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Fortunately, cancer in children and adolescents is rare, although the overall incidence of childhood cancer has been slowly increasing since 1975. Children and adolescents with
cancer should be referred to medical centers that have a multidisciplinary team
of cancer specialists with experience treating the cancers that occur during
childhood and adolescence. This multidisciplinary team approach incorporates
the skills of the primary care physician, pediatric surgical subspecialists,
radiation oncologists, pediatric medical oncologists/hematologists,
rehabilitation specialists, pediatric nurse specialists, social workers, and
others to ensure that children receive treatment, supportive care, and
rehabilitation that will achieve optimal survival and quality of life. (Refer to the PDQ Supportive and Palliative Care summaries for specific information about supportive care for children and adolescents with cancer.)
Guidelines for pediatric cancer centers and their role in the treatment of
pediatric patients with cancer have been outlined by the American Academy of
Pediatrics. At these pediatric cancer centers, clinical trials are
available for most types of cancer that occur in children and
adolescents, and the opportunity to participate in these trials is offered to
most patients/families. Clinical trials for children and adolescents with
cancer are generally designed to compare potentially better therapy with
therapy that is currently accepted as standard. Most of the progress
made in identifying curative therapies for childhood cancers has been achieved
through clinical trials. Information about ongoing clinical trials is
available from the NCI Web site.
Dramatic improvements in survival have been achieved for children and adolescents with cancer. Between 1975 and 2002, childhood cancer mortality has decreased by more than 50%. For Hodgkin lymphoma, the 5-year survival rate has increased over the same time from 81% to more than 94% for children and adolescents. Childhood and adolescent cancer survivors require close follow-up because cancer therapy side effects may persist or develop months or years after treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)
Childhood Hodgkin lymphoma is one of the few pediatric malignancies that shares aspects of its biology and natural history with an adult cancer. When treatment approaches for children were modeled after those used for adults, substantial morbidities (primarily musculoskeletal growth inhibition) resulted from the unacceptably high radiation doses. Thus, new strategies utilizing chemotherapy and lower-dose radiation were developed. Approximately 90% to 95% of children with Hodgkin lymphoma can be cured, prompting increased attention to devising therapy that produces less long-term morbidity for these patients. Contemporary treatment programs use a risk-adapted approach in which patients receive multiagent chemotherapy with or without low-dose involved-field radiation therapy.
Prognostic factors used in determining chemotherapy intensity include stage, presence or absence of B symptoms (fever, weight loss, and night sweats), and/or bulky disease.
Hodgkin lymphoma comprises 6% of childhood cancers. In the United States, the incidence of Hodgkin lymphoma is age-related and is highest among adolescents aged 15 to 19 years (29 cases per million per year), with children ages 10 to 14 years, 5 to 9 years, and 0 to 4 years having approximately threefold, eightfold, and 30-fold lower rates, respectively. In non-European Union countries, there is a similar rate in young adults but a much higher incidence in childhood.
Hodgkin lymphoma has the following unique epidemiological features:
Epstein-Barr virus (EBV) has been implicated in the causation of Hodgkin lymphoma. A large proportion of patients with Hodgkin lymphoma have high EBV titers, suggesting that an enhanced activation of EBV may precede the development of Hodgkin lymphoma in some patients. EBV genetic material can be detected in Reed-Sternberg cells from some patients with Hodgkin lymphoma.
The incidence of EBV-associated Hodgkin lymphoma also shows the following distinct epidemiological features:
EBV serologic status is not a prognostic factor for failure-free survival in pediatric and young adult Hodgkin lymphoma patients. Patients with a prior history of serologically confirmed infectious mononucleosis have a fourfold increased risk of developing EBV-positive Hodgkin lymphoma; these patients are not at increased risk for EBV-negative Hodgkin lymphoma.
Among individuals with immunodeficiency, the risk of Hodgkin lymphoma is increased, although not as high as the risk of non-Hodgkin lymphoma.
Characteristics of Hodgkin lymphoma presenting in the context of immunodeficiency are as follows:
The following presenting features of Hodgkin lymphoma result from direct or indirect effects of nodal or extranodal involvement and/or constitutional symptoms related to cytokine release from Reed-Sternberg cells.
As the treatment of Hodgkin lymphoma has improved, factors that are associated with outcome have become more difficult to identify. Several factors, however, continue to influence the success and choice of therapy. These factors are interrelated in the sense that disease stage, bulk, and biologic aggressiveness are frequently codependent. Further complicating the identification of prognostic factors is their use in determining the aggressiveness of therapy. For example, in a report from the German-Austrian Pediatric multicenter trial DAL-HD-90, bulky disease was not a prognostic factor for outcome on multivariate analysis. However, in this study, boost irradiation doses were given to patients who had postchemotherapy residual disease, which could have obfuscated the relevance of bulky disease at presentation. This underscores the complexity in determining prognostic factors.
Pretreatment factors associated with an adverse outcome in one or more studies include the following:
Prognostic factors identified in selected multi-institutional studies include the following:
The rapidity of response to initial cycles of chemotherapy also appears to be prognostically important and is being used in the research setting to determine subsequent therapy. Positron emission tomography (PET) scanning is being evaluated as a method to assess early response in pediatric Hodgkin lymphoma. Fluorodeoxyglucose-PET avidity after two cycles of chemotherapy for Hodgkin lymphoma in adults has been shown to predict treatment failure and progression-free survival. Further studies in children are required to assess the role of early response based on PET. The value of PET avidity to predict outcome and whether improved outcome can be achieved by altering the therapeutic strategy based on early PET response is to be determined.
Although prognostic factors will continue to change because of risk stratification and choice of therapy, parameters such as disease stage, bulk, systemic symptomatology, and early response to chemotherapy are likely to remain relevant to outcome.
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Chang ET, Montgomery SM, Richiardi L, et al.: Number of siblings and risk of Hodgkin's lymphoma. Cancer Epidemiol Biomarkers Prev 13 (7): 1236-43, 2004.
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Westergaard T, Melbye M, Pedersen JB, et al.: Birth order, sibship size and risk of Hodgkin's disease in children and young adults: a population-based study of 31 million person-years. Int J Cancer 72 (6): 977-81, 1997.
Crump C, Sundquist K, Sieh W, et al.: Perinatal and family risk factors for Hodgkin lymphoma in childhood through young adulthood. Am J Epidemiol 176 (12): 1147-58, 2012.
Armstrong AA, Alexander FE, Cartwright R, et al.: Epstein-Barr virus and Hodgkin's disease: further evidence for the three disease hypothesis. Leukemia 12 (8): 1272-6, 1998.
Araujo I, Bittencourt AL, Barbosa HS, et al.: The high frequency of EBV infection in pediatric Hodgkin lymphoma is related to the classical type in Bahia, Brazil. Virchows Arch 449 (3): 315-9, 2006.
Makar RR, Saji T, Junaid TA: Epstein-Barr virus expression in Hodgkin's lymphoma in Kuwait. Pathol Oncol Res 9 (3): 159-65, 2003.
Herling M, Rassidakis GZ, Medeiros LJ, et al.: Expression of Epstein-Barr virus latent membrane protein-1 in Hodgkin and Reed-Sternberg cells of classical Hodgkin's lymphoma: associations with presenting features, serum interleukin 10 levels, and clinical outcome. Clin Cancer Res 9 (6): 2114-20, 2003.
Claviez A, Tiemann M, Lüders H, et al.: Impact of latent Epstein-Barr virus infection on outcome in children and adolescents with Hodgkin's lymphoma. J Clin Oncol 23 (18): 4048-56, 2005.
Jarrett RF, Stark GL, White J, et al.: Impact of tumor Epstein-Barr virus status on presenting features and outcome in age-defined subgroups of patients with classic Hodgkin lymphoma: a population-based study. Blood 106 (7): 2444-51, 2005.
Chabay PA, Barros MH, Hassan R, et al.: Pediatric Hodgkin lymphoma in 2 South American series: a distinctive epidemiologic pattern and lack of association of Epstein-Barr virus with clinical outcome. J Pediatr Hematol Oncol 30 (4): 285-91, 2008.
Herling M, Rassidakis GZ, Vassilakopoulos TP, et al.: Impact of LMP-1 expression on clinical outcome in age-defined subgroups of patients with classical Hodgkin lymphoma. Blood 107 (3): 1240; author reply 1241, 2006.
Hjalgrim H, Askling J, Rostgaard K, et al.: Characteristics of Hodgkin's lymphoma after infectious mononucleosis. N Engl J Med 349 (14): 1324-32, 2003.
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Nachman JB, Sposto R, Herzog P, et al.: Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol 20 (18): 3765-71, 2002.
Rühl U, Albrecht M, Dieckmann K, et al.: Response-adapted radiotherapy in the treatment of pediatric Hodgkin's disease: an interim report at 5 years of the German GPOH-HD 95 trial. Int J Radiat Oncol Biol Phys 51 (5): 1209-18, 2001.
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Dieckmann K, Pötter R, Hofmann J, et al.: Does bulky disease at diagnosis influence outcome in childhood Hodgkin's disease and require higher radiation doses? Results from the German-Austrian Pediatric Multicenter Trial DAL-HD-90. Int J Radiat Oncol Biol Phys 56 (3): 644-52, 2003.
Smith RS, Chen Q, Hudson M, et al.: Prognostic factors in pediatric Hodgkin's disease. [Abstract] Int J Radiat Oncol Biol Phys 51 (3 Suppl 1): 119, 2001.
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Metzger ML, Castellino SM, Hudson MM, et al.: Effect of race on the outcome of pediatric patients with Hodgkin's lymphoma. J Clin Oncol 26 (8): 1282-8, 2008.
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Gallamini A, Hutchings M, Rigacci L, et al.: Early interim 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography is prognostically superior to international prognostic score in advanced-stage Hodgkin's lymphoma: a report from a joint Italian-Danish study. J Clin Oncol 25 (24): 3746-52, 2007.
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Hodgkin lymphoma is characterized by a variable number of characteristic multinucleated giant cells (Reed-Sternberg cells) or large mononuclear cell variants (lymphocytic and histiocytic cells) in a background of inflammatory cells consisting of small lymphocytes, histiocytes, epithelioid histiocytes, neutrophils, eosinophils, plasma cells, and fibroblasts. The inflammatory cells are present in different proportions depending on the histologic subtype. It has been conclusively shown that Reed-Sternberg cells and/or lymphocytic and histiocytic cells represent a clonal population. Almost all cases of Hodgkin lymphoma arise from germinal center B cells that cannot synthesize immunoglobulin. The histologic features and clinical symptoms of Hodgkin lymphoma have been attributed to the numerous cytokines, chemokines, and products of the tumor necrosis factor receptors (TNF-R) family secreted by the Reed-Sternberg cells.
The hallmark of classic Hodgkin lymphoma is the Reed-Sternberg cell, which has the following features:
Hodgkin lymphoma can be divided into the following two broad pathologic classes:
Classical Hodgkin lymphoma is divided into the following four subtypes:
These subtypes are defined according to the number of Reed-Sternberg cells, characteristics of the inflammatory milieu, and the presence or absence of fibrosis.
Characteristics of the histological subtypes of classical Hodgkin lymphoma include the following:
A study of over 600 patients with nodular sclerosis Hodgkin lymphoma from three different university hospitals in the United States showed that two haplotypes in the HLA class II region were identified, which correlated with 70% increased risk of developing nodular sclerosis Hodgkin lymphoma. Another haplotype was associated with a 60% decreased risk. It is hypothesized that these haplotypes result in atypical immune responses that lead to Hodgkin lymphoma.
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Bazzeh F, Rihani R, Howard S, et al.: Comparing adult and pediatric Hodgkin lymphoma in the Surveillance, Epidemiology and End Results Program, 1988-2005: an analysis of 21 734 cases. Leuk Lymphoma 51 (12): 2198-207, 2010.
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Stein H, Marafioti T, Foss HD, et al.: Down-regulation of BOB.1/OBF.1 and Oct2 in classical Hodgkin disease but not in lymphocyte predominant Hodgkin disease correlates with immunoglobulin transcription. Blood 97 (2): 496-501, 2001.
Boudová L, Torlakovic E, Delabie J, et al.: Nodular lymphocyte-predominant Hodgkin lymphoma with nodules resembling T-cell/histiocyte-rich B-cell lymphoma: differential diagnosis between nodular lymphocyte-predominant Hodgkin lymphoma and T-cell/histiocyte-rich B-cell lymphoma. Blood 102 (10): 3753-8, 2003.
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Staging and evaluation of disease status is undertaken at diagnosis and performed again early in the course of chemotherapy and at the end of chemotherapy.
The diagnostic and staging evaluation is a critical determinant in the selection of treatment. Initial evaluation of the child with Hodgkin lymphoma includes the following:
The following three specific constitutional symptoms (B symptoms) correlate with prognosis and are considered in assignment of stage:
Additional Hodgkin-associated constitutional symptoms without prognostic significance include the following:
Anatomic information from CT is complemented by PET functional imaging, which is sensitive in determining initial sites of involvement, particularly sites too small to be considered abnormal by CT criteria.
The posteroanterior chest radiograph remains important since the criterion for bulky mediastinal lymphadenopathy used in North American protocols is defined by the ratio of the diameter of the mediastinal lymph node mass to the maximal diameter of the rib cage on an upright chest radiograph; a ratio of 33% or higher is considered bulky. This definition is no longer used in some European protocols because it does not influence risk classification.
The criteria for bulky peripheral (nonmediastinal) lymphadenopathy have varied per cooperative group study protocols from aggregate nodal masses exceeding 4 to 6 cm. This disease characteristic has not been consistently used among all groups for risk stratification.
Defining strict CT size criteria for the establishment of lymphomatous nodal involvement is complicated by a number of factors, such as overlap between benign reactive hyperplasia and malignant lymphadenopathy and obliquity of node orientation to the scan plane. Additional difficulties more specific to children include greater variability of normal nodal size with body region and age and the frequent occurrence of reactive hyperplasia.
General concepts to consider in regard to defining lymphomatous involvement by CT include the following:
The recommended functional imaging procedure for initial staging is now PET. In PET scanning, uptake of the radioactive glucose analog, 18-fluoro-2-deoxyglucose (FDG) correlates with proliferative activity in tumors undergoing anaerobic glycolysis. PET-CT, which integrates functional and anatomic tumor characteristics, is often used for staging and monitoring of pediatric patients with Hodgkin lymphoma. Residual or persistent FDG avidity has been correlated with prognosis and the need for additional therapy in posttreatment evaluation.
General concepts to consider in regard to defining lymphomatous involvement by FDG-PET include the following:
FDG-PET has limitations in the pediatric setting. Tracer avidity may be seen in a variety of nonmalignant conditions including thymic rebound commonly observed after completion of lymphoma therapy. FDG-avidity in normal tissues, for example, brown fat of cervical musculature, may confound interpretation of the presence of nodal involvement by lymphoma.
After a careful physiologic and radiographic evaluation of the patient, the least invasive procedure should be used to establish the diagnosis of lymphoma.
Key issues to consider in choosing the diagnostic approach include the following:
Stage is determined by anatomic evidence of disease using CT scanning in conjunction with functional imaging. The staging classification used for Hodgkin lymphoma was adopted at the Ann Arbor Conference held in 1971  and revised in 1989. Staging is independent of the imaging modality used.
Involvement of a single lymphatic site (i.e., nodal region, Waldeyer's ring, thymus, or spleen) (I); or localized involvement of a single extralymphatic organ or site in the absence of any lymph node involvement (IE).
Involvement of two or more lymph node regions on the same side of the diaphragm (II); or localized involvement of a single extralymphatic organ or site in association with regional lymph node involvement with or without involvement of other lymph node regions on the same side of the diaphragm (IIE).
Involvement of lymph node regions on both sides of the diaphragm (III), which also may be accompanied by extralymphatic extension in association with adjacent lymph node involvement (IIIE) or by involvement of the spleen (IIIS) or both (IIIE,S).
Diffuse or disseminated involvement of one or more extralymphatic organs, with or without associated lymph node involvement; or isolated extralymphatic organ involvement in the absence of adjacent regional lymph node involvement, but in conjunction with disease in distant site(s). Stage IV includes any involvement of the liver or bone marrow, lungs (other than by direct extension from another site), or cerebrospinal fluid.
Designations applicable to any stage
Fever (temperature >38ºC), drenching night sweats, unexplained loss of >10% of body weight within the preceding 6 months.
Involvement of a single extranodal site that is contiguous or proximal to the known nodal site.
aReprinted with permission from AJCC: Hodgkin and non-Hodgkin lymphomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 607-11.
Extralymphatic disease resulting from direct extension of an involved lymph node region is designated E. Extralymphatic disease can cause confusion in staging. For example, the designation E is not appropriate for cases of widespread disease or diffuse extralymphatic disease (e.g., large pleural effusion that is cytologically positive for Hodgkin lymphoma), which should be considered stage IV. If pathologic proof of noncontiguous involvement of one or more extralymphatic sites has been documented, the symbol for the site of involvement, followed by a plus sign (+), is listed. Current practice is to assign a clinical stage on the basis of findings of the clinical evaluation; however, pathologic confirmation of noncontiguous extralymphatic involvement is strongly suggested for assignment to stage IV.
After the diagnostic and staging evaluation data are acquired, patients are further classified into risk groups for the purposes of treatment planning. The classification of patients into low-, intermediate-, or high-risk categories varies considerably among the various pediatric research groups, and often even between different studies conducted by the same group, as summarized in Table 2.
Children's Oncology Group
IA bulk or E; IB; IIA bulk or E; IIB; IIIA, IVA
IA, IIA with no bulk
IA, IB, IIA with no bulk, no hilar nodes and <4 sites
IA, IB, IIA with bulk, hilar nodes or ≥4 sites; III
IIB/IIIB with bulk, IV
IB, IIA, IIIA1 with bulk; IIIA2
IIB, IIIB, IV
GPOH-HD 95; GPOH-HD 2002; PHL-C1
IEA/B;IIEA; IIB; IIIA
IIEB; IIIEA/B; IIIB; IV
Stanford/St. Jude/Dana-Farber Cancer Institute Consortium
IB, IIIA, IA/IIA with E, ≥3 sites or bulk
IA, IIA with no bulk, E and <3 sites
E = extralymphatic.
aAdapted from Kelly.
Although all major research groups classify patients according to clinical criteria, such as stage and presence of B symptoms, extranodal involvement, or bulky disease, comparison of outcomes across trials is further complicated because of differences in how these individual criteria are defined.
Further refinement of risk classification may be performed through assessment of response after initial cycles of chemotherapy or at its completion.
The interim response to initial therapy, which may be assessed on the basis of volume reduction of disease, functional imaging status, or both, is an important prognostic variable in both early- and advanced-stage pediatric Hodgkin lymphoma. Definitions for interim response are variable and protocol specific, but can range from volume reductions of greater than 50% to the achievement of a complete response with a volume reduction of greater than 95% by anatomic imaging or resolution of FDG-PET avidity.
The rapidity of response to early therapy has been used in risk stratification to tailor therapy in an effort to augment therapy in higher-risk patients or to reduce the late effects while maintaining efficacy.
Restaging is carried out upon the completion of all planned initial chemotherapy and may be used to determine the need for consolidative radiation therapy. Key concepts to consider include the following:
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Long-term survival has been achieved in children and adolescents with Hodgkin lymphoma using radiation, multiagent chemotherapy, and combined-modality therapy. In selected cases of localized lymphocyte-predominant Hodgkin lymphoma, complete surgical resection may be curative and obviate the need for cytotoxic therapy.
Treatment options for children and adolescents with Hodgkin lymphoma include the following:
Contemporary treatment for pediatric Hodgkin lymphoma uses a risk-adapted and response-based paradigm that assigns the length and intensity of therapy based on disease-related factors such as stage, number of involved nodal regions, tumor bulk, the presence of B symptoms, and early response to chemotherapy by functional imaging. Age, gender, and histological subtype may also be considered in treatment planning.
Histological subtype may direct therapy in patients with stage I completely resected, nodular lymphocyte-predominant Hodgkin lymphoma, whose initial treatment may be surgery alone.
This treatment approach is supported by the following findings from the literature:
A summary of treatment approaches for nodular lymphocyte-predominant Hodgkin lymphoma can be found in Table 8.
As discussed in the previous sections, most newly diagnosed children will be treated with risk-adapted chemotherapy alone or in combination with consolidative radiation therapy (RT). RT volumes can have variable and protocol-specific definitions, but generally encompass lymph node regions initially involved at the time of diagnosis, without extensive inclusion of uninvolved regions. RT field reductions are made to account for tumor regression with chemotherapy.
With advancements in systemic therapy, RT field definitions have evolved and become increasingly restricted. RT is no longer needed to sterilize all disease. Advancements in radiologic imaging allow more precise radiation target definition. Historically, concerns about the symmetry of growth in young children with unilateral disease involvement often prompted treatment of the contralateral tissues. With contemporary treatments utilizing 15 to 21 Gy, treatment of contralateral uninvolved sites is not necessary in all but perhaps the very young.
General trends in radiation treatment volume are summarized as follows:
Neck and/or supraclavicularb/infraclavicular
Supraclavicular/infraclavicular and lower neck
Axilla ± supraclavicular/infraclavicular
Mediastinum, hila, and infraclavicular/supraclavicularb,c
Spleen ± para-aortic
Para-aortic ± spleen
Iliac, inguinal, femoral
External iliac, inguinal, femoral
aAdapted from Terezakis et al.
bUpper cervical region is not treated if supraclavicular involvement is an extension of the mediastinal disease.
cPrechemotherapy volume is treated except for lateral borders of the mediastinal field.
A breast-sparing radiation-therapy plan using proton therapy is being evaluated to determine if there is a statistically significant reduction in dose. Long-term results are awaited.
Traditional definitions of lymph node regions can be helpful for defining IFRT but may not be sufficient. The following issues should be considered in IFRT treatment planning:
The dose of radiation is also variously defined and often protocol specific. General considerations regarding radiation dose include the following:
Technical considerations for the use of radiation therapy to treat Hodgkin lymphoma include the following:
Because all children and adolescents with Hodgkin lymphoma receive chemotherapy, a question commanding significant attention is whether patients who achieve a rapid early response or a CR to chemotherapy require RT. Conversely, the judicious use of LD-IFRT may permit a reduction in the intensity or duration of chemotherapy below toxicity thresholds that would not be possible if single modality chemotherapy were used, thus decreasing overall acute and late toxicities.
Key points to consider in regard to the role of radiation in pediatric Hodgkin lymphoma include the following:
Additionally, when considering the role of RT in the initial management of Hodgkin lymphoma, one must carefully consider the endpoint that is being evaluated. Unlike most other pediatric malignancies, Hodgkin lymphoma is often salvageable if initial treatment does not result in a CR or if relapse occurs. For example, studies comparing combination chemotherapy with or without RT in adults with advanced-stage Hodgkin lymphoma showed that EFS was higher for patients who received initial chemotherapy and RT; however, OS was no different for patients whose initial therapy was chemotherapy alone. Among adult Hodgkin lymphoma patients, study results conflict regarding whether adjuvant RT improves OS compared with chemotherapy alone, despite an improvement in EFS, because of the ability to effectively salvage patients who relapse after initial therapy. Thus, it is not clear whether EFS or OS should be the appropriate endpoint for a trial comparing chemotherapy with or without radiation.
Finally, an inherent assumption is made in a trial comparing chemotherapy alone versus chemotherapy and radiation that the effect of radiation on EFS will be uniform across all patient subgroups. However, it is not clear how histology, presence of bulky disease, presence of B symptoms, or other variables affect the efficacy of postchemotherapy radiation.
All of the agents in original MOPP and ABVD regimens continue to be used in contemporary pediatric treatment regimens. COPP (substituting cyclophosphamide for mechlorethamine) has almost uniformly replaced MOPP as the preferred alkylator regimen in most frontline trials. Etoposide has been incorporated into treatment regimens as an effective alternative to alkylating agents in an effort to reduce gonadal toxicity and enhance antineoplastic activity.
Combination chemotherapy regimens used in contemporary trials are summarized in Table 4.
Dacarbazine substituted for procarbazine in COPP
1, 8, 15
IV = intravenous; PO = oral.
The Pediatric Oncology Group organized two trials featuring response-based, risk-adapted therapy utilizing ABVE (doxorubicin [Adriamycin], bleomycin, vincristine, and etoposide)  for favorable low-stage patients and dose-dense ABVE-PC (prednisone and cyclophosphamide) for unfavorable advanced-stage patients in combination with 21 Gy IFRT.
Key findings from these trials include the following:
The Children’s Cancer Group (CCG) undertook a randomized controlled trial comparing survival outcomes in children treated with risk-adapted COPP/ABV hybrid chemotherapy alone with those treated with COPP/ABV hybrid chemotherapy plus LD-IFRT. The study was closed early because of a significantly higher number of relapses among patients treated with chemotherapy alone. Long-term results include the following:
Another CCG Study (COG-59704) evaluated response-adapted therapy featuring four cycles of the dose-intensive BEACOPP regimen followed by a gender-tailored consolidation for pediatric patients with stages IIB, IIIB with bulky disease, and IV Hodgkin lymphoma.[Level of evidence: 2Dii] For rapid early responding girls, an additional four courses of COPP/ABV (without IFRT) were given. Rapid early responding boys received two cycles of ABVD followed by IFRT. Slow early responders received four additional courses of BEACOPP and IFRT. Eliminating IFRT from the girl's therapy was intended to reduce the risk of breast cancer. Key findings from this trial include the following:
The Stanford, St. Jude Children's Research Hospital, and Boston Consortium administered a series of risk-adapted trials over the last 20 years. Key findings include the following:
In the last 30 years, German investigators have implemented a series of risk-adapted trials evaluating gender-based treatments featuring multiagent chemotherapy with OPPA/COPP and IFRT.
Contemporary trials for pediatric Hodgkin lymphoma involve a risk-adapted, response-based treatment approach that titrates the length and intensity of chemotherapy and dose of radiation based on disease-related factors including stage, number of involved nodal regions, tumor bulk, the presence of B symptoms, and early response to chemotherapy as determined by functional imaging. In addition, vulnerability related to age and gender is also considered in treatment planning.
Chemotherapy (No. of Cycles)a
No. of Patients
Survival (No. of Years of Follow-up)
(No. of Years of Follow-up)
VAMP (4) 
VAMP (4) 
COPP/ABV (4) 
CS IA/B, IIAc
OEPA/OPPA (2) 
ABVE (2-4) 
IA, IIA, IIIA1
CS = clinical stage; IFRT = involved-field radiation therapy; N/A = not applicable; No. = number.
aRefer to Table 4 for more information about the chemotherapy regimens.
bWithout bulky mediastinal (defined as one-third or more of intrathoracic ratio measured on an upright posteroanterior chest radiograph) or peripheral lymphadenopathy (defined as 6 cm or more) or B symptoms.
cWithout adverse features, defined as one or more of the following: hilar adenopathy, involvement of more than four nodal regions; mediastinal tumor with diameter equal to or larger than one-third of the chest diameter, and node or nodal aggregate with a diameter larger than 10 cm.
dResults from as-treated analysis.
COPP/ABV (6) 
CS I/IIb, CS IIB, CS III
OEPA/OPPA (2) + COPP (2) 
IIEA, IIB, IIIA
OEPA/OPPA (2) + COPDAC (2) 
IE, IIB, IIEA, IIIA
ABVE-PC (3–5) 
IB, IIA, IIIA
CS = clinical stage; E = extralymphatic; IFRT = involved-field radiation therapy; N/A = not applicable.
aRefer to Table 4 for more information about the chemotherapy regimens.
bWith adverse disease features, defined as one or more of the following: hilar adenopathy, involvement of more than four nodal regions; mediastinal tumor with diameter equal to or larger than one-third of the chest diameter, and
node or nodal aggregate with a diameter larger than 10 cm.
cResults from as-treated analysis.
OEPA/OPPA (2) + COPP (4) 
IIEB, IIIEA/B, IIIB, IVA/B
OEPA/OPPA (2) + COPDAC (4) 
ABVE-PC (3-5) 
IB, IIA, IIIA
BEACOPP (4); COPP/ABV (4) (RER; girls) 
IIB, IIIB, IV
BEACOPP (4); ABVD (2) (RER; boys) 
BEACOPP (8) (SER) 
E = extralymphatic; IFRT = involved-field radiation therapy; N/A = not applicable; No. = number; RER = rapid early response; SER = slow early response.
The use of combination chemotherapy and/or radiation therapy can achieve excellent long-term progression-free survival and OS in patients with nodular lymphocyte-predominant Hodgkin lymphoma. Late recurrences have been reported and are typically responsive to re-treatment. Because deaths observed among individuals with this histological subtype are more frequently related to complications from cytotoxic therapy, risk-adapted treatment assignment is particularly important for limiting exposure to agents with established dose-related toxicities. Table 8 summarizes the results of contemporary treatment approaches used for nodular lymphocyte-predominant Hodgkin lymphoma, some of which feature surgery alone for completely resected disease and limited cycles of chemotherapy with or without low-dose IFRT. Because of the relative rarity of this subtype, most trials are limited by small cohort numbers and nonrandom allocation of treatment.
Event-Free Survival (No. of Years of Follow-up)
Survival (No. of Years of Follow-up)
CVP (3) 
IFRT = involved-field radiation therapy; N/A = not applicable; No. = number.
bAllocation to radiation therapy or no radiation therapy based on response to therapy.
cAllocation based on clinical response.
dAll involved lymph nodes surgically resected.
The treatment approach used for adolescents and young adults with Hodgkin lymphoma may vary based on community referral patterns and age restrictions at pediatric cancer centers. In patients with high-risk disease, the standard of care in medical oncology practices typically involves at least six cycles of ABVD chemotherapy that would deliver a cumulative anthracycline dose of 300 mg/m2. In late-health outcomes studies of pediatric cancer survivors, the risk of anthracycline cardiomyopathy has been shown to exponentially increase after exposure to cumulative anthracycline doses of 250 mg/m2 to 300 mg/m2. Subsequent need for mediastinal radiation can further enhance the risk of a variety of late cardiac events. In an effort to optimize disease control and preserve both cardiac and gonadal function, pediatric regimens for low-risk disease most often feature a restricted number of cycles of ABVD or derivative combinations, whereas alkylating agents and etoposide are integrated into anthracycline-containing regimens for those with intermediate- and high-risk disease.
Participation in a clinical trial should be considered for adolescent and young adult patients with Hodgkin lymphoma. Information about ongoing clinical trials is
available from the NCI Web site.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I childhood Hodgkin lymphoma, stage II childhood Hodgkin lymphoma, stage III childhood Hodgkin lymphoma and stage IV childhood Hodgkin lymphoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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The excellent response to frontline therapy among children and adolescents with Hodgkin lymphoma limits opportunities to evaluate second-line (salvage) therapy. Because of the small number of patients that fail primary therapy, no uniform second-line treatment strategy exists for this patient population. Adverse prognostic factors after relapse include the following:[Level of evidence: 3iiA]
Children with localized favorable (relapse ≥12 months after completing therapy) disease recurrences whose original therapy involved reduced cycles of risk-adapted therapy or with chemotherapy alone and/or low-dose involved-field radiation therapy (LD-IRFT) consolidation have a high likelihood of achieving long-term survival following treatment with more intensive conventional chemotherapy.
Key concepts in regard to treatment of refractory/recurrent Hodgkin lymphoma in children and adolescents are as follows:
Agents used alone or in combination regimens in the treatment of refractory/recurrent Hodgkin lymphoma include the following:
Brentuximab vedotin has been evaluated in adults with Hodgkin lymphoma. A phase I study in adults with CD30-positive lymphomas identified a recommended phase II dose of 1.8 mg/kg on an every 3-week schedule and showed an objective response rate of 50% (6 of 12 patients) at the recommended phase II dose.[Level of evidence: 2Div] A phase II trial in adults with Hodgkin lymphoma (N = 102) who relapsed after autologous stem cell transplantation showed a complete remission rate of 32% and a partial remission rate of 40%. The number of pediatric patients treated with brentuximab vedotin is not sufficient to determine whether they respond differently than adult patients. There are ongoing trials to determine the toxicity and efficacy of combining brentuximab vedotin with chemotherapy.
Patients treated with HCT may experience relapse as late as 5 years after the procedure; they should be monitored for relapse and late treatment sequelae.
Salvage rates for patients with primary refractory Hodgkin lymphoma are poor even with autologous HCT and radiation. However, intensification of therapy followed by HCT consolidation has been reported to achieve long-term survival in some studies.
The following is an example of a national and/or institutional clinical trial that is currently being conducted or is under analysis. Information about ongoing clinical trials is available from the NCI Web site.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent/refractory childhood Hodgkin lymphoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
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Children and adolescent survivors of Hodgkin lymphoma are at risk for numerous late complications of treatment related to radiation, specific chemotherapeutic exposures, and surgical staging. Adverse treatment effects may impact oral/dental health; musculoskeletal growth and development; endocrine, reproductive, cardiovascular and pulmonary function; and risk of secondary carcinogenesis. In the past 30 to 40 years, pediatric Hodgkin lymphoma therapy has changed dramatically to proactively limit exposure to radiation and chemotherapeutic agents, such as anthracyclines, alkylating agents, and bleomycin. When counseling individual patients about the risk for specific treatment complications, the era of treatment should be considered.
The following table summarizes late health effects observed in Hodgkin lymphoma survivors followed by a limited discussion of the common late effects. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for a full discussion of the late effects of cancer treatment in children and adolescents.)
Any chemotherapy in a patient who has not developed permanent dentition
Dental maldevelopment (tooth/root agenesis, microdontia, root thinning and shortening, enamel dysplasia)
Radiation impacting oral cavity and salivary glands
Salivary gland dysfunction
Accelerated dental decay
Radiation impacting thyroid gland
Radiation impacting cardiovascular structures
Subclinical left ventricular dysfunction
Heart valve dysfunction
Coronary, carotid, subclavian vascular disease
Subclinical left ventricular dysfunction
Congestive heart failure
Radiation impacting the lungs
Subclinical pulmonary dysfunction
Radiation of musculoskeletal tissues in any patient who is not skeletally mature
Bone mineral density deficit
Alkylating agent chemotherapy
Overwhelming post-splenectomy sepsis
Subsequent neoplasm or disease
Myelodysplasia/acute myeloid leukemia
Solid benign and malignant neoplasms
Hodgkin lymphoma survivors exposed to doxorubicin or thoracic radiation therapy are at risk for long-term cardiac toxicity. The effects of thoracic radiation therapy are difficult to separate from those of anthracyclines because few children undergo thoracic radiation therapy without the use of anthracyclines. The pathogenesis of injury differs, however, with radiation primarily affecting the fine vasculature of the heart, and anthracyclines directly damaging myocytes.
The risks to the heart are related to the amount of radiation delivered to different depths of the heart, volume and specific areas of the heart irradiated, total and fractional irradiation dose, age at exposure, and latency period.
(Refer to the Cardiovascular Disease in Select Cancer Subgroups: Hodgkin lymphoma section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for information on studies evaluating cardiovascular toxicity associated with radiation.)
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This information is provided by the National Cancer Institute.
This information was last updated on August 22, 2014.