Rolf Peter Mueller
Department of Radiation Oncology University of Cologne Kerpener Str. 62 50937 Koeln (Germany)

Abstract:

Background: There has been continuous discussion about the best treatment for patients with early favourable Hodgkin lymphoma (HL). Open questions included the choice between combined modality treatment or chemotherapy only, the number of chemotherapy cycles needed and the optimal radiation dose. The GHSG thus conducted a randomized study for patients with early-stage favourable Hodgkin lymphoma (HD10) which addressed these questions were.

Methods: HD10 was an international prospectively randomized multicenter trial comparing 2 and 4 cycles of ABVD as well as 20Gy or 30Gy involved field radiotherapy (IFRT) in a 2 x 2 statistical design. Between 5/1998 and 1/2003, a total of 1370 patients from 329 centres were randomized into four arms: 4 x ABVD + 30Gy; 4 x ABVD + 20Gy; 2 x ABVD + 30Gy; 2 x ABVD + 20Gy. All patients had their initial histology reviewed by a lymphoma expert panel. Documentation was complete in more than 99,1% of cases for this final analysis.

Results: Patients were equally balanced for age, gender, stage, histology, performance status and risk factors between arms. There were significant differences in major toxicity (WHO grade III/IV) between 4 x ABVD and 2 x ABVD in the overall number of events (52% vs. 33%) including leukopenia (24% vs. 15%) and hair loss (28% vs. 15%). In terms of radiation dose, there also was a difference in grade III/IV toxicity between 30Gy and 20Gy IFRT (all events: 8.7% vs. 2.9%), dysphagia (3% vs. 2%), mucositis (3.4% vs. 0.7%). Complete remission was achieved in 97% of patients treated with 4 x ABVD, 97% with 2 x ABVD, 99% after 30Gy and 97% after 20Gy. With a median follow-up of 79 – 91 months, there was no significant difference between 4 x ABVD and 2 x ABVD in terms of overall survival at 5 years (OS: 4 x ABVD 97.1%; 2 x ABVD: 96.6%), freedom from treatment failure (FFTF: 93.0% vs. 91.1%) and progression free survival (PFS: 93.5% vs. 91.2%). For the radiotherapy question, there were also no significant differences between patients receiving 30Gy IFRT and those with 20Gy IFRT with respect to OS (97.6% vs. 97.5%), FFTF (93.4% vs. 92.9%) and PFS (93.7% vs. 93.2%). Importantly, there was also no significant difference relative to OS, FFTF and PFS when all four arms were compared.

Conclusion: Two cycles of ABVD followed by 20Gy IFRT is the new GHSG standard of care for Hodgkin patients in early favourable stages.