Risk adapted combined modality treatment in children with Hodgkin’s disease: NCI, Cairo

Objective : The objective of this study is to maximize the chance of cure while minimizing surgery, radiotherapy and chemotherapy as much as possible to avoid late effects and toxicity of combined modality treatment in children with Hodgkin's disease. Patients and Methods: One hundred twenty-one (121) children under the age of 18 years with a histopathologic diagnosis of Hodgkin’s disease were enrolled into this study. Patients were stratified according to stage into 3 risk groups : low (Stages : I, II A), intermediate (Stages : II B, III A) and high risk group (Stages: III B, IV). Oral Etoposide was used in this study instead of procarbazine in the management of boys with HD to reduce the gonadotoxic effects of procarbazine. Two cycles of OPPA for females and E-OPA for males were effective induction treatment for children with all stages of HD and stagetailored chemotherapy (2, 4, 6 cycles of OPPA, E-OPA/ COPP) was sufficient to eradicate occult microfoci. Involved field radiotherapy was given in doses of 30, 25, 20 Gy, depending on the extent of initial chemotherapy and risk status. Staging laparotomy was performed in 30 patients out of the 121 patients, 24 of them underwent splenectomy. Patients who received whole neck radiotherapy were submitted to thyroid U/S and thyroid hormonal profile. Only 3 adolescent patients did semen analysis. Results : The overall and disease-free survival rates at 6 years were 95.3% and 86.1% (95% CI), respectively (entire group), 96.1%, 92.3% (95% CI) for low risk, 96.1%, 80.7% (95% CI) for intermediate risk and 93.3%, 80% (95% CI) for high risk patients. During the followup period all patients had normal thyroid functions. Conclusions: In children with HD, only low dose involved field radiotherapy with reduced doses is needed, if a risk-dependent chemotherapy is given. In this series the strategy of selective laparotomy and restrictive splenectomy is very useful in the context of combined modality treatment, in which laparotomy was omitted if both abdominal U/S and CT were negative.