Linfoma Hodking

The

n e w e ng l a n d j o u r na l

of

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review article
Current Concepts

Early-Stage Hodgkin’s Lymphoma
James O. Armitage, M.D.

F

or more than a century after Thomas Hodgkin first described
the disease that now bears his name, the illness was considered incurable.
The discovery of radiotherapy as a treatment technique in the early 20th century led to long-termsurvival free of recurrent lymphoma in some patients with
what we would today call early-stage disease.1-3 The concept of staging Hodgkin’s
lymphoma was solidified at the Ann Arbor Conference in 1971.4 Whereas staging
laparotomy was once used to define the extent of the disease in patients with earlystage (i.e., stage I or stage II) Hodgkin’s lymphoma, currently available imaging
techniquesand effective systemic therapies have relegated staging laparotomy to a
historical footnote.
Studies of the use of mechlorethamine in the 1940s showed that the rate of response to systemically administered anticancer agents in patients with Hodgkin’s
lymphoma could be high. After the discovery of several other active agents, investigators at the National Cancer Institute combined four of thesedrugs for use in
the initial treatment of patients with disseminated Hodgkin’s lymphoma. The resulting report, released in 1970, made it clear that a cure was possible with chemotherapy alone.5 Studies of chemotherapy administered as adjuvant treatment after
radiotherapy in patients with high-risk, early-stage disease showed a reduction in
the risk of relapse6; subsequent studies investigatedthe effects of the initial use
of chemotherapy followed by the application of adjuvant radiotherapy to smaller
treatment fields.7,8
Investigators in Uganda who were studying the treatment of Burkitt’s lymphoma
in children and young adults in the 1970s9,10 also saw patients with early-stage
Hodgkin’s lymphoma, but radiotherapy was not available to them. These studies
showed that chemotherapyalone could yield a high rate of complete and durable
remission in patients with early-stage Hodgkin’s lymphoma. Increasing recognition of the long-term, toxic effects of treatment and the very high survival rates
among patients with early-stage Hodgkin’s lymphoma who received the most recent
therapy regimens led to a series of studies in which efforts were made to reduce or
eliminate theradiotherapy used in these regimens and to minimize the number of
chemotherapy cycles. In this issue of the Journal, Engert et al. report on a large
study in Germany that investigated the efficacy of reduced cycles of doxorubicin,
bleomycin, vinblastine, and dacarbazine (ABVD) with or without reductions in the
radiation dose.11
Patients with early-stage Hodgkin’s lymphoma are not a homogeneousgroup,
and treatment toxicities are changing as chemotherapy regimens and radiotherapy
techniques change. However, some of the most serious toxic effects of treatment
tend to occur late — after most deaths attributable to the lymphoma have occurred. These issues complicate the process of determining what treatment to
recommend for a patient with early-stage Hodgkin’s lymphoma.

n engl j med363;7

nejm.org

From the Division of Oncology–Hematology, University of Nebraska Medical
Center, Omaha. Address reprint requests
to Dr. Armitage at the Division of Oncology–Hematology, University of Nebraska
Medical Center, 8722 LTC, 42nd and
Emile, Omaha, NE 68198, or at joarmita@
unmc.edu.
N Engl J Med 2010;363:653-62.
Copyright © 2010 Massachusetts Medical Society.

august 12, 2010The New England Journal of Medicine as published by New England Journal of Medicine.
Downloaded from www.nejm.org by JACQUES BADENHORST on August 15, 2010. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.

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