Hodgkin's lymphoma in stage III, IVA, and IVB
GENERAL Information
Advanced Hodgkin lymphoma is considered to be those patients whose diseases are classified in stages III or IV with "A" or "B" symptoms, in stage II with "B" symptoms or in bulky disease (more than 10 centimeters).
There is a wide variety of factors influencing patients ' decision to receive cancer treatment. The purpose of treatment may be to improve symptoms by local cancer control, increase patient healing possibilities, or prolong life. The benefits expected from cancer treatment should be carefully weighed with regard to your potential risks.
Here is a general overview of the treatment for Hodgkin's lymphoma in the advanced stage. The individual circumstances of your situation and the prognostic factors of your cancer are what influences, at the end of the day, the way in which these general principles of treatment apply to your situation. The information on this website is an educational aid for you about your treatment options and facilitates the decision making process, mutual or shared, with the medical oncologist who treats you.
Most new treatments arise from clinical experiments, i.e. from studies evaluating the effectiveness of new drugs or treatment strategies. The progress of the most effective treatments for cancer requires the evaluation of new and innovative therapies in cancer patients. Participation in a clinical experiment can provide access to better treatments and enable the advancement of existing knowledge in relation to the treatment of this cancer. Clinical experiments are available for most types of cancer. Patients interested in participating in a clinical experiment should evaluate their risks and their benefits in conjunction with their physicians. To make sure that you are getting the best treatment for your cancer, it is important to be aware of the latest news about cancer, so that you have knowledge about new treatments and the results of clinical trials.
Advanced-stage Hodgkin lymphoma is a curable cancer because it is very susceptible to chemotherapy treatment and radiation therapy. In the years 60, physicians of the National Cancer Institute (MOPP) created the combined chemotherapy regimen (methotrexate, nitrogen mustard, procarbazine and prednisone), which makes possible the healing of almost half of all patients With Hodgkin's lymphoma in the advanced stage. In the years 70, it was found that a new regimen of ABVD chemotherapy with 4 drugs (doxorubicin, bleomycin, Velban ®, dacarbazine) is superior to MOPP and with fewer long-term side effects. In clinical experiments many variations of drug combinations for MOPP and ABVD chemotherapy have been compared and none have shown to be superior to ABVD. In addition, the ABVD chemotherapy regimen appears to produce fewer side effects, especially in patients older than 55 years. ABVD may also produce lower long-term side effects against chemotherapy regimens that use MOPP or similar combinations.
Radiation therapy may also play a role in the treatment of Hodgkin's lymphoma in the advanced stage; However, this is not well defined. The reason for using radiation therapy in Hodgkin's lymphoma is that it is very active in the elimination of cancer cells and in many patients in whom the cancer progresses after treatment undergo a relapse in the same place of Hodgkin's lymphoma. Previous. Radiation is a local treatment capable of eliminating cancer cells within a defined radiation field. Administering radiation with beam to areas with large amounts of cancer or a "bulky" tumor can effectively prevent local recurrence of cancer. However, radiation therapy is associated with additional side effects.
In a clinical experiment, direct comparison of modern combined chemotherapy versus combined chemotherapy plus radiation therapy was performed. The number of live patients without relapse of cancer to 5 years of treatment did not increase in patients who received radiation in addition to chemotherapy. Currently, standard treatment for advanced Hodgkin's lymphoma is the typical chemotherapy combined with ABVD with or without radiation therapy for bulky disease sites.
Improvement of methods for detecting residual lymphoma: the appearance of a residual mass after the initial treatment of lymphoma can create problems for management because the mass can represent an active cancer or just be a scar or tissue Killed by a chemotherapy injury. The usual method of evaluating these residual masses is with repeated CT scans or surgical biopsy. CT scan has not been very effective in recognizing cancer in the face of the scar or dead tissue because it recognizes only abnormal masses. Surgical biopsy is often needed to determine the cancer's remanet. PET Scan (positron emission tomography) can help physicians determine more accurately the presence of residual cancer after treatment.
Pet Scan is similar to CT scan; However, PET scan can detect a live cancerous tissue. Before a PET scan, the patient receives an injection of a substance containing a type of sugar linked to a radioactive isotope. The cancerous cells "take" the sugar and the linked isotope, which emits low energy radiation with positive charge (positrons). The positron reacts with the electrons in the cancerous cell creating a gamma-ray production. Gamma rays are detected by the pet machine, which transforms the information into an image. If gamma rays are not detected in the scanned area, the mass in question is unlikely to contain live cancerous cells.
Recently, doctors in Belgium reported that a PET scan was more effective in detecting residual cancer than CT scan. In patients with Hodgkin's disease, relapse occurs in 100% of patients with a residual mass detected in a PET scan, compared to only 26% of patients with a residual mass in a TC scan. In the future, PET scan should help identify patients who need additional treatment after initial treatment.
Complications of HODGKIN's lymphoma treatment
The evolution of a second radiation-induced cancer, chemotherapy, or combination of radiation and chemotherapy used to treat Hodgkin's lymphoma is one of the greatest side effects of Hodgkin's lymphoma treatment. In a trial that assessed the risk of second cancers in more than 5,500 patients treated for Hodgkin lymphoma, 322 second cancers were presented. Therefore, 6% of all treated patients manifested a second cancer. In another study with 420 patients, the risk of exhibiting a second cancer 15 years after treatment was 11.7%. This includes cancers of the gastrointestinal tract, lung, breast, bone, soft tissue, and leukemia.
Strategies to improve treatment
The progress that has been made in the treatment of Hodgkin's lymphoma in the advanced stage is the result of improving and
L Progress of chemotherapy regimens combined with multiple drugs and participation in clinical experiments. In the future, progress will be achieved from continued participation in appropriate clinical experiments.
Today there are many active research areas aimed at improving the treatment of Hodgkin's lymphoma in the advanced stage.
Continuous evaluation of the role of radiation therapy in the management of patients at risk of treatment failure: More than 70% of patients with advanced Hodgkin's disease achieve complete remission after initial combination treatment of Chemotherapy with or without radiation therapy. However, 20 to 30% of patients who achieved complete remission end up experiencing a cancer relapse. The adequate cure rate for patients with advanced Hodgkin's disease is in a range of 40 to 70%. The role of radiation therapy in achieving optimal control of Hodgkin's lymphoma in the advanced stage is controversial and attempts are made to treat such patients with only chemotherapy.
In 1989, researchers in France initiated a clinical experiment to compare chemotherapy alone with chemotherapy plus radiation therapy for the treatment of patients with Hodgkin lymphoma in the advanced stage. 559 patients with advanced-stage Hodgkin lymphoma were randomly allocated to receive chemotherapy plus total ganglion irradiation (radiation therapy to the lymph nodes of the chest, neck, and abdomen) or chemotherapy only. 5-year survival without relapse of cancer was 74% in patients treated with only chemotherapy and 79% for those treated with chemotherapy plus radiation. Overall 5-year survival was 94% for patients treated with chemotherapy only and 78% for treatment with chemotherapy and radiation therapy. These results show that chemotherapy plus radiation is not superior to chemotherapy alone. These researchers advised that patients with Hodgkin's lymphoma in the advanced stage would receive a total of 8 cycles of combined chemotherapy when a complete remission with 6 cycles of treatment is achieved.
Evolution of multi-modality strategies: the treatment of Hodgkin's disease is usually a combination of chemotherapy with or without radiation therapy. Commonly used medications in chemotherapy include nitrogen mustard, Oncovin ®, Procarbazine, and prednisone, combined with Dexorubicina, bleomycin, Velban ®, and Dacarbazine. The new regime known as Stanford V consists of the use of such drugs for a short time (12 weeks) to effectively reduce the total doses administered of Dexorubicina, bleomycin and nitrogen mustard.
Researchers from many medical centers treated the Stanford V chemotherapy regimen to 47 people with voluminous Hodgkin disease to the mediastinum (space between the rib cage and lungs), both for stage I to II, or advanced III or IV stages of the Hodgkin's disease. After chemotherapy, radiation therapy was administered directly to areas with voluminous disease. About 5 years after treatment, 45 patients survived (96%) and only 7 underwent a relapse (return) of the cancer. Six of the seven patients who had relapse received high doses of chemotherapy with autologous stem cell transplantation. After three years, five of these patients survived without the disease. Two deaths were presented in the study, one for Hodgkin's disease and another for acute leukemia.
These results indicate that a general treatment program using in principle chemotherapy with the Stanford V regimen, followed by radiation therapy for voluminous diseases and high doses of transplant chemotherapy for patients with Relapse of cancer is very effective in the treatment of people with advanced or voluminous Hodgkin's disease.
Creation of less toxic regimens for children: Hodgkin's disease in children is a relatively rare cancer with high rates of curaciónDebido at the highest rate obtained with chemotherapy and radiation, the principal objective of the researchers in the past Decade was to try to reduce the long-term side effects of therapy while maintaining the high level of the cure rate. Among the possible effects of chemotherapy and radiation are sterility, cataracts and the evolution of new cancers.
Physicians in Germany and Austria conducted a clinical experiment in several centers to evaluate changes in the standard combined chemotherapy regimen for the purpose of reducing long-term side effects. This experiment was conducted in 319 children and 259 girls with Hodgkin's disease who received their treatment between the years 1990 and 1995. Based on stage classification, cancer was classified as early, intermediate, or advanced. The treatment program consisted of chemotherapy with Oncovin ®, prednisone, procarbazine and doxorubicin, or cyclophosphamide, Oncovin ®, prednisone, and procarbazine, with or without radiation. In children, a common-use agent was replaced in chemotherapy, Etoposida, by Procarbazine, in order to avoid damage to the testicles. In addition, both the field and the radiation dose were decreased. These changes were expected to decrease side effects without affecting the cure rate.
After five years of initiation of treatment, 91% of the children survived without evidence of cancer relapse and 98% of the children were still alive. In the treatment regimen there was an important finding by physicians, Etoposida could be replaced by procarbazine in the treatment regimen without increasing the rate of relapse of cancer and radiotherapy could be focused on sites involved with cancer When it was combined with chemotherapy. With these changes, children were less likely to experience side effects in the testicles.
These physicians concluded that this regimen provides adequate treatment for all stages of Hodgkin's disease in children, which allows for excellent control of the disease and a reduction in long-term side effects. Additional disease studies in the early stages are underway to further refine treatment and to determine whether radiation therapy can be completely omitted without compromising long-term cure rates.
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