Treatment of high-risk Hodgkin Lymphoma with a modified Stanford V
regimen in the AHOPCA: substituting chemotherapy agents and hampered
outcomes
Abstract
Background/Objectives: High-risk Hodgkin lymphoma (HRHL) in children is
a curable with combined modality therapy. The AHOPCA is a consortium of
cancer centers from Central America. In 2004, AHOPCA implemented a
guideline with a short course of chemotherapy (mStanfordV), strict
diagnostics and radiation guidelines, aimed at reducing abandonment and
improving outcomes. Methods: Newly diagnosed children less than 18 years
of age with high-risk HL (Ann Arbor stages: IIB, IIIB, IV) from AHOPCA
centers were staged with chest X-ray, and ultrasound or CT. Therapy was
a modified StanfordV (mStanfordV) substituting cyclophosphamide for
mechlorethamine and involved field radiation. Results: Of 219 patients
with HRHL, 181 patients were eligible and evaluable;146 (81%) were
boys, 22% being less than 6 years; 43 were stage IIB, 84 IIIB and 54
IV. Thirty-one (17%) abandoned therapy, 28 (15%) progressed, 30 (17%)
relapsed and 8 (4%) died of toxicity. Radiation guidelines were not
followed. Five-year abandonment-sensitive event-free survival and
overall survival (AS-EFS, AS-OS±SE) for the cohort were 46±4% and
56±4%; 5-year AS-OS for stages IIB, IIIB and IV was 76±7%, 59±7%, and
35±7% (p=0.0006). Conclusion: Despite instituting a short treatment
guideline, it did not improve the abandonment rate (17%) and did not
achieve the reported outcomes of StanfordV. The cyclophosphamide dose
used to replace merchlorethamine was inadequate. Despite strict
guidelines, the radiation therapy application was inaccuarate. Weekly
chemotherapy may have adversely affected abandonment of therapy by
increasing the burden of travel-time. Based on these results, AHOPCA
established a new abandonment strategy and a new guideline.