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Treatment

Optimal treatment of Hodgkin lymphoma depends on the histologic stage of the disease. The following table summarizes the recommended treatment according to these factors using an algorithm depending on information determined from the recommended staging procedures above. Patients who do not have a complete response to the primary treatment noted in this table should be discussed with a medical or radiation oncologist.

Definitions 

Involved Node Radiotherapy (INRT)

Adopted mainly from Campbell’s papers on “INRT<5cm” = pre- and post-chemo involved lymph nodes (within post-chemo anatomical limits) + 1.5-5cm to field edge[1] or to PTV[2], [3]

  • CTV = pre- and post-chemo involved lymph node(s), restricted by post-chemo anatomic limits, + 1cm axially and 1-4cm cranio-caudally along lymphatic pathways
    • o cranio-caudal margin adjusted based on level of uncertainty in localization of PET-avid abnormality (allows for positional and anatomical changes from pre-chemo PET to RT)[2], [3]
  • PTV = CTV + ~1cm, depending on set-up variation and physiological intra-fraction and inter-fraction movement[4]
  • Mediastinal Area[4], [5]
    • Length of CTV = length of mediastinal mass or LN(s) before chemo
    • Width of CTV = width of mediastinal mass or LN(s) after chemo
    • The normal mediastinum is contoured and the CTV should not exceed the lateral mediastinal boundaries, except where LN remnants persist

Residual Disease Radiotherapy (RDRT)

  • CTV = pre- and post-chemo involved lymph node(s), restricted by post-chemo anatomic limits, + 1cm axially and 1-4cm cranio-caudally along lymphatic pathways
    • cranio-caudal margin adjusted based on level of uncertainty in localization of PET-avid abnormality (allows for positional and anatomical changes from pre-chemo PET to RT)[2], [3]
    • Do not include any pre-chemo involved LN region that is far away from the residual disease
  • PTV = CTV + ~1cm, depe​nding on set-up variation and physiological intra-fraction and inter-fraction movement[4]
  • Mediastinal Area[4], [5]
    • Length of CTV = length of mediastinal mass or LN(s) before chemo
    • Width of CTV = width of mediastinal mass or LN(s) after chemo
    • The normal mediastinum is contoured and the CTV should not exceed the lateral mediastinal boundaries, except where LN remnants persist

References

[1] B. A. Campbell et al., “Involved-Nodal Radiation Therapy As a Component of Combination Therapy for Limited-Stage Hodgkin's Lymphoma: A Question of Field Size,” Journal of Clinical Oncology, vol. 26, no. 32, pp. 5170–5174, Oct. 2008.

[2] B. A. Campbell et al., “Long-term outcomes for patients with limited stage follicular lymphoma,” Cancer, vol. 116, no. 16, pp. 3797–3806, May. 2010.

[3] B. A. Campbell, J. M. Connors, R. D. Gascoyne, W. J. Morris, T. Pickles, and L. H. Sehn, “Limited-stage diffuse large B-cell lymphoma treated with abbreviated systemic therapy and consolidation radiotherapy,” Cancer, vol. 118, no. 17, pp. 4156–4165, Jan. 2012.

[4] T. Girinsky, “Radiotherapy Recommendations for Patients with Early Stage Hodgkin's Lymphoma: Involved Node Radiation Therapy (INRT),” pp. 1–9, Mar. 2008.

[5] T. Girinsky et al., “The conundrum of hodgkin lymphoma nodes: To be or not to be included in the involved node radiation fields. The EORTC-GELA lymphoma group guidelines,” Radiotherapy and Oncology, vol. 88, no. 2, pp. 202–210, Aug. 2008.

[6] P. J. Hoskin, P. Díez, M. Williams, H. Lucraft, and M. Bayne, “Recommendations for the Use of Radiotherapy in Nodal Lymphoma,” Clinical Oncology, vol. 25, no. 1, pp. 49–58, Jan. 2013.

Standard and Experimental Treatment - Overview

  1. The standard treatment of early stage Hodgkin lymphoma at BCCA is two cycles of chemotherapy followed by assessment with PET scan. If the PET scan is negative treatment should be concluded with two more cycles of chemotherapy. If the PET scan is positive treatment should be concluded with residual disease radiation therapy.
  2. Standard chemotherapy of advanced Hodgkin lymphoma at BCCA is ABVD. This type of chemotherapy has been shown to be the best available in large prospective randomized trials. (Canellos, NEJM, 1992;327:1478; Duggan, J Clin Oncol 2003;21:607.)
  3. High risk disease. Criteria which can identify patients with high risk advanced Hodgkin lymphoma are available (Hansenclever, New Engl J Med, 1998;339: 1506-14). Each of the following factors has an equivalent negative impact on survival.

 Age

 >45 years

 Gender 

 male

 Stage

 IV

 Hemoglobin

 <105 g/L

 Albumin, serum 

 <40 g/L

 WBC

 >15.0 x 109/L

 Lymphocytes

 count <0.6 x 109/L or percent <8% of WBC


When three or more of these factors are present at diagnosis (high risk), risk of treatment failure is high and the likelihood of cure with ABVD alone is only about 70%. Therefore, patients less than 66 years of age with advanced Hodgkin lymphoma and four or more of these factors should be offered treatment with experimental treatment on a clinical trial if available. Please check with one of the chemotherapists associated with the Lymphoma Tumor Group for information about which such clinical trials are available. 

Standard Treatment - Specific Details

 Stage 

 Bulk*

 Risk Factors**

 Age    (y)

 Treatment

 1A,  1B  or  2A

 low

 0-7

 any

 CT***x 2 then PET scan

 if PET neg -> CT x 2 more cycles

 if PET pos -> INRT

 1A, 1B  or 2A

 high

 0-7*****

 any

 CTx6 then CT scan and marrow biopsy if originally  positive

 If CR, no further treatment

 If otherwise in CR but residual mass > 2 cm do PET  scan

 If PET neg, no further treatment

 If PET pos and encompassable in a reasonable  radiation volume-> RDRT

 If PET pos and not encompassable in a reasonable  radiation volume-> close observation or biopsy to  direct further treatment on proof of persistent  lymphoma

 2B
 3A or  3B
 4A or  4B

 any


* Bulk: low = no tumor mass >10 cm; high = any single tumour mass > = 10 cm (note: round to nearest whole cm, e.g. 9.5 cm = 10 cm but 9.4 cm = 9 cm)
** Risk defined using the prognostic index described above in section 2.3.2.3
*** CT=chemotherapy, ABVD
**** RDRT=residual disease radiation therapy
***** If 4 or more risk factors present consider enrollment on clinical trial, if available

SOURCE: Treatment ( )
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