission after four cycles of ABVD, no difference was observed in OS or FFS either with high-dose therapy with autologous stem cell transplant or with four more cycles of ABVD.[18][Level of evidence: 1iiA]

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