13/M
Rt cervical LN pathy
B symtoms+. individual LN non bulky althoough comglomerate mass
PET confirmed involvement of only Rt cervical region
Post 3# ABVD PET shows CR
Recieved additional 1# ABVD.
What should be the dose of RT. NCCN has given a range of dose from 20-30 Gy.
TMH protocol would say 19.8 Gy
The answer to you question is in the GHSD HD11
This is a 4 arm randomisation of 4 # ABVD or 4 # BEACOPP followed by either 20 or 30 Gy IFRT.
The Final anlaysis presented recently concludes that radiation dose may be reduced from 30 to 20 Gy in the setting of treatment with BEACOPP, but not following ABVD.
Nilesh, i would suggest you to go through this abstract from the 51st Annual ASH meeting in Dec 2009.
http://ash.confex.com/ash/2009/webprogram/Paper21230.html
Perhaps once this article is published and peer reviewed, TMH guidelines may be updated in future.
Over and out !
Rohit
PET cr and in 13 year old 20gy as per pediatric protocols.
I think Rajesh is right -
Technically IB is not unfavorable risk according to GHSG protocols and the above abstract does not apply to early favorable disease. The tradiational offprotocol recommendation for early favorable is 2 cycles of ABVD followed by 30Gy in GHSG. Since this child has had 4 Cycles - we cannot say clearly what his dose should be. Most pediatric protocols are now gravitating towards around 20Gy or no RT after CR.
Nilesh - you should research a bit more and find a protocol you would want to follow - why don't you ask dr Laskar - and certainly there will be a reason behind the TMH policy.
The 20Gy dose is based on the following trials for early favorable Hodgkin's.
(Early favorable is defined as Stage I/II A/B without the following risk factors - large mediastinal mass, extranodal disease, >=3 sites and ESR >50 in A and >30 in B)
Both are prelim results of large European trials presented in ASCO 2005
EORTC-GELA H9 EBVP x 6 + 36Gy vs 20Gy vs no RT. First 2 arms equivalent. Last arm definitely worse
http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=34&abstractID=30245
GHSG HD-10: 4 vs 2 cycles of ABVD and 30vs 20Gy IFRT. No difference between arms.
http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=34&abstractID=33416
Or see the videos on this page:
http://www.asco.org/ASCOv2/MultiMedia/Virtual+Meeting?&vmview=vm_session_presentations_view&confID=34&sessionID=847
For this kid, I don't know the ESR - but if <30 then he can be treated to 20Gy. If not he is unfavorable risk and probably requires 30Gy.
My lymphoma is really rusty - so that'e the best I can do for now. The fact that this is a child also tends to take the dose lower (can't tell you why).
There are numerous trials that show a detriment of leaving IFRT out altogether, but despite the majority of pediatric trial protocols have at least one arm without RT. God save the kids.
IFRT is a must. For adults we do 30 Gy in this situation. However your patient is 13 yrs young guy so I would go by evidence (20Gy). Read the papers for yourself that everyone has quoted and find out the right dose.
Indranil, may i ask you to check your statement and reference on Favourable and Unfavourable Early stage HD.
Entry to the HD10 trial was restricted to patients with HD with Ann Arbor clinical or pathologic stage IA, IIA, or IIB without any of the following risk factors: (1) bulky mediastinal mass (one-third or more maximal transverse thorax diameter); (2) extranodal involvement; (3) erythrocyte sedimentation rate ≥50 mm/h; and (4) involvement of three or more lymph node areas.
The HD11 trial included patients with Stage IA, IB, or IIA with at least one of the above risk factors and those with Stage IIB with the third or fourth risk factor only.
Ref for above inclusion criteria: http://linkinghub.elsevier.com/retrieve/pii/S0360301603019321
For Early Stage Favourable HD —- GHSG HD 10 showed 2 # ABVD —> 20 Gy IFRT is new std of care
http://ash.confex.com/ash/2009/webprogram/Paper21388.html
For Early Stage Unfavourable HD (which includes IB) — GHSG HD 11 has shown 4 # ABVD —> IFRT 30 Gy
or 4 # BEACOPP —> IFRT 20 Gy
The trend has been to reduce the dose of RT or omit it as in some UKCCLG trials, but the chemo regimes are also different,
that is use OEPA ( avoid anthracylines)
Anyways, EORTC GELA also has used EBVP, so not relevant here.
Lets talk about only trials, with ABVD.
I agree age group in these trials was 16-75 years.
But i dont have any evidence of trials in children or adolescence which fit in with best evidence.
Correct me if if you know of any other trials, besides these best trials of HD10 and HD 11.
Pediatric protocols are based on some evidence as well. I agree the past practice has been 20 Gy, but consider the new evidence from HD11 ( 1375 pts) if we believe this kid is Unfavourable.
I m somehow looking as the odd man out.
Apologies Indranil, i think you are right
On the internet its very confusing to find these definitions of Favourable and Unfavourable
I have now found a further reference which says exactly what you mentioned, hats off to you
ESR > 30 and B symptoms makes him unfavourable,
but if its < 30 with B symptoms he is still Favourable.
Somehow i cant find the HD 11 protocol on the internet.
Your rusty knowledge is still pretty good, i sure must admit.
I now have the same stand as yours :
If ESR <30 then he can be treated to 20Gy. If not he is unfavorable risk and probably requires 30Gy as per GHSG HD 11.
However, there is one more points i would like to point out.
1) If this is Favourable HD , why has he been offered 4 # IFRT, how do you take that into equation.
as HD 10 has very clearly shown 2 # as good as 4 # ABVD
hence, it may be fair to assume, Nilesh then that your Medical oncologist or Hematologist gave 4 # ABVD based on the fact that he was Unfavourable early HD to begin with.
I again re-iterate that this GHSG HD 11 has just been presented in ASH 51st Conference Dec 2009 by Volker Diehl, the current godfather of Hodgkins disease.
It has yet not been published, hence corporates and other groups wouldnot have yet implemented these in their guidelines
hence many of you may have previous guidelines as 20 Gy, but in future its gonna be 30 Gy for Unfavourable HD.
But if any of you use regimes other than ABVD ( like OEPA, EBVP or BEACOPP), it may be safe to use 20 Gy even in unfavourable risk HD.
See how confusing life is on internet.
The Germans use favourable and unfavourable as described earlier
The Americans designate pts as having early unfavorable Hodgkin lymphoma (HL) if they have clinical stage I or stage II disease and one or more of the following risk factors:
B symptoms (fever ≥38°C, soaking night sweats, weight loss ≥10% within 6 months).
Extranodal disease.
Bulky disease (≥10 cm or >33% of the chest diameter on chest x-ray).
Three or more sites of nodal involvement.
Sedimentation rate of 50 or more.
http://www.cancer.gov/cancertopics/pdq/treatment/adulthodgkins/HealthProfessional/page7
So far we have been concentrating on the Adult side of Hodgkins
See what the Pediatric world is like -
the NCI website classifies them as Low, Intermediate and High Risk
http://www.cancer.gov/cancertopics/pdq/treatment/childhodgkins/HealthProfessional/page6#Section_226
Accepted Treatment Strategies for Newly Diagnosed Children and Adolescent Patients with Hodgkin Lymphoma
Low-Risk Disease (stages I–IIA; no bulk; no B symptoms)
VAMP × 4 plus LD-IFRT.
COPP/ABV hybrid × 4 plus LD-IFRT.
DBVE × 2 to 4 and LD-IFRT (2 vs. 4 cycles based on early response).
OEPA (males) or OPPA (females) × 2 and LD-IFRT (German studies suggest that these patients may not require radiation therapy if a CR is obtained).
Intermediate-Risk Disease (all stage I and II patients not classified as early stage; stage IIIA; stage IVA)
COPP/ABV × 6 plus LD-IFRT.
DBVE-PC × 3 or 5 plus LD-IFRT (3 vs. 5 cycles based on early response).
OPPA/OEPA × 2; COPP × 2 plus LD-IFRT.
High-Risk Disease (stages IIIB, IVB)
DBVE-PC × 3 or 5 plus LD-IFRT (3 vs. 5 cycles based on early response).
Intensive chemotherapy with cytarabine/etoposide,
COPP/ABV or CHOP (2 cycles of each) plus LD-IFRT.
Escalated dose BEACOPP × 8 plus LD-IFRT.
OPPA/OEPA × 2; COPP × 4 plus LD-IFRT.
LD-IFRT includes radiation dosages between 15 Gy and 25 Gy
Note there is no ABVD regime used at all for Pediatric HD, of course they have replaced the anthracyclines in view of the late toxicty and the impact it may have on gonads.
