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Hodgkin Lymphoma

 

 

Risk Adapted Therapy

 

 

Treatment is generally based on a risk adapted approach.

The aim is to minimize late effects and at the same time not compromise the chance of cure2.

Risk stratification schemata are developed in the context of specific treatment protocols.

Risk depends on:

  • Stage at diagnosis
  • Presence/absence of bulky disease
  • Response to therapy

Response is assessed after the first two cycles of chemotherapy.

In broad terms:

  • If Rapid Early Responder (RER) with a complete response, therapy is modified to be less intense to reduce long term complications of therapy.
  • If Slow Early Responder (SER) with partial response, therapy is intensified to improve the chance of cure.


The Children’s Oncology Group using the following schema
Specific details are outlined for each risk category:

 

Definition of Different risk categories in Hodgkin lymphoma:

Risk Category Features

Low Risk

Localized (Stage I & II) nodal involvement.

No bulky disease.

No B symptoms

Intermediate Risk

Localized Stage IA and IIA disease with one or more unfavourable features:
• Bulky lymphadenopathy
• Hilar adenopathy
• Involvement of more than 3 nodal regions
• Extranodal extension to contiguous structures

Stage IB and IIB disease

 

Stage IIIA disease and IVB

 

High Risk

Advanced stage disease  - Stage IIIB and IVB

 

 

 

Response criteria:

Response Definition

Complete response

(CR)

Complete resolution of pathologic palpable lymphadenopathy.

  • At least 80% reduction in size of each of the nodal masses including the mediastinum
  • Return to normal size with no residual nodal mass greater than 2.0 cm in max transverse diameter as measured in the axial plane on CT.
  • Within the mediastinum, a > 2.0 cm residual nodal mass is permissible provided, the mass has decreased by at least 80%.
  • Individual nodes that were previously confluent must have regressed by more than 80% compared with the size of the original mass.
  • No new lesions.

 

Nodal masses that have not regressed at least 80% or returned to normal size may be due to either fibrosis or residual disease and biopsy should be considered.

 

Focal lesions of the liver or spleen or other organ considered due to lymphoma have resolved completely.

 

Gallium or PET scan negative.

 

Very Good Partial Response

(VGPR)

At least 60% reduction in each of the areas of measurable disease, or return to normal nodal size, but not a CR.

  • Individual nodes that were previously confluent must have regressed by more than 60% compared to the size of the original mass.
  • Small nodal masses that have not regressed by at least 60% in their PPD or returned to normal size may reflect lack of VGPR or fibrotic changes.
  • No progression of non measurable assessable disease sites.
  • No new lesion(s).

Rapid Early Response (RER)

Complete Response (CR) or very good partial response (VGPR) after 2 cycles of chemotherapy.
Slow Early Response (SER) Less than very good partial response (<VGPR) following 2 cycles of chemotherapy.

Partial Response

(PR)

At least 50% reduction in size of each of the areas of measurable disease, or return to normal nodal size, but not constituting a CR.

  • Individual nodes that were previously confluent must have regressed by more than 50% compared to the size of the original mass.
  • No progression of non measurable assessable disease sites.
  • No new lesion(s).

Stable Disease

(SD)

 Less than a partial response but not progressive disease
Progressive Disease (PD)
  • At least 50% increase in the size of any of the involved nodes or nodal masses.
  • At least 50% increase in the in the size of any of the focal organ lesions.
  • New lesion(s).
  • Progression of a non measurable assessable disease site.

 

 

 

 

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