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historical management of Hodgkin's disease

Management: 1) treatment based on stage (older recommendations) a) Stage IA & IIA: - involved field radiation alone - extended field radiation alone for older patients b) Stage IIIA: radiation or chemotherapy c) Stage IIIB & IV: chemotherapy d) B symptoms: chemotherapy 2) chemotherapy (historical) a) the first effective combination chemotherapy for Hodgkin's disease was introduced in 1960, MOPP (mechlorethamine (nitrogen mustard), vincristine (Oncovin), procarbazine, prednisone) b) MOPP has been associated with 84% complete remission & 48% 14 year survival c) toxicities of MOPP include - nausea & vomiting - bone marrow suppression - sterility d) MOPP therapy has been associated with a 2% risk of developing secondary leukemia within 10 years of therapy; the leukemia is acute non-lymphocytic leukemia e) none of the newer regimens has proven superior to the original MOPP - ABVD (adriamycin, bleomycin, vinblastine, & dacarbazine) - has been used to treat Hodgkin's disease refractory to MOPP - toxicities of ABVD are similar to MOPP, but may be associated with fewer secondary malignancies, but increased incidence of myocardial & pulmonary damage - preferred 1st line agent [1] - 4 cycles of ABVD - 2-3 cycles may be sufficient for early stage (stage I & II) Hodgkin's disease [1,2,4] - sequential combinations of MOPP & ABVD may show more favorable outcomes - brentuximab vedotin (Adcetris) FDA-approved for relapsed or refractory Hodgkin's lymphoma - bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine & prednisone for patients with disease activity demonstrated on PET scan after 3 cycles of ABVD [1,3] f) chemotherapy alone (without radiation) for stage 3 or 4

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015
  2. Engert A et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med 2010 Aug 12; 363:640. PMID: 20818855
  3. Kostakoglu L, Coleman M, Leonard JP et al PET predicts prognosis after 1 cycle of chemotherapy in aggressive lymphoma and Hodgkin's disease. J Nucl Med. 2002 Aug;43(8):1018-27. PMID: 12163626
  4. Ferme C, Eghbali H, Meerwaldt JH et al Chemotherapy plus involved-field radiation in early-stage Hodgkin's disease. N Engl J Med. 2007 Nov 8;357(19):1916-27. PMID: 17989384