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Adult Hodgkin Lymphoma Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Early Unfavorable Hodgkin Lymphoma

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In the HDII trial, the GHSG randomly assigned 1,395 patients with early unfavorable HL to:

  • Four cycles of ABVD plus 30 Gy of IF-XRT.
  • Four cycles of ABVD plus 20 Gy of IF-XRT.
  • Four cycles of BEACOPP plus 30 Gy of IF-XRT.
  • Four cycles of BEACOPP plus 20 Gy of IF-XRT.

With a 6.8 year median follow-up no differences were observed in OS (93%–96%) for all four groups.[12,13][Level of evidence: 1iiA] In the arms of the study with 30 Gy of IF-XRT, there was no difference in FFTF between BEACOPP and ABVD (P = .65), but a significant difference in favor of BEACOPP was seen for FFTF when 20 Gy of IF-XRT was used (P = .02).[13][Level of evidence: 1iiD]

A prospective, randomized trial from the European Organization for Research and Treatment of Cancer and Groupe d'Etudes de Lymphomes de L'Adulte of 808 patients with early unfavorable HL compared:

  • Four cycles of ABVD plus 30 Gy of IF-XRT.
  • Six cycles of ABVD plus 30 Gy of IF-XRT.
  • Four cycles of BEACOPP plus 30 Gy of IF-XRT.

With a 64-month median follow-up, in a preliminary report in abstract form, no differences were observed in event-free survival (89%–92%; P = .38) or OS (91%–96%; P = .98).[14][Level of evidence: 1iiA]

In summary, these randomized trials support the use of ABVD for four cycles with 20 Gy to 30 Gy IF-XRT. Could the radiation therapy be omitted to minimize late morbidity and mortality from secondary solid tumors and from cardiovascular disease?[15] The NCIC study is the only trial to address this question in patients with early unfavorable HL; although four to six cycles of ABVD alone has improved OS compared with a combined modality approach, the use of EF-XRT in the combined modality arm is excessive by current standards, and late effects will be magnified with these larger fields.[7] In addition, chemotherapy alone was 8% worse in freedom-from-progression compared to the combined modality approach. How can we balance an improvement in freedom-from-progression using radiation therapy with chemotherapy against late morbidity and mortality from late effects?[15,16] Randomized studies with or without IF-XRT would be required, but no such studies are currently under way.[15] A Cochrane meta-analysis of 1,245 patients in five randomized, clinical trials suggested improved survival for combined modality therapy versus chemotherapy alone (HR, 0.40; 95% CI, 0.27–0.61), but long-term follow-up, which would account for late toxicities and deaths from therapy, will not be forthcoming from most of these trials.[17]

Patients with bulky disease (≥10 cm) or massive mediastinal involvement were excluded from most of the aforementioned trials. Based on historical comparisons to chemotherapy or radiation therapy alone, these patients currently receive combined modality therapy.[18,19][Level of evidence: 3iiiDiii]

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WebMD Public Information from the National Cancer Institute

Last Updated: February 25, 2014
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.
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