Abstract
Response-adapted randomized trials have used positron emission tomography-computed tomography to attempt to identify patients with early-stage favorable Hodgkin lymphoma (ESFHL) who could be treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiation therapy (RT). While maximal efficacy is demonstrated with combined modality therapy, RT is often omitted in fear of late adverse effects; however, the application of modern RT could limit these toxic effects. To determine the radiation doses delivered to organs at risk with modern involved-site RT among patients with ESFHL treated with 20 Gy after 2 cycles of ABVD. This case series included 42 adult patients with ESFHL (according to the German Hodgkin Study Group criteria) who were treated between 2010 and 2019, achieved complete response by positron emission tomography-computed tomography (1-3 on 5-point scale) following 2 cycles of ABVD, and then received consolidative RT. The study was conducted at a single comprehensive cancer center. 2 cycles of chemotherapy followed by 20-Gy involved-site RT. The medical records of patients with ESFHL were examined. Organs at risk were contoured, and doses were calculated. Progression-free survival, defined from date of diagnosis to disease progression, relapse, or death, and overall survival were estimated using the Kaplan-Meier method. The cohort comprised 42 patients with ESFHL (median [range] age at diagnosis, 35 [18-74] years; 18 [43%] women; 24 [57%] with stage II disease). At a median follow-up of 44.6 (95% CI, 27.6-61.6) months, the 3-year progression-free survival and overall survival rates were 91.2% (95% CI, 74.9%-97.1%) and 97.0% (95% CI, 80.4%-99.6%), respectively. The mean heart dose was less than 5 Gy (mean, 0.8 Gy; SD, 1.5 Gy; range, 0-4.8 Gy) in all patients. The mean (SD) breast dose for both breasts was 0.1 (0.2) Gy (left breast range, 0-1.0 Gy; right breast range, 0-0.9 Gy). In this study, combined modality therapy with 2 cycles of ABVD and 20 Gy for ESFHL was highly effective and avoided excess doses to organs at risk, which may limit long-term toxic effects.
Highlights
The HD.[6] trial, which compared outcomes among patients with limited-stage Hodgkin lymphoma (HL) who were treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) alone vs subtotal nodal radiation therapy (RT) with or without 2 cycles of ABVD, demonstrated superior 12-year progression-free survival (PFS) with combined modality therapy (CMT) but inferior 12-year overall survival (OS) rates, which were attributed to increased cardiovascular events and secondary malignant neoplasms.[1]
early-stage favorable HL (ESFHL), as defined by the German Hodgkin Study Group (GHSG), who achieved a complete response according to PET-CT imaging (1-3 on a 5-point scale, per Lugano criteria) after 2 cycles of chemotherapy and went on to receive 20 Gy of consolidative involved-site radiation therapy (ISRT) were eligible for inclusion in the retrospective analysis.[5,12]
11 (79%) had disease that extended below the carina, and 2 (14%) had disease that extended below the left main coronary artery
Summary
The HD.[6] trial, which compared outcomes among patients with limited-stage Hodgkin lymphoma (HL) who were treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) alone vs subtotal nodal radiation therapy (RT) with or without 2 cycles of ABVD, demonstrated superior 12-year progression-free survival (PFS) with combined modality therapy (CMT) but inferior 12-year overall survival (OS) rates, which were attributed to increased cardiovascular events and secondary malignant neoplasms.[1] This trial is cited as a cautionary tale for oncologists who recommend CMT; it is not reflective of today’s treatment approaches, which incorporate involved-site radiation therapy (ISRT) delivered with modern techniques. Other responseadapted HL studies have used PET-CT imaging to identify patients who could be treated with abbreviated ABVD without consolidative RT.[7,8] While these studies have demonstrated maximal disease control for patients treated with CMT, concerns regarding potential long-term radiationrelated toxic effects, including secondary malignant neoplasms and cardiac damage, have prompted some oncologists to offer ABVD alone as an alternative treatment strategy.[9]
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