eMedicine Specialties > Hematology > Stem Cells and Disorders

Hodgkin Disease: Treatment & Medication

Author: Scott K Dessain, MD, PhD, Associate Professor, Lankenau Institute for Medical Research
Coauthor(s): James L Spears, MD, Consulting Staff, Bux-Mont Hematology Oncology Medical Associates; Athanassios Argiris, MD, Associate Professor, Department of Medicine, Division of Hematology-Oncology, University of Pittsburgh
Contributor Information and Disclosures

Updated: Oct 4, 2009

Treatment

Medical Care

Principles of therapy for Hodgkin disease (Hodgkin's lymphoma)

  • Published guidelines from the National Comprehensive Cancer Network (NCCN),12 the European Society of Medical Oncology (ESMO),13 and the International Harmonization Project14 provide consensus opinions from leading experts on evidence-based approaches to the diagnosis and treatment of Hodgkin disease (Hodgkin's lymphoma).
  • Hodgkin disease (Hodgkin's lymphoma) is considered to be a curable malignancy, but therapies for this disease can have significant long-term toxicity. Therefore, advances in treatment protocols have sought to (1) minimize the treatment given to patients with early stage, low-risk disease and (2) safely maximize the treatment given to patients with disease that is likely to be refractory to standard therapies.
  • Combined-modality therapy (radiation therapy [XRT] and chemotherapy) is frequently the preferred approach in for most patients. In early stage disease, combined-modality therapy provides a synergistic effect while limiting the total exposure to any particular agent.15 In patients with advanced Hodgkin disease (Hodgkin's lymphoma), involved-field XRT can be used for sites of persistent disease following chemotherapy. XRT to sites of disease that were bulky at diagnosis is a standard feature of the Stanford V regimen (see Chemotherapy, Stanford V regimen, below).
  • The high sensitivity of positron emission tomography (PET) scanning for classic Hodgkin disease (Hodgkin's lymphoma) has this imaging modality a prominent role in the assessment of treatment response in affected patients. A positive PET scan following therapy correlates strongly with a high risk of relapse. An early attainment of a negative PET scan during therapy is a positive prognostic indicator, but studies have not yet provided information on whether a course of therapy can be safely shortened in this situation.16,17 PET/CT scans should be obtained at least 3 weeks, and preferably 6-8 weeks following the last therapy in order to lessen the risk of false-positive scans resulting from nonmalignant inflammatory responses.18 Biopsies of PET-positive lesions are typically done in order to test for persistent Hodgkin disease (Hodgkin's lymphoma).
  • The goal of therapy is to induce a complete remission (CR), which is defined as the "disappearance of all evidence of disease," as evaluated by PET/CT scanning, physical examination, and bone marrow examination (if appropriate). A partial remission (PR) is defined as "regression of measurable disease and no new sites" of disease.
  • Despite the high rate of cure for this disease, many cases Hodgkin disease (Hodgkin's lymphoma) do relapse. In most of these cases, salvage chemotherapy followed by high-dose chemotherapy (HDC) with autologous hematopoietic stem cell support is indicated.19
  • The role of allogeneic hematopoietic stem cell transplantation for Hodgkin disease (Hodgkin's lymphoma) is being explored.20 It is possible that a graft-vs-lymphoma effect may contribute to favorable outcomes in affected patients, but mortality directly resulting from the transplant procedure has been unacceptably high. Newer transplant protocols that use less-intensive conditioning regimens (chemotherapy) offer the potential for long-term disease-free survival (DFS) with less transplant-related mortality.21 Allogeneic hematopoietic stem cell transplantation should ideally be pursued only in the context of a clinical trial.
  • Because of the limited number of patients with Hodgkin disease (Hodgkin's lymphoma) and the importance of the clinical questions that remain about optimal disease management, patient involvement in clinical trials is strongly encouraged.
  • NLPHD is clinically distinct from classic Hodgkin disease (Hodgkin's lymphoma) in that it generally presents as early stage disease that can be treated with local measures (surgery, radiation) or followed expectantly. Some cases of NLPHD can transform to aggressive non-Hodgkin lymphomas that are treated using standard paradigms.
XRT

For treatment of classic Hodgkin disease (Hodgkin's lymphoma), XRT is generally administered in combination with chemotherapy. Radiation fields and doses are selected to minimizing the potential side effects of therapy, while maximizing the potential for long-term DFS. Involved-field therapy encompasses only the areas of observed disease. Regional-field therapy extends the involved field to include adjacent lymph regions.

Other fields that have been used historically and may be used in exceptional clinical circumstances include the mantle field, covering the mediastinal, cervical, and axillary nodes, and the inverted Y field, covering the para-aortic, pelvic, and inguinal nodes. Subtotal nodal irradiation involves the mantle field plus the para-aortic nodes. The mantle field is shaped in order to reduce radiation exposure to the heart and lungs. Careful avoidance of the spinal cord can reduce the risk of myelitis. Shielding the testes and oophoropexy (temporary surgical suspension of the ovaries [eg, outside of a radiation field]) are important during the reproductive years.

The dose of radiation to be administered is tailored to the specific clinical scenario. Doses used in combined modality therapy are 30-36 Gy for bulky disease sites and 20-30 Gy for nonbulky disease sites. When used alone, doses may range from 30-44 Gy.

In the NLPHD subtype of Hodgkin disease (Hodgkin's lymphoma), involved-field XRT may be recommended for stage IA and IIA disease.

Chemotherapy

Induction regimens are those given as initial treatment for Hodgkin disease (Hodgkin's lymphoma).

  • MOPP regimen (mechlorethamine, vincristine, procarbazine, prednisone) was the first effective combination chemotherapy developed for Hodgkin disease (Hodgkin's lymphoma). It is a 4-drug regimen developed by Vincent DeVita and colleagues at the NCI in the mid 1960s and is primarily of historical importance.
  • The ABVD regimen (Adriamycin, bleomycin, vinblastine, dacarbazine) was designed in Italy by Gianni Bonadonna and his colleagues in the early 1970s. This combination has now become the standard chemotherapy regimen for Hodgkin disease (Hodgkin's lymphoma). ABVD is superior to MOPP in terms of DFS and has a lower incidence of sterility and secondary leukemia.22
  • [#StanfordV]The Stanford V regimen (doxorubicin, vinblastine, mustard, bleomycin, vincristine, etoposide, prednisone) is a multidrug regimen created at Stanford University by Sandra Horning and colleagues.23 The drugs are administered weekly, alternating myelosuppressive and nonmyelosuppressive agents, for 12 weeks. Involved-field XRT at the conclusion of the 12-week regimen is an important part of this regimen. A potential advantage of the Stanford V regimen is that its use of a broad spectrum of chemotherapy drugs can limit the exposure (and potential side-effects) of any single drug.
  • The BEACOPP regimen (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) was developed in Germany by Volker Diehl and colleagues.24 A dose-intensified version of BEACOPP (escalated BEACOPP), with higher doses of etoposide, Adriamycin, and cyclophosphamide and the addition of granulocyte colony-stimulating factor (G-CSF) for neutrophil support, has also been developed, which may be useful for unfavorable, advanced-stage Hodgkin disease (Hodgkin's lymphoma). However, escalated BEACOPP is associated with greater hematologic toxicity and a higher incidence of secondary malignancies, including acute myelogenous leukemia (AML).
Ongoing clinical trials will directly compare the ABVD regimen to the Stanford V and escalated BEACOPP regimens.


Salvage chemotherapy

For patients whose disease has failed induction chemotherapy, salvage chemotherapy is generally given. Salvage regimens incorporate drugs that are complementary to those that failed during induction therapy. Commonly used salvage regimens include ICE (ifosfamide, carboplatin, etoposide), DHAP (cisplatin, cytarabine, prednisone), and ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin).

HDC with bone marrow transplantation

HDC at doses that ablate the bone marrow is feasible with reinfusion of the patient's previously collected hematopoietic stem cells (autologous transplantation) or infusion of stem cells from a donor source (allogeneic transplantation). Historically, hematopoietic stem cells have been obtained from bone marrow, but they are now typically obtained by pheresis of peripheral blood lymphocytes. A validated and relatively safe conditioning regimen for autologous transplantation is the BEAM regimen (carmustine [BCNU], etoposide, cytarabine, melphalan).19


Specific Regimens

Each of the medications in all of the regimens described in the article are given intravenously, except for prednisone and procarbazine, which are given orally.


Induction (for initial disease treatment)

MOPP regimen
 Every 28 days for 6 or more cycles.

  • Mechlorethamine: 6 mg/m2, days 1 and 8
  • Vincristine: 1.4 mg/m2, days 1 and 8
  • Procarbazine: 100 mg/m2, days 1-14
  • Prednisone: 40 mg/m2, days 1-14, cycles 1 and 4 only

ABVD regimen
Every 28 days for 6 or more cycles.

  • Adriamycin: 25 mg/m2, days 1, 15
  • Bleomycin: 10 mg/m2, days 1, 15
  • Vinblastine: 6 mg/m2, days 1, 15
  • Dacarbazine: 375 mg/m2, days 1, 15

Stanford V regimen25
XRT is administered to bulky sites 2-4 weeks following the end of chemotherapy.

  • Vinblastine: 6 mg/m2, weeks 1, 3, 5, 7, 9, 11
  • Doxorubicin: 25 mg/m2, weeks 1, 3, 5, 9, 11
  • Vincristine: 1.4 mg/m2, weeks 2, 4, 6, 8, 10, 12
  • Bleomycin: 5 units/m2, weeks 2, 4, 8, 10, 12
  • Mechlorethamine: 6 mg/m2, weeks 1, 5, 9
  • Etoposide: 60 mg/m2 twice daily, weeks 3, 7, 11
  • Prednisone: 40 mg/m2, every other day, weeks 1-10, tapered weeks 11, 12

Escalated BEACOPP regimen
Every 3 weeks for 8 cycles.

  • Bleomycin: 10 mg/m2, day 8
  • Etoposide: 200 mg/m2, days 1-3
  • Doxorubicin: 35 mg/m2, day 1
  • Cyclophosphamide: 1,250 mg/m2, day 1
  • Vincristine: 1.4 mg/m2, day 8
  • Procarbazine: 100 mg/m2, days 1-7
  • Prednisone: 40 mg/m2, days 1-14


Salvage Therapy (for primary refractory or relapsed disease)

ICE regimen

  • Ifosfamide: 5 g/m2, day 2
  • Mesna: 5 g/m2, day 2
  • Carboplatin: AUC 5, day 2
  • Etoposide: 100 mg/m2, days 1-3

DHAP regimen

  • Cisplatin: 100 mg/m2, day 1
  • Cytarabine: 2 g/m2, given twice on day 2
  • Dexamethasone: 40 mg, days 1-4

EPOCH regimen – In this regimen, etoposide, vincristine, and doxorubicin are given together over a total of 96 hours in a continuous intravenous infusion.

  • Etoposide: 50 mg/m2, days 1-4
  • Vincristine: 0.4 mg/m2, days 1-4
  • Doxorubicin: 10 mg/m2, days 1-4
  • Cyclophosphamide: 750 mg/m2, day 5
  • Prednisone: 60 mg/m2, days 1-6


Myeloablative Regimens (high-dose therapy requires hematopoietic stem cell support for recovery)

BEAM regimen

 Different schedules for BEAM exist that vary primarily in the dose of etoposide administered. This is the version used by Schmitz et al in a key randomized, prospective clinical trial.19 Following this chemotherapy, autologous hematopoietic stem cells are administered on day 0.

  • BCNU 300 mg/m2, day –7
  • Etoposide 150 mg/m2, every 12 hours, total of 8 doses, days –7 to –4
  • Cytarabine 200 mg/m2, every 12 hours, total of 8 doses, days –7 to –4
  • Melphalan 140 mg/m2, day –3


Targeted Therapies

Targeted immunotherapeutic agents are currently being evaluated for potential use in Hodgkin disease (Hodgkin's lymphoma).26 The CD30 cell surface antigen, which is expressed at high levels on Reed-Sternberg cells, is a target of 2 monoclonal antibodies, SGN-30 and MDX-60.27,28,29 Each has shown modest activity when administered to patients with refractory or recurrent Hodgkin disease (Hodgkin's lymphoma).

Specifics of treatment by stage and clinical presentation

Treatment of Hodgkin disease (Hodgkin's lymphoma) is tailored to disease type, disease stage, and an assessment of the risk of resistant disease. Two sets of consensus guidelines currently help guide the standard of care for Hodgkin disease (Hodgkin's lymphoma), written by the NCCN and the ESMO.

The guidelines are very similar, but the NCCN guidelines have more specific recommendations for response evaluation and follow-up. In addition, a set of revised response criteria for malignant lymphoma, including Hodgkin disease (Hodgkin's lymphoma), and recommendations for using PET scanning to monitor Hodgkin disease (Hodgkin's lymphoma) were published by the International Harmonization Project. Together, these provide specific guidance for evaluating the response of disease therapy.

Goals of therapy

The primary goal of therapy is to induce a CR, which is defined as the "disappearance of all evidence of disease," as evaluated by PET/CT scanning, physical examination, and bone marrow examination (if appropriate).14 PET/CT scanning should be obtained at least 3 weeks and preferably 6-8 weeks following the last therapy in order to lessen the risk of false-positive scans resulting from nonmalignant inflammatory responses. A PR is defined as "regression of measurable disease and no new sites" of disease. A failure to achieve a CR with initial therapy or a relapse after having attained a CR is an indication for additional HDC and/or XRT, often with autologous hematopoietic stem cell support.

Early stage, low-risk disease

This group is defined as patients with clinical stages IA or IIA classic Hodgkin disease (Hodgkin's lymphoma) who do not have unfavorable factors (bulky disease, elevated ESR, >3 sites of involvement, B symptoms, extranodal disease).15,30 These patients generally should receive 4 cycles of the ABVD regimen or 8 weeks of the Stanford V regimen, followed by involved-field XRT. Radiation alone has been shown to be inferior to the combined modality approach in early stage, low-risk disease. If XRT is contraindicated or not possible, then chemotherapy should continue for 2 additional cycles following the attainment of a CR.

Early stage disease with unfavorable factors

This group is defined as patients with clinical stages I or II with bulky disease, with or without unfavorable factors (elevated ESR, >3 sites of involvement, B symptoms, extranodal disease). These patients are candidates for 4-6 cycles of the ABVD regimen or 12 weeks of the Stanford V regimen, followed by involved-field XRT.

Advanced and/or high-risk disease

These patients have stage I or II disease with B symptoms (IB, IIB), or stages III or IV. The NCCN recommends either 4 cycles of the ABVD regimen or 12 weeks of the Stanford V regimen, followed by restaging with PET/CT scanning. If a patient has positive results on PET scans following the ABVD regimen, an additional 2 cycles are administered. Once a CR has been achieved, involved-field XRT is given. If, after 12 weeks of the Stanford V regimen, a patient is in a CR or PR has been attained, then involved-field XRT is standard.

EMSO recommends that patients with this category of disease receive either 8 cycles of the ABVD regimen or the standard-dose BEACOPP regimen, with involved-field XRT applied only to tumors initially more than 7.5 cm or to sites of residual disease following chemotherapy. For patients with advanced-stage disease, the use of the escalated BEACOPP regimen has support in the literature.

NLPHD

Early-stage NLPHD can be treated with local excision, involved-field XRT, or expectant management (close observation).31 Advanced-stage disease may represent histologic transformation to T-cell rich B-cell lymphoma (TCR-BCL) or diffuse large cell B-cell lymphoma (DLCBL). These are types of non-Hodgkin lymphoma that should be treated with a typical non-Hodgkin regimen, such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone).

Rituximab is a humanized monoclonal antibody that is specific for CD20, a cell-surface antigen expressed by the malignant L&H cells in NLPHD. It has shown activity as a single agent in NLPHD. The German Hodgkin Lymphoma Study Group (GHSG) published long-term follow-up data on the use of rituximab in patients with relapsed/refractory NLPHD.32 The investigators observed a 94% overall response rate, with 8 complete remissions from their population of 15 patients.32 Therefore, rituximab is a promising agent for advanced NLPHD, although the use of rituximab in NLPHD, especially in early-stage disease, should ideally be pursued in the context of a clinical trial.

Hodgkin disease (Hodgkin's lymphoma) with concomitant HIV infection

In patients with advanced Hodgkin disease (Hodgkin's lymphoma) and HIV, the results with standard chemotherapy (eg, ABVD, BEACOPP) can be dramatically improved by simultaneous treatment with highly active antiretroviral therapy (HAART). Such therapy generally involves 3 drugs: 2 nucleoside reverse transcriptase inhibitors combined with either a protease inhibitor, a nonnucleoside reverse transcriptase inhibitor, or a viral fusion inhibitor.

Relapsed or primary refractory disease

Hodgkin disease (Hodgkin's lymphoma) that has never entered a CR or that has relapsed after the attainment of a CR is associated with a very poor prognosis when treated with standard chemotherapy and radiation. Therefore, for patients with relapsed or refractory disease, HDC with autologous stem cell transplantation is recommended.33 In this procedure, salvage chemotherapy is first administered to help reduce the size of the persistent disease and obtain a CR, if possible. The number of cycles to be administered depends on how well the disease is responding to therapy. An optimal situation is one in which the disease enters a CR with negative PET scan findings, although one study demonstrated that patients may achieve long-term DFS, even if their condition has little or no response.34

Following one of the cycles of salvage chemotherapy, hematopoietic stem cells are collected from the peripheral blood by leukapheresis and are stored frozen. Following the administration of myeloablative chemotherapy (eg, BEAM), the stored hematopoietic stem cells are thawed and reinfused into the patient to facilitate hematopoietic recovery. HDC with autologous stem cell transplantation can provide better than 50% long-term, progression-free survival for patients with relapses, although specific predicted outcomes vary widely depending on patient-specific risk factors.

Many questions relating to salvage and HDC therapy for patients with Hodgkin disease (Hodgkin's lymphoma) need to be addressed and are the subject of ongoing clinical trials. These include (1) the optimal salvage regimen or regimens, (2) the ideal conditioning regimen or regimens, (3) the potential benefits of twin transplants compared with single transplants, and (4) how to prospectively identify those patients who are unlikely to benefit from HDC and how to best manage their disease.

In some cases in which HDC fails, allogeneic stem cell transplantation may be a viable option. In this method, myeloablative therapy (chemotherapy and sometimes XRT) is followed by the infusion of hematopoietic stem cells from a genetically matched donor.20 This offers the potential for an immunologic antitumor effect from T cells provided by the hematopoietic stem cell donor, which may improve the chances for cure of the disease.

Historically, allogeneic stem cell transplantation for Hodgkin disease (Hodgkin's lymphoma) has been considered too high risk for most patients due a high transplant-related mortality. However, new transplant protocols use less toxic conditioning regimens and may be safer and more effective for patients with refractory Hodgkin disease (Hodgkin's lymphoma).21

Consultations

The following consultations should be sought in cases of Hodgkin disease (Hodgkin's lymphoma)

  • Hematologist/oncologist
  • Radiation oncologist
  • Social worker
  • Tertiary care center for consideration of clinical trial enrollment

More on Hodgkin Disease

Overview: Hodgkin Disease
Differential Diagnoses & Workup: Hodgkin Disease
Treatment & Medication: Hodgkin Disease
Follow-up: Hodgkin Disease
References
Further Reading
[ CLOSE WINDOW ]

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  43. Loge JH, Abrahamsen AF, Ekeberg, Kaasa S. Fatigue and psychiatric morbidity among Hodgkin's disease survivors. J Pain Symptom Manage. Feb 2000;19(2):91-9. [Medline].

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Further Reading

Additional resources on Hodgkin Disease are available at Medscape’s Hodgkin Disease Resource Center.

Further Resources

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

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Keywords

Hodgkin disease, Hodgkin's lymphoma, Hodgkin's disease, Hodgkin lymphoma, HD, malignant lymphoma, malignant lymphogranuloma, Reed-Sternberg cells, lymph cancer, Epstein-Barr virus, EBV, nodular sclerosis Hodgkin disease, NSHD, mixed-cellularity Hodgkin disease, MCHD, lymphocyte-depleted Hodgkin disease, LDHD, lymphocyte-depleted Hodgkin's disease, lymphocyte-rich Hodgkin disease, nodular Hodgkin disease, NHD, nodular lymphocyte-predominant Hodgkin disease, NLPHD, lymph node cancer

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Contributor Information and Disclosures

Author

Scott K Dessain, MD, PhD, Associate Professor, Lankenau Institute for Medical Research
Scott K Dessain, MD, PhD is a member of the following medical societies: American Society of Hematology
Disclosure: Nothing to disclose.

Coauthor(s)

James L Spears, MD, Consulting Staff, Bux-Mont Hematology Oncology Medical Associates
James L Spears, MD is a member of the following medical societies: American Society of Clinical Oncology
Disclosure: Nothing to disclose.

Athanassios Argiris, MD, Associate Professor, Department of Medicine, Division of Hematology-Oncology, University of Pittsburgh
Athanassios Argiris, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Koyamangalath Krishnan, MD, FRCP, FACP, Paul Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, Program Director, Hematology-Oncology Fellowship, James H Quillen College of Medicine at East Tennessee State University
Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, and Royal College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Wendy Hu, MD, Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center
Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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