Issues in the treatment of Hodgkin's disease

The treatment of Hodgkin's disease is changing strikingly. In early stages of disease, extended field irradiation to date has been the standard treatment resulting in excellent cure rates. Due however to the recognition of the fatal long-term effects, especially the high rates of second solid tumors, extended field radiation therapy is now being abandoned by most study groups. Instead, mild chemotherapy for control of occult disease is combined with involved field irradiation. In intermediate stage Hodgkin's disease, where combined modality treatment already is the treatment of choice, extended field irradiation is substituted by involved field irradiation for the same reasons. In advanced stage Hodgkin's disease, eight cycles of standard polychemotherapy (plus additional radiotherapy for large tumor masses and residual lymphomas after chemotherapy) for decades has cured only about 50% of the patients. While until recently all modifications of the standard chemotherapy regimens could not change the poor outcome of advanced-stage patients, the development of new dose-intensified regimens now for the first time has significantly improved their prognosis. In patients with relapse of Hodgkin's disease after polychemotherapy, long-term survival after salvage chemotherapy is low. Numerous phase II studies suggest an improvement of their poor prognosis by high-dose chemotherapy followed by autologous bone marrow transplantation or peripheral-blood stem cell transplantation. There are still no results of prospective, randomized trials which convincingly demonstrate the benefit of this therapeutic approach, however.