Stage III/IVA or B Hodgkin’s Lymphoma

Overview

Patients classified as having stage III or IV disease with “A” or “B” symptoms, stage II disease and “B” symptoms, or bulky disease (site of disease greater than 10 centimeters) are all considered to have advanced stage Hodgkin’s lymphoma.

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

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The following is a general overview for the treatment of advanced stage Hodgkin’s lymphoma. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.

Advanced stage Hodgkin’s lymphoma is a curable cancer because it is very susceptible to treatment with chemotherapy and radiation therapy. In the 1960’s, doctors at the National Cancer Institute developed the MOPP (methotrexate, nitrogen mustard, procarbazine and prednisone) combination chemotherapy regimen, which was able to cure approximately half of all patients with advanced stage Hodgkin’s lymphoma. In the 1970’s, a new 4-drug chemotherapy regimen ABVD (doxorubicin, bleomycin, Velban®, dacarbazine) was found to be superior to MOPP and had fewer long-term side effects. Several variations of MOPP and ABVD chemotherapy drug combinations have been compared in clinical trials and none have been shown to be superior to ABVD. In addition, the ABVD chemotherapy regimen appears to produce fewer side effects, especially in patients over 55 years of age. ABVD may also produce fewer long-term side effects compared to chemotherapy regimens utilizing MOPP or similar combinations.

Radiation therapy also may play a role in the treatment of advanced stage Hodgkin’s lymphoma; however this role is not well defined. The rationale for using radiation therapy in Hodgkin’s lymphoma is that it is very active in killing cancer cells and many patients whose cancer progresses after treatment experience a relapse in a site of previous Hodgkin’s lymphoma. Radiation is a local treatment capable of killing cancer cells within a defined radiation field. Delivery of the radiation beam to areas with a large amount of cancer or “bulky” disease may effectively prevent local cancer recurrences. However, radiation therapy is associated with additional side effects.

One clinical trial has been performed that directly compared modern combination chemotherapy to combination chemotherapy plus radiation treatment. The number of patients alive without cancer recurrence 5 years from treatment was not improved in patients who received radiation in addition to chemotherapy. Currently, the standard treatment of advanced Hodgkin’s lymphoma is combination chemotherapy typically with ABVD with or without radiation therapy to sites of bulky disease.

Improved Methods to Detect Residual Lymphoma: The appearance of a residual mass after initial treatment of lymphoma can create problems for management because the mass may represent active cancer or merely be scar or dead tissue from chemotherapy damage. The usual method of evaluating a residual mass is with repeated CT scans or surgical biopsy. CT scans have not been very effective at recognizing cancer versus scar or dead tissue since they only recognize an abnormal mass. Often, a surgical biopsy is necessary to determine whether cancer remains. PET (positron emission tomography) scanning may help doctors more accurately determine the presence of residual cancer following treatment.

A PET scan is similar to a CT scan; however, PET scans can detect live cancer tissue. Prior to a PET scan, the patient receives an injection of a substance that contains a type of sugar attached to a radioactive isotope. The cancer cells “take up” the sugar and attached isotope, which emits positively charged, low energy radiation (positrons). The positrons react with electrons in the cancer cells, which creates the production of gamma rays. The gamma rays are then detected by the PET machine, which transforms the information into a picture. If no gamma rays are detected in the scanned area, it is unlikely that the mass in question contains living cancer cells.

Doctors in Belgium recently reported that PET scans were more effective in detecting residual cancer than CT scans. In patients with Hodgkin’s disease, relapse occurred in 100% of patients with a residual mass detected on a PET scan, compared to only 26% of patients with a residual mass on a CT scan. In the future, PET scans should help identify patients who need further treatment after initial treatment.

Complications of Treatment for Hodgkin’s Lymphoma

One of the major side effects of treatment of Hodgkin’s lymphoma is the development of a second cancer. These second cancers are caused by the radiation, chemotherapy or the combination of radiation and chemotherapy used to treat Hodgkin’s lymphoma. In one clinical study evaluating the risk of second cancers in over 5,500 patients treated for Hodgkin’s lymphoma, there were 322 second cancers. Thus 6% pf all treated patients developed a second cancer. In another study of 420 patients, the risk of developing a second cancer 15 years following treatment was 11.7%. These included cancers of the gastrointestinal tract, lung, breast, bone, soft tissue and leukemia.

Strategies to Improve Treatment

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