Chemotherapy plus involved-field radiation in early-stage Hodgkin's disease
New England Journal of Medicine (Impact Factor: 55.87). 03/2008; 358(7):742; author reply 743. DOI: 10.1056/NEJMc073375
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ABSTRACT: Le traitement standard des stades I–II sus-diaphragmatiques est défini selon les facteurs de risque et comporte une chimiothérapie ABVD, trois cycles (patients sans facteur de risque) ou quatre cycles (patients avec facteurs de risque), suivis d’une irradiation des territoires ganglionnaires initialement atteints à la dose de 30 Gy. L’analyse finale des essais récents est attendue pour préciser la possibilité de réduire la dose d’irradiation à 20 Gy après réponse complète induite par la chimiothérapie. Un traitement par chimiothérapie exclusive n’est pas actuellement recommandé, en dehors des essais thérapeutiques en cours qui intègrent la TEP après deux cycles comme élément décisionnel d’un traitement sans radiothérapie. Les techniques modernes d’irradiation et d’imagerie sont développées pour réduire les volumes irradiés aux seuls ganglions initialement atteints. The risk-adapted therapeutic strategy used for adult patients with Hodgkin’s lymphoma is defined taking into account their risk factors and includes standard first-line ABVD chemotherapy. In early-stage supradiaphragmatic disease, 3 chemotherapeutic courses are applied for patients without risk factors while 4 courses are used for patients with risk factors, followed by a radiation therapy targeting initially involved fields (IFRT) at a dose of 30 Gy. Final analysis of the results of recent trials is expected to determine whether IFRT doses may be reduced to 20 Gy in patients showing chemotherapy-induced complete remission. Chemotherapy alone is not recommended currently, except in ongoing clinical trials in which positron emission tomography (PET) scans are used to evaluate the early response to chemotherapy without radiation. Modern radiation and imaging modalities are expected to permit the restriction of radiation-targeted volumes to initially involved nodes only.
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ABSTRACT: Radiotherapy for Hodgkin lymphoma (HL) increases the risk of salivary gland carcinomas (SGC). To the authors' knowledge, however, the magnitude of the risk has not been assessed to date. The risks of SGC among 20,928 1-year survivors of HL who were diagnosed between 1973 and 2003 were evaluated in 11 population-based cancer registry areas of the Surveillance, Epidemiology, and End Results (SEER) program. Observed-to-expected ratios (O/E) were assessed by radiation treatment, sex, age at the time of HL diagnosis, calendar year of diagnosis, attained age, time since HL diagnosis, histologic type of SGC, and site of occurrence in the major salivary glands. Among 11,047 HL patients who received radiotherapy as part of their initial treatment for HL, 21 developed subsequent invasive SGC (O/E = 16.9; 95% confidence interval [95% CI], 10.4-25.8). The risk of radiation-related SGC was highest for younger HL patients (age <20 years) (O/E = 45.5; 95% CI, 12.4-116.5) and among 10-year survivors (O/E = 23.9; 95% CI, 13.1-40.1), with risks remaining elevated for at least 2 decades after irradiation. Significant differences in risk by histologic type were observed, with a particularly high risk of developing mucoepidermoid carcinomas (O = 14; O/E = 44.2 [95% CI, 24.2-74.2]) and adenocarcinomas (O = 4; O/E = 30.6 [95% CI, 8.3-78.2]) noted. HL patients treated with radiotherapy experienced a significantly increased risk of SGC, particularly when exposed at young ages or for at least 2 decades after exposure. Although the results of the current study reflect the late effects of former HL treatment approaches, they point to the importance of long-term follow-up and a heightened awareness of SGC risk in this population. Cancer 2008. Published 2008 by the American Cancer Society.