Re-visiting the role of radiation therapy in Hodgkin's disease

Over the last four decades, advances in radiation therapy (RT) and the advent of combination chemotherapy have tripled the cure rate of patients with Hodgkin's disease (HD). In 1995, more than 75% of all newly diagnosed HD patients should expect a disease-free normal life span. HD is sensitive to radiation and to many chemotherapy drugs, and in most stages there is more than one option of effective treatment. Although the successful experience in the treatment of HD with RT is nearing a centennial, and radiation alone has remained the treatment of choice for most patients with early stage HD, the optimal implementation of RT in all stages of HD has changed and requires a reassessment. Recent data from European and Canadian studies challenge the "classical" prerequisite for pathological staging when treating with radiation alone. Concurrently, attempts to examine chemotherapy alone as an alternative to RT in early stage disease produced conflicting and confusing results that require clarification. Recently developed combined modality strategies for early stage disease have yielded favorable results. Hopefully, longer follow-up of these regimens will also demonstrate a lower risk for the long-term complications, such as secondary malignancies and coronary heart disease that have become a major concern in the curative treatment of HD. New information regarding modality-related complication risk will be reviewed. Although RT is the most potent single agent in the treatment of HD, the role of irradiation as an adjunct to combination chemotherapy in the management of advanced stage HD and in high dose salvage programs of refractory and relapsed patients has not been clearly defined. The increasing utilization of high dose salvage regimens with bone marrow transplantation implies an evaluation of all effective modalities for salvage. Recent studies that examined the potential contribution of RT in programs for advanced and relapsed stages are analyzed.