Hodgkin's disease in children

Hodgkin's disease may now be managed with several different regimens with the expectation of curing approximately 90 per cent of patients. Radiotherapy alone achieves this cure rate only in unilateral high cervical or inguinal stage 1 presentations. With all other presentations, radiotherapy requires the addition of chemotherapy to sustain the 90 per cent cure level. Combined modality regimens offer the patient the advantage of reduced doses of each modality in terms of number of Gy and courses of chemotherapy. The contribution of the staging laparotomy to combination therapy is now being questioned. This issue becomes pressing as imaging of the lymphatic system and commonly involved extranodal sites of disease is improved by computed tomography, magnetic resonance, and ultrasound technology. Only the spleen escapes adequate examination. The failure of imaging techniques to adequately determine the status of the spleen is compensated by the chemotherapy sensitivity of splenic disease, as often demonstrated in the treatment of patients with stage IV disease. Staging laparotomy for preadolescent children should be done on special indications, because splenectomy confers a life-long (50 years or more) threat of overwhelming infection despite administration of pneumococcal vaccine and the use of oral penicillin prophylaxis. The use of radiotherapy in a dose range that inhibits bone and dental development in immature, preadolescent children can no longer be condoned. Treatment with chemotherapy alone must be considered as the option for preadolescent and younger adolescent children. Radiotherapy in a low dose range (2000 to 2200 cGy) in combination with chemotherapy constitutes a possible alternative treatment. In combined therapy regimens, it appears unnecessary to deliver six full courses of chemotherapy because regimens using three or four courses have demonstrated effectiveness in adults with early stage disease. The selection of the chemotherapy regimen should be made with care so as to eliminate drugs causing sterility in the young male, ovarian dysfunction in females, and second malignant tumors including acute myeloid leukemia (AML). In addition, doxorubicin should be used only in noncardiotoxic cumulative doses. Pretreatment determinations of the cardiac ejection fraction provide some assurance of safety during doxorubicin therapy.(ABSTRACT TRUNCATED AT 400 WORDS)