Evolving approaches to primary treatment of Hodgkin lymphoma.

Two challenges confront the clinician treating Hodgkin lymphoma today: achieving a high level of effectiveness while minimizing toxicity. At least 80% of patients can be cured with currently available chemotherapy regimens, augmented in selected patients with the addition of involved field radiation or intensified chemotherapy assisted by granulocyte growth factors or stem cell transplantation. Major late toxicity including infertility, premature menopause, cardiovascular disease and second neoplasms can be avoided in most patients if the treatment program is chosen carefully. The extent of disease (stage) and, for advanced stage lymphoma, the presence of well-characterized prognostic factors can be established with readily available clinical, laboratory and imaging techniques. Results from carefully designed and analyzed clinical trials have identified optimal treatment approaches for patients with limited and advanced stage disease. Those with limited stage Hodgkin lymphoma should be treated with brief chemotherapy, only augmented with involved field irradiation if an early complete remission is not achieved. Most patients with advanced stage lymphoma can be cured with an extended course of ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine). The small minority under the age of 60 years with an International Prognostic Factors Project score of 5 or greater should be considered for intensified chemotherapy. Patients known to have bulky tumor(s) (> 10 cm) at diagnosis may require adjuvant irradiation at the conclusion of chemotherapy, but its utility has not been unequivocally established and radiation should be avoided in those who achieve a complete remission, where it is known to be ineffective. With careful selection of treatment program most patients found to have Hodgkin lymphoma today can be offered a high probability of cure and a low likelihood of major late toxicity. However, without detailed attention to the extent of lymphoma and other prognostic factors, there is as much danger of over-treatment as under-treatment. Only by thoughtfully adjusting the treatment program to the extent of disease and response to treatment can the clinician determine the optimal approach, maximizing likelihood of cure and minimizing late toxicity.