Treatment Approach for Children and Adolescents with Hodgkin Lymphoma
Investigators have evaluated a regimen of vincristine, doxorubicin, methotrexate, and prednisone (VAMP) to treat children and adolescents with Hodgkin lymphoma. Results were good for patients with low-stage disease without B symptoms or bulky disease. VAMP combined with COP (cyclophosphamide, vincristine, and procarbazine) was inadequate for the treatment of patients with advanced disease.
Certain protocols have used dexrazoxane with doxorubicin in an effort to lower cardiopulmonary toxicity.; [Level of evidence: 1iiDi] There remains controversy about the risk of treatment-related AML (tAML) in Hodgkin lymphoma patients receiving dexrazoxane concurrent with etoposide.[12,19] Listed below (Table 1) are the combination chemotherapy regimens that have been utilized for children and young adults with Hodgkin lymphoma.
Table 1. Combination Chemotherapy Regimens Commonly Used for Children and Young Adults with Hodgkin Lymphoma
|Chemotherapy Regimen ||Corresponding Agents|
|ABVD ||doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine|
|ABVE ||doxorubicin (Adriamycin), bleomycin, vincristine, etoposide|
|VAMP ||vincristine, doxorubicin (Adriamycin), methotrexate, prednisone|
|OPPA +/- COPP (females) [11,21]||vincristine (Oncovin), prednisone, procarbazine, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine|
|OEPA +/- COPP (males) ; OEPA +/- COPDAC (males)||vincristine (Oncovin), etoposide, prednisone, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine, dacarbazine|
|COPP/ABV ||cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine, doxorubicin (Adriamycin), bleomycin, vinblastine|
|BEACOPP (advanced stage) ||bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine|
|COP(P) (with or without prednisone)||cyclophosphamide, vincristine (Oncovin), � prednisone, procarbazine|
|CHOP||cyclophosphamide, doxorubicin (Adriamycin), vincristine (Oncovin), prednisone|
|ABVE-PC ||doxorubicin (Adriamycin), bleomycin, vincristine, etoposide, prednisone, cyclophosphamide|
|MOPP/ABV ||mechlorethamine, vincristine (Oncovin), procarbazine, prednisone, doxorubicin (Adriamycin), bleomycin, vinblastine|
Radiation Therapy for Children and Adolescents with Hodgkin Lymphoma
As discussed in the previous sections, most newly diagnosed children will be treated with risk-adapted chemotherapy alone or in combination with LD-IFRT. LD-IFRT involves the use of meticulous and judiciously designed fields to achieve local control of disease and to minimize damage to normal tissue.
The appropriate treatment volume is often protocol-specific but generally includes the initially involved lymph node region(s). Additional considerations relate to the location of disease (e.g., pericardium, and chest wall). In early stage Hodgkin lymphoma, the definition of IFRT depends on the anatomy of the region in terms of lymph node distribution, patterns of disease extension into regional areas, and consideration for match line problems should disease recur. Traditional definitions of lymph node regions can be helpful but may not be sufficient. For example, the cervical and supraclavicular (SCV) lymph nodes are generally treated when abnormal nodes are located anywhere within this area; this is consistent with the anatomic definition of lymph node regions used for staging purposes. The hila are irradiated when the mediastinum is involved, however, despite the fact that the hila and mediastinum are separate lymph node regions. Similarly, the SCV lymph nodes are often treated when the axilla or mediastinum is involved, and the ipsilateral external iliac nodes are often treated when the inguinal nodes are involved. In both these situations, however, care must be taken to shield relevant normal tissues as much as possible (such as the breast when the axilla or mediastinum is involved and ovaries when the inguinal nodes are involved). Moreover, the decision to treat the axilla or mediastinum without the SCV lymph nodes and the inguinal nodes without the iliac nodes may be appropriate, depending on the size and distribution of involved nodes at presentation.