Innovations in the treatment of hodgkin's lymphoma

Specialists of Department of Hematology at Memorial Şişli Hospital gave information about Hodgkin's Lymphoma disease and treatment methods. Hodgkin's Lymphoma is one of the types of cancer that has become the most successful in terms of treatment today. This disease usually reveals itself by the growth of lymph nodes. Sweating, weakness, weight loss, or fever that is not caused by infection can be symptoms of the disease. Depending on the area where the body the lymph nodes located; symptoms such as shortness of breath and cough may also occur. The objective of the treatment of the disease is to completely eliminate the disease if possible, and to prevent relapse of the disease. There are some groups in the world that are working to make advances in the treatment of Hodgkin's Lymphoma disease and are doing large-scale studies. A few of them are German Hodgkin Study Group (GHSG), EORTC, Canadian NCI. Until today, 15,000 Hodgkin's patients have participated in the research of German Hodgkin Study Group (GHSG). If the disease has not spread much throughout the body, the disease can be eliminated with a mild chemotherapy, and treatments involving irradiation. If the disease has progressed and spread more throughout the body, more effective chemotherapy treatments have also been developed to increase chances of destroying the disease. It is vital that the disease is treated by a physician who has experience with Hodgkin's lymphoma.

Symptoms of the disease

Hodgkin's Lymphoma usually reveals itself by growth in the lymph nodes or spleen. The most common involvement of the lymph nodes occurs in the neck; but the lymph nodes inside parts of the body can also grow. In addition, involvement also occurs in spleen, liver, or other organs. In some patients, symptoms such as weight loss (10% in the last six months), sweating at night, recurrent fever that is not caused by an infection emerge. These symptoms are called “B symptoms”.

Diagnosis of the disease

For the diagnosis of the disease, it is necessary to take an appropriate lymph node and examine it. Hodgkin's lymphoma includes several subtypes in pathological examination, and the treatment of these groups may vary. In addition to this examination, research indicating how much the disease has spread throughout the body is also carried out, indeed it is called “staging”. The stages (stages) of the disease are:

Stage I: Involvement of a single lymph node region,

Stage II: Involvement of 2 or more lymph node sites, as in one side of the diaphragm (the muscle separating the chest and abdominal cavity),

Stage III: Involvement on both sides of the diaphragm,

Stage IV: Diffuse involvement of an organ except the spleen (spleen is considered to be a lymph node site in this disease).

Computerized tomography is required to determine the stage of the disease, and some blood tests are also required to plan treatment, and tests that show how organs such as the heart, lungs function.

In addition to staging, some signs also identify bad risk factors of the disease. The findings, that we call the risk factor, have a negative impact on the recovery rate of the disease depending on the situation, but they should be evaluated together with other data. In order to save patients with a bad risk factor, it may be necessary to apply a more effective treatment according to its stage.

According to German Hodgkin Study Group (GHSG), these risk factors are:

• Involvement of three or more lymph node areas,
• Elevation of sedimentation rate in the blood,
• Large mediastinal mass that is located in posterior side of the lungs within thoracic cage (wider than 1/3 of the chest),
• Extranodal (except for lymph nodes) involvement.

Treatment of the disease

According to pathological findings, the disease is divided into a classic type of Hodgkin's Lymphoma and subtype that is observed less commonly (lymphocyte predominant). This subtype that is observed less commonly shows features.

It is important to start the treatment of the disease without loss of time and to apply the treatment correctly. In terms of treatment, the disease can be divided into three groups:

• Group: Early stage, it does not contain bad risk factor

• Group: Early stage, but it contains some risk factors

• Group: Advanced disease.

Recent studies have specifically targeted the stages in 2 issues. The first of these includes patients with an early stage and without bad risk factors. Since the results of treatment in these patients are already very good, the studies conducted were aimed at preserving good results, but reducing the side effects of treatment. The second issue is to increase the success rate of the treatment and elimination rate in the patients with Hodgkin's lymphoma who have a more advanced disease.

Early stage, patients who do not have bad risk factors

2 cycles of very short chemotherapy and a low-dose radiation therapy provide better treatment option for the patients whose stage is I or II and whom none of bad risk factors is observed. This study carried out with 1370 patients by German Hodgkin Study Group (GHSG) indicated that less side effect occurred significantly in the patients who were treated with only 2 cycles of chemotherapy and radiotherapy. This study, published in New England Journal, one of the most respected international publications, determined that patient rate in which the treatment is still successful is 91%, 5 years later the treatment in the patients who had received 2 cycles of chemotherapy and radiotherapy. When compared with radiotherapy with 20 or 30 Gray doses, no difference was found in terms of impact.

Early-stage patient who have some risk factors

This group includes patients with Hodgkin's lymphoma not stated above and below group. In these cases, usually 4 cycles of ABVD chemotherapy and 30 Gray doses of radiation therapy are seen as standard treatment. For patients under the age of sixty in this group, there is a study conducted in 1522 patients by German Hodgkin Study Group (GHSG). This study indicated that survival rate increases in the rate of 6% without progression (without increase in the disease) 5 years later when 2 cycles of protocol called “escalated BEACOPP”, and 2 cycles of ABVD and radiotherapy are administered instead of 2 cycles of chemotherapy protocol called ABVD and radiotherapy; for this reason, this treatment method offers better option.

Advanced disease group

This group includes patients with stage III or IV, in addition, stage IIB, and patents who have large mediastinal mass or extranodal (except lymph nodes) involvement. In patients with this condition, it is more difficult to achieve complete elimination of the disease than in the patients of other group. 6-8 cycles of ABVD chemotherapy can be administered to these patients as outpatient. Another option is chemotherapy protocol called “escalated BEACOPP”. As a result of studies conducted by German Hodgkin Study Group (GHSG), it was published that the possibility of control of the diseases with chemotherapy protocol called “escalated BEACOPP” is better than standard chemotherapy in the patients who are within this group and under 60 years old. The patient should be hospitalized when administering of the 1st cycle of “escalated BEACOPP” protocol that is applied in 6 cycles. "Escalated BEACOPP" protocol is more intensive protocol that requires good patient monitoring and experience. Radiotherapy is not required for some patients according to the results of PET-CT (a device that allows that the results of Positron Emission Tomography and Computed Tomography images can be achieved simultaneously) after the treatment is finished.

Resistant or recurrent disease

In this case, if the patient is younger than 65 years old, a treatment usually involving stem cell transplantation (bone marrow transplantation) is recommended. Stem cells are collected from the patient, this type of stem cell transplantation is called an “autologous transplantation”.

There are some drug options for patients who stem cell transplantation cannot be performed. The antibody called "Brentuximab vedotin" is also among new treatment possibilities.

Screening

Follow up of the patient and disease at particular intervals have great importance after the treatment is completed.

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