Management of early stage Hodgkin's disease: The role of radiation therapy and/or chemotherapy

The treatment of early stage HD has become more complicated over the past 10 years. The development of standards for both radiation therapy and chemotherapy have made it more feasible to treat HD in community practice settings. Yet initial treatment decisions may have profound longterm effects on patients who are young and likely to have a long survival. Whenever possible, routine cases should be treated along guidelines of standard accepted practice, and physicians should refer patients to major centres for the management of more complicated cases. There is hope that less toxic chemotherapy will be effective in curing occult microscopic disease, perhaps eventually obviating the need for staging laparotomy and splenectomy. Yet for now, there are little long-term data defining specifics of treatment, or the long-term efficacy or toxicity of modified regimens. Thus at present, the management of patients with I-ID in ways that do not adhere to standard practice, such as modifying standard RT or chemotherapy, should be strongly discouraged outside controlled clinical trials. In parts of the USA there is still a general acceptance of staging laparotomy and splenectomy as a means to aggressively stage patients in order to minimize treatment. By utilizing diagnostic laparotomy and splenectomy, the majority of patients with PS IA-IIA HD will be cured with RT alone thus sparing them the toxicity of combined chemotherapy and RT, and preserving the effectiveness of chemotherapy in case of relapse. Using this approach, patients who are likely to need chemotherapy due to a high risk of relapse (LMA, or extensive B symptoms), or high risk for having abdominal involvement (more than one positive abdominal radiographical test) should not undergo a staging laparotomy. In addition, chemotherapy and limited field irradiation may be preferred under special circumstances (i.e. for paediatric patients). Diagnostic staging laparotomy and splenectomy is not routinely performed outside the continental USA. Academic centres in Canada, Europe and South America have identified prognostic factors to aid in determining treatment for clinically staged patients. Patients with the most favourable characteristics receive RT alone with CMT used for the remainder of patients. On average, without the information obtained at staging laparotomy, patients require more treatment, either with larger radiation fields, or with the more frequent use of chemotherapy.