Current issues in the management of advanced Hodgkin's disease

During the past two decades, the standard drug regimen has been the MOPP program and its variants MVPP or ChlVPP. The search for less toxic chemotherapy in terms of decreased sterility and myelodysplasia-acute non-lymphocytic leukemia prompted the design of ABVD. Recent data from different countries indicate that adriamycin-based combinations as ABVD or MOPP alternating with ABVD appear very useful to improve treatment outcome compared to MOPP alone. The combination of chemotherapy and radiation has been utilized by many institutions in practically all stages of Hodgkin's disease. The intent is to optimize the cure rate and with the theory that less intensive therapy of both modalities may carry a lower risk of iatrogenic complications without compromising treatment outcome. In patients relapsing from curative radiotherapy, combination chemotherapy such as ABVD or MOPP/ABVD is recommended as the most effective salvage regimen, associated to further irradiation if technically feasible. In patients relapsing from primary chemotherapy, clinicians have first to take into consideration whether the duration of first complete remission is longer than 12 months. In this case, retreatment with the same drug regimen remains the treatment of choice. In patients with progressive lymphoma while on primary chemotherapy or showing remission duration lesser than 12 months, non-cross resistant chemotherapy or high dose therapy plus autologous bone marrow transplantation are indicated.