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Radiotherapy omission safe in pediatric patients with early-stage HL
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The omission of radiotherapy in pediatric patients in complete remission after chemotherapy for early-stage Hodgkin’s lymphoma appeared safe and effective at 10 years follow-up, according to final data from the German Society of Pediatric Oncology and Hematology’s Hodgkin Lymphoma Trial 95.
Data further suggest that decreasing the radiotherapy dose from 25 Gy to 20 Gy may be successful among those in incomplete remission.
“The most important and striking result of the trial is that patients with early-stage disease could be cured with only two cycles of chemotherapy if they achieved complete remission,” Wolfgang Dörffel, MD, of the department of pediatrics at HELIOS Hospital Berlin-Buch in Berlin, Germany, told HemOnc Today. “Radiation therapy could safely be omitted. In contrast, chemotherapy alone was not sufficient in patients with intermediate and advanced stages, even if they had obtained [complete remission] after four and six cycles of chemotherapy, respectively.”
The current study aimed to assess the reduction of treatment intensity to reduce the risk for long-term adverse effects associated with treatment among 925 pediatric patients with classical Hodgkin’s lymphoma. Researchers further assessed reducing the standard radiotherapy dose from 25 Gy to 20 Gy among patients in incomplete remission.
Patients were categorized into three groups: early-stage disease, intermediate-stage disease and advanced-stage disease.
At 10 years follow-up, overall OS was 96.3%, PFS was 88.2% and EFS was 85.4%.
In the early-stage disease group, PFS was 97% among patients who did not undergo radiotherapy compared with 92.2% among those who did (P=.214).
In the intermediate-stage disease group, PFS was 68.5% among patients who did not undergo radiotherapy compared with 91.4% among those who did (P<.001).
In the advanced-stage group, PFS was 82.6% among patients who did not undergo radiotherapy compared with 88.7% among those who did (P=.259).
When the researchers decreased the standard radiation dose from 25 Gy to 20 Gy among 787 patients with incomplete remission, EFS at 5 years was 90%. That result was similar to the 5-year 91% EFS rate observed in the DAL-HD90 trial.
The EuroNet–Pediatric Hodgkin’s Lymphoma Group is testing procarbazine-free chemotherapy, fewer indications and lower dose for boost radiotherapy, as well as early response evaluation with fluorodeoxyglucose PET with the hope of omitting radiotherapy in a larger proportion of patients.
“Further trials should aim at reducing or avoiding radiation therapy in children and adolescents with early response to chemotherapy because of the serious late effects, like secondary malignant neoplasia or cardiopulmonary sequelae,” Dörfell said. “Today, FDG-PET offers an even better method to identify patients with very good early response to chemotherapy.”
Perspective
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Morton Coleman, MD
What our European pediatric colleagues have found is that which has been increasingly apparent to adult oncologists treating Hodgkin’s disease. Radiation, particularly in higher doses, can be avoided if post-treatment evaluation shows a complete remission. This report was not based on the more accurate technique of PET scanning, yet the conclusions are the same: Most people who attain a complete remission do not need radiation. We are now finding that less is better, provided post-treatment staging is done carefully and accurately. For example, with limited-stage Hodgkin’s disease in particular, not only may radiation be avoided, but chemotherapy may be shortened as well.
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