Treatment and Therapy Hodgkin's Lymphoma

Therapy can be viewed from several aspects:

a. have or have not been treated.

b. Early stage (st I + II) or advanced stage (III + IV st)

c. Will use the means-single-therapy (radiotherapy or chemotherapy only) or a means of combination therapy (combination therapy rather than a means of combination chemotherapy).

Chemotherapy for this disease can be a single chemotherapy (using one drug), combination chemotherapy (using more drugs) and the recently developed high-dose chemotherapy plus autologous stem cell transplantation to rescue (rescue) system blood aplasia caused by high-dose chemotherapy earlier. (KDT + rPSC autologous).

I. The cases have not been previously treated (initial therapy)

a. Radiotherapy only.

In historical, just use radiotherapy, can be curative for early Hodgkin's disease (st I + II) A. but decreases when no disease below the diaphragm, therefore, stage IA and IIA are planned to be given a curative course of radiation therapy is staging laparotomy necessary to ensure the presence or absence of lesions below the diaphragm. If there is a lesion under the diaphragm, then the only use of radiotherapy is not enough, so need to be supplemented by chemotherapy. If there are signs of poor prognosis such as: B symptoms and bulky tumors, it should be a combination of radiotherapy + chemotherapy (combinations of treatment means = combined modality therapy) due to radiotherapy alone is no longer curative. To chemotherapy is usually

MOPP 6x considered sufficient as an adjuvant (additional) in radiotherapy. When no lesions below the diaphragm (evidenced by the staging-laparotomy) for stage IA are given extended field radiotherapy, for stage IIA given total nodal irradiation (TNI), is considered sufficiently curative.

b. The combination of chemotherapy + radiotherapy.

For all circumstances where there is disease below the diaphragm radiotherapy should be combined with adjuvant chemotherapy, has considered curative. Therapy with a combination of these modalities are also indicated if the disease stage IIA but the patient refused laparotomy or laparotomy is not going to do because there are contraindications.

For an advanced stage (st III and IV) the main curative treatment is chemotherapy. If there is a large lesions (bulky mass) with the addition of the letter X on a staged, it was added in place of curative doses of adjuvant radiotherapy after chemotherapy.

The combination of chemotherapy + radio is also recommended to those who show signs of poor prognosis, namely:

1. Large mediastinal mass.

 2. B-symtoms.

 3. dihilus lung abnormalities.

 4. histologinya not Lymphocytic predominant.

5. ≥ Stage III.

c. Chemotherapy

Originally given chemotherapy as primary therapy for stage III and IV, but often relapse, especially when there are bulky mass because it is for places where bulky lesions after radiotherapy adjuvant chemotherapy need to place a bulky mass was originally there. In this way the cure rate is quite high. Many experts of Medical Oncology giving chemotherapy as primary therapy since stage II coupled with adjuvant radiotherapy to the bulky mass, thus staging laparotomy needs fewer, not even necessary anymore because of this action is too invasive, while the result is the same, but there is still disagreement, especially between expert

radiotherapy with a medical oncologist.

Many chemotherapy regimens are made for Hodgkin's disease. Some are using alkylating agents, there is not. Alkylating agent is suspected as the cause of secondary cancers and sterility. Adrianisin cause cardiac abnormalities; bleomycin pulmonary abnormalities, especially when

combined with radiotherapy of the mediastinum.

Curative regimen, the regimen was always using a combination of drugs. Regimens using alkylating agents, for example:

MOPP: nitrogen mustard-M = 6mg/sqm i.v. day to 1.8

- O = Onkovin = vincristine 1.2 mg / sqm i.v. day to 1.8

- P = procarbazine 100 mg / sqm p.o 1-14 days

- P = Prednisone 40 mg / sqm p.o. repeated 1-14 days to lapse 28 days if eligible.

MOPP regimen modification was also there that Copp and LOPP.

In Copp M is replaced with C + Cyclophosphamide 800 mg / sqm iv

day to 1.8 or 3x50 mg / sqm p.o. dd day to 1-14. whereas in LOPP M replaced by L + Leukeren = chlorambucil 8 mg / sm ss po ke1-14 days.

Regimens without alkylating agent such as ABVD or ABV only.

A = adriamycin 25 mg / sqm i.v. days 1 and 14

B = bleomycin 10 mg / sqm i.v. days 1 and 14

V = vinblastine 6 mg / sqm i.v. days 1 and 14

(D) = DTIC 150 mg / sqm i.v. days 1-5 repeated intervals of 4 weeks

So the two regimens were used as initial therapy. Both regimens were not cross-resistant. Consistent with the hypothesis of Goldie and Coldman MOPP can be used first, or ABV (D) first, or alternating MOPP-ABVD-regimen MOPPABVD dst or hybrid MOPP-ABV (D), the results are equally good, but there is still disagreement.

II. Therapy cases that had been treated previously

Here therapies intended to cases of relapse, refractory since initial therapy, or after being treated several times. Sometimes MOPP or ABVD can still be used to obtain remission for two non-crossresistant this regimen, but the number of small and fast remisinya relapse. If the two standard regimens were no longer able to help other regimens used regimen-which fall in salvage-therapy (= salvage therapy). So Salvage chemotherapy is given to those who:

1. relapse after complete remission

2. resistant to therapy

Table several regimens for salvage therapy (second-line therapy in Hodgkin's Lymphoma Relapse or Resistant)

V = vinblastine 6 mg / sqm i.v. every 3 weeks

A = Adrianmisin 40 mg / sqm i.v. every 3 weeks

B = bleomycin 15 U 1-v-once every week

C = Lomustin (CCNU) 80 mg / sqm p.o. every 6 weeks

D = Dakarbasin 800 mg / sqm i-v-every 3 weeks

C = Lomustin (CCNU) 80 mg / sqm p.o. days to 1

E = etoposide 100 mg / sqm p.o. days to 1

P = Prednimustin 60 mg / sqm ivhari to 1, given the lapse 3-6minggu

E = etoposide 200 mg / sqm p.o. 1-5 days

V = vincristine 2 mg / sqm i.v. days to 1

A = adriamycin 20 mg / sqm i.v. days 1, 3-week intervals were given

M = Methyl-GAG 500 mg / sqm i.v. 1-14 days

I = ifosfamide 1 g / sqm i.v. 1-5 days

M = Methotrexate 30 mg / sqm i.v. day 3

E = etoposide 100 mg / sqm i.v. days 1-4, given the 3-week interval

C = Lomustin 100 mg / sqm p.o. days to 1

E = etoposide 100 mg / sqm h. to 1-3 and 21-23

M = Methotrexate 30 mg / sqm p.o. days 1,8,21,28, given the lapse of 6 weeks

M = Methotrexate 30 mg / sqm i.v. every 6 hours for 4 days starting the 1st day and 8 with rescue

C = Cyclophosphamide 750 mg / sqm i.v.h. to 15

H = Doxorubicin 50 mg / sqm i.v.h to 15

O = vincristine 1 mg / sqm i.v. day 15 and 22

P = Prednisone 100 mg / sqm p.o. 22-26 days, given the lapse of 4 weeks

E = etoposide 120 mg / sqm i.v. day 1,8,15

V = vinblastine 4 mg / sqm i.v. day 1,8,15

A = Ara-C 30 mg / sqm i.v. day 1,8,15

P = Platinum 40 mg / sqm i.v. days 1,8,15, repeated intervals of 4 weeks

M = Methotrexate 120 mg / sqm i.v. day 15 and 22 plus rescue

O = vincristine 2 mg i.v.h. 15 and 22

P = Prednisone 60 mg / sqm p.o. 1-14 days

L = Leukovorin rescue

A = Ara-C 300 mg / sqm i.v. day 15 and 22

C = Cyclophosphamide 750 mg / sqm i.v. days to 1

Salvage-therapy regimen regimens include: VABCD, ABDIC, CBVD, CEP, EVA, LVB, MIME, M-CHOP, CEM, EVAP, MOPLACE dll.Kemajuan field of bone marrow transplant or stem cell (stemcell) - Autologous also impact in therapy-resistant lymphoma.

In this condition given very high doses of chemotherapy to arise aplasi marrow (myeloablative chemotherapy), then performed the rescue with autologous stem cell transplant from peripheral blood taken after the previously given Hemopoetic Growth Factors.

Populations that require very high-dose chemotherapy plus stem-cell rescue (KDTrPSC) is an advanced Hodgkin's disease accompanied with poor prognosis factors which include:

1. Those who fail to obtain complete remission (CR) or partial (PR) is good (stable) (defined as very likely because of residual fibrosis with initial therapy).

2. Those who experienced progressive disease (PD) as initial therapy.

3. CR duration of less than 1 year

4. Recurrent relapses (≥ 2x) without looking at the length of remission

5. Presence of B symptoms at first relapse

6. Relapses after previously having stage IV

The factors mentioned above is also a predictor of poor outcome with treatment to the second line (salvage therapy), they are good candidates for KDTrPSC mentioned above. Those without the facto-bad factor when relapses can still be tested with a second-line chemotherapy to obtain a second CR, but likely only 35% only, the rest eventually also require KDTrPSC; even have begun to study the use of KDTrPSC as initial therapy, but there is still no conclusion .