Clinical profile and outcome of classical Hodgkin lymphoma treated with a risk‐adapted approach in a tertiary cancer center in India

Abstract

BackgroundClassical Hodgkin lymphoma (cHL) has excellent survival rates, but late effects are an issue and dictate modern approaches. We analyzed the clinical profile and outcome of cHL treated on a risk‐adapted approach aimed at reducing late effects while improving historical outcomes at our center.ProcedureChildren (≤15 years) consecutively treated for cHL from January 2013 through December 2016 were retrospectively analyzed. 18FDG‐PET‐CT–based staging and response assessment was done after two cycles for early response (ERA) and end of chemotherapy (late‐response assessment [LRA]) if not in complete response (CR; Deauville < 4) at ERA. Stages IA/IB/IIA were low risk (LR) and received two cycles of ABVD (adriamycin/bleomycin/vinblastine/dacarbazine). Stages IAX/IBX/IIAX/IIB/IIIA were intermediate risk (IR), and stages IIBE/IIBX/IIIAE/IIIAX/IIIB/IVA/IVB were high risk (HR). Both received two cycles of OEPA (oncocristine/etoposide/prednisolone/adriamycin). Those in ERA‐CR received two cycles of ABVD if LR, and two and four cycles of COPDac (cyclophosphamide/oncocristine/prednisolone/dacarbazine), respectively, for IR and HR. Involved‐field radiotherapy (IFRT) was given to bulky sites and ERA < CR. Those at LRA < CR (Deauville < 3) or progression at any stage received salvage regimens.ResultsIn the study period, 126 patients were identified who received the above protocol. There were 12 LR, and 114 advanced staged Hodgkin lymphoma (AHL) (18, IR; 96, HR) of which 91 (79.8%) had bulky sites. Eight (66.6%) LR and 93 (83%) AHL patients achieved ERA‐CRs. IFRT was given to 4 (33.3%) LR patients with ERA < CR, and 92 (80.7%) of AHL (91 bulky sites; 1 ERA < CR). At a median follow‐up of 31 months (range, 17–62), three‐year event‐free survival (EFS) and overall survival (OS) were both 100% for LR, and 94.4% (95% CI, 66.0%–99.2%) for IR, whereas for HR it was 90.3% (95% CI, 82.2%–94.8%) and 92.6% (95% CI, 85.2%–96.4%), respectively.ConclusionsChildren with HL have favorable outcomes with manageable toxicities when treated on a risk‐stratified and adapted approach. A high proportion of AHL have bulky disease necessitating IFRT, a concern that will have to be factored in future strategies.

Comment on: The COVID‐19 pandemic: A rapid global response for children with cancer from SIOP, COG, SIOP‐E, SIOP‐PODC, IPSO, PROS, CCI, and St Jude Global

“…These strategies have consistently yielded us acceptable and often excellent outcomes. [5][6][7][8] We rolled out a comprehensive set of measures including these and similar adaptations, and summarized them for easy reference. 9 These guidelines helped us to successfully brace for the ini- ORCID Chetan Dhamne https://orcid.org/0000-0002-3637-2880…”

The COVID‐19 pandemic: A rapid global response for children with cancer from SIOP, COG, SIOP‐E, SIOP‐PODC, IPSO, PROS, CCI, and St Jude Global

“…Many LMIC settings during the pandemic will not have access to functional imaging for response-based treatment stratification, and access to radiotherapy may be very limited. In these settings, a chemotherapy-only approach to treatment without radiotherapy is safe and reasonable, especially for low-and intermediaterisk disease 26,[29][30][31][32]. Patients in many resource-limited settings with advanced disease, complicated by weight loss and poor nutrition, require careful attention to supportive care and nutritional support during the initiation of treatment.…”

Treating early‐stage Hodgkin lymphoma in resource‐limited settings: InPOG‐HL‐15‐01 experience

“…Satisfactory outcomes with ABVD have been reported in children 3–7 but at the cost of six or more cycles of chemotherapy with RT delivered to a varying proportion of patients. Limiting treatment to four cycles of ABVD to patients with early‐stage HL with RT to all 16 or RT limited to those with bulky disease or suboptimal response has also been evaluated, albeit in small numbers in a retrospective fashion 17,18 …”