Treatment of childhood Hodgkin's disease with COPP or COPP-ABV (hybrid) without radiotherapy in Nicaragua

Background: Childhood Hodgkin's disease (HD) in low-income countrieshas been reported to have distinct presenting features, including a highprevalence of the mixed cellularity subtype, which also seems to be associatedwith poorer prognosis. Further investigations are needed to evaluate theseissues. Another controversial aspect of childhood HD is the use ofradiotherapy (RT) in its treatment and the growing concern about its seriousadverse side effects. In this paper, data on the diagnosis and outcome ofchildren treated without RT in a low-income country (Nicaragua) are reported.Patients and methods: Forty-eight consecutive children aged0–15 years, diagnosed at La Mascota Hospital of Managua (Nicaragua)from January 1990 to October 1995, entered this study. Follow-up was updatedin May 1996. Clinical and histopathological staging was performed accordingto Ann Arbor and Rye criteria, respectively. Treatment consisted of COPP (sixcycles) for stages I or IIA, or COPP-ABV (hybrid): eight cycles for stages IIBor III, and 10 cycles for stage IV. Total cumulative doses of adriamycin andbleomycin in this protocol are, respectively, 200 and 80 mg/sqm for stages IIB or III and 250 and 100 mg/sqm for stage IV.Results: The median age of the 48 patients at diagnosis was sevenyears, and the mean age was 7.9 years (range 3–15 years). Clinicalstages were IA in 5, IIA in 9, IIB in 6, IIIA in 5, IIIB in 14, and IVB in 9.Histopathologically, 25 cases presented with mixed cellularity, 15 withnodular sclerosis, 5 with lymphocytic predominance and 3 with lymphocyticdepletion. Four patients did not proceed with treatment and were lost tofollow-up. Two patients (stages IIIB and IVB), who never achieved completeremission (CR) during treatment, presented progressive disease at the end ofthe scheduled chemotherapy. The remaining 42 patients were in completeremission at the end of chemotherapy. Following discontinuation of therapy,one patient (stage IA) was lost to follow-up and two patients with stage IIIB,who were in CR after the second chemotherapy cycle, relapsed 20 and 9 monthsfollowing the diagnosis. EFS at three years is 100% for the 25 patientswith stages I, II, IIIA and 74.9% for the 23 patients with stages IIIBor IV.Conclusion: The presenting features found in these patients aresimilar to those reported from other low-income countries. In our experience,however, the high prevalence of the mixed cellularity subtype was notassociated with poorer prognosis. Satisfactory results have been achieved inpatients with stages I, II or IIIA HD using COPP or COPP-ABV (hybrid) regimenswithout RT. The treatment was also well tolerated and can thus be recommendedfor these patients in low-income countries, where RT facilities may be scarceor unavailable. The use of more aggressive treatment schedules and/or RT oninvolved fields in front-line treatment may, however, be needed for the moreadvanced stages IIIB or IV. Large studies with adequate follow-up are neededto evaluate whether, if RT is omitted, higher cumulative doses of more toxicdrugs are required and thus compare the long-term toxic effects of differenttreatment modalities.