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Prathima Prodduturi, James O ArmitageUniversity of Nebraska Medical Center, Omaha, NE, USAAbstract: Early-stage Hodgkin’s lymphoma which includes patients with Ann Arbor stages I or II, accounts for more than 50% of all cases of the illness and is curable in a high proportion of patients. Long-term follow-up has shown that the mortality in favorable-risk patients with early-stage Hodgkin’s lymphoma is exceeded by other causes including secondary malignancies and cardiac disease. Over the decades the treatment paradigm in Hodgkin’s lymphoma has evolved from extended field radiotherapy to combined modality therapy using involved field radiotherapy to using chemotherapy alone. The data on long-term complications from using low dose and limited field radiation therapy is still awaited since we know that most of the secondary malignancies occur late (ie, more than 10 years after the treatment). By changing the chemotherapy regimens from mechlorethamine, vincristine, procarbazine, prednisone (MOPP) to doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) the incidence of infertility and leukemia has been reduced. Since the late toxicity was high with radiotherapy, recent studies have focused on using chemotherapy alone. The results of interim positron emission tomography (PET) scans after two cycles of chemotherapy are being tested to see whether minimizing therapy in rapidly-responding patients will still maintain excellent cure rates. Here, we have reviewed some of the important clinical trials in early-stage Hodgkin’s lymphoma and focus on some of the recent trials emphasizing reduced intensity treatment in early-stage Hodgkin's lymphoma.Keywords: Hodgkin’s lymphoma, treatment, early-stage, intensity, mortality

Anemia is a widely prevalent complication among cancer patients. At the time of diagnosis, 30% to 40% of patients with non-Hodgkin Lymphoma or Hodgkin lymphoma and up to 70% of patients with multiple myeloma are anemic; rates are higher among persons with myelodysplastic syndromes. Among patients with solid cancers or lymphomas, up to half develop anemia following chemotherapy. For almost 2 decades, erythropoiesis-stimulating agents (ESAs) were the primary treatment for cancer-related anemia. However, reassessments of benefits and risks of ESAs for cancer-associated anemia have occurred internationally. We reviewed guidelines and notifications from regulatory agencies and manufacturers, reimbursement policies, and utilization for ESAs in the cancer and chronic kidney disease settings within the United States, Europe, and Canada. In 2008 the US Food and Drug Administration (FDA) restricted ESAs from cancer patients seeking cure. Reimbursement is limited to hemoglobin levels < 10 g/dL. In the United States, ESA usage increased 340% between 2001 and 2006, and decreased 60% since 2007. The European Medicines Agency (EMEA) recommended that ESA benefits do not outweigh risks. In Europe between 2001 and 2006, ESA use increased 51%; since 2006, use decreased by 10%. In 2009, Canadian manufacturers recommended usage based on patient preferences. In Canada in 2007, approximately 20% of anemic cancer patients received ESAs, a 20% increase since 2004. In contrast to Europe, where ESA use has increased over time, reassessments of ESA-associated safety concerns in the United States have resulted in marked decrements in ESA use among cancer patients. [ABSTRACT FROM AUTHOR]

When oncologists diagnose patients suspected of lymphoid malignancy, it is important to consider the possibility of adult T-cell leukemia/lymphoma (ATL) with a routine check for serum human T-cell lymphotropic virus type 1 (HTLV-1) antibody. The following points are essential for the diagnosis of ATL: (1) cytologically or histologically proven peripheral T-cell malignancy, and (2) positivity for anti-HTLV-1 antibody. When a patient is diagnosed with ATL, it is important to make an accurate diagnosis of clinical subtype in order to make appropriate treatment decisions. For patients with smoldering or chronic type ATL, close observation with careful monitoring for opportunistic infections is recommended. For patients with the acute or lymphoma type requiring therapy, enrollment in a clinical trial is recommended. When there is no active trial or the patient is ineligible for a trial, we recommend intensive chemotherapy used for aggressive non-Hodgkin lymphoma such as the LSG15 regimen (VCAP-AMP-VECP) based on a recent phase III study. Because most patients with ATL are not curable with current chemotherapy regimens, it is reasonable to consider the applicability of allogeneic stem cell transplantation in patients who show responses to chemotherapy. For relapsed or refractory patients, enrollment in a new-agent trial should be considered in addition to stem cell transplantation. [ABSTRACT FROM AUTHOR]

Burkitt lymphoma is a unique B-cell malignancy with a high proliferation rate and characteristic genetic changes involving the c-myc oncogene. Burkitt lymphoma is common in children but also occurs in adults, where distinction from diffuse large B-cell lymphoma may pose a problem. The development of brief, very intensive chemotherapy regimens has led to a very high cure rate in children with Burkitt lymphoma. The use of these regimens in adults, often in combination with the antibody rituximab (Rituxan), has also made the cure of a majority of adults possible. Burkitt lymphoma in adults cannot be treated effectively with the common regimens used for diffuse large B-cell lymphoma such as CHOP-R (cyclophosphamide, doxorubicin HCl, vincristine [Oncovin], prednisone, rituximab). Prompt diagnosis and initiation of appropriate therapy with attention to the possibility of tumor lysis syndrome are necessary for optimal results. [ABSTRACT FROM AUTHOR]

Approximately 7350 new cases of Hodgkin lymphoma (HL) are diagnosed annually in the United States. The Incidence of HL has a bimodal pattern, with the highest incidence seen in young adults and in elderly patients. The disease is composed of 2 distinct entities: the more commonly diagnosed classical HL and the rare nodular lymphocyte-predominant HL. Classical HL includes the subgroups nodular sclerosis, mixed cellularity, lymphocyte depletion, and lymphocyte rich. Selection of the appropriate therapy Is based on accurately assessing the stage of disease. Patients with early-stage disease are treated with combined modality strategies using abbreviated courses of combination chemotherapy followed by Involved-field radiation therapy, whereas those with advanced-stage disease receive a longer course of chemotherapy without radiation therapy. Currently, more than 80% of all patients with newly diagnosed HL are expected to be long-term survivors. Although many patients respond well to initial therapies and have durable long-term remissions, a subset of patients has resistant disease and experiences relapse even after subsequent high-dose chemotherapy and autologous stem cell transplantation. New therapies are clearly needed for these patients. [ABSTRACT FROM AUTHOR]

Non-Hodgkin Lymphomas are always treatable and frequently curable malignancies. However, choosing the most appropriate therapy requires accurate diagnosis and a careful staging evaluation. New patients with non-Hodgkin Lymphoma should have their tumors classified using the World Health Organization classification. The specific choice of therapy is dependent on a careful staging evaluation. Patients with non-Hodgkin Lymphoma are assigned an anatomic stage using the Ann Arbor system. However, patients should also be classified using the International Prognostic Index. New insights into the biology of the lymphomas in the coming years might well improve our ability to evaluate patients and choose therapy. [ABSTRACT FROM AUTHOR]

Physicians, hospitals, and other health care facilities will assume the responsibility for aiding individuals injured by a terrorist act involving radioactive material. Scenarios have been developed for such acts that include a range of exposures resulting in few to many casualties. This consensus document was developed by the Strategic National Stockpile Radiation Working Group to provide a framework for physicians in internal medicine and the medical subspecialties to evaluate and manage large-scale radiation injuries. Individual radiation dose is assessed by determining the time to onset and severity of nausea and vomiting, decline in absolute lymphocyte count over several hours or days after exposure, and appearance of chromosome aberrations (including dicentrics and ring forms) in peripheral blood lymphocytes. Documentation of clinical signs and symptoms (affecting the hematopoietic, gastrointestinal, cerebrovascular, and cutaneous systems) over time is essential for triage of victims, selection of therapy, and assignment of prognosis. Recommendations based on radiation dose and physiologic response are made for treatment of the hematopoietic syndrome. Therapy includes treatment with hematopoietic cytokines; blood transfusion; and, in selected cases, stem-cell transplantation. Additional medical management based on the evolution of clinical signs and symptoms includes the use of antimicrobial agents (quinolones, antiviral therapy, and antifungal agents), antiemetic agents, and analgesic agents. Because of the strong psychological impact of a possible radiation exposure, psychosocial support will be required for those exposed, regardless of the dose, as well as for family and friends. Treatment of pregnant women must account for risk to the fetus. For terrorist or accidental events involving exposure to radioiodines, prophylaxis against malignant disease of the thyroid is also recommended, particularly for children and adolescents. [ABSTRACT FROM AUTHOR]

The news in this field is largely good. Although BMT is still largely an investigational treatment for solid tumors, it may cure many hematologic and immune system cancers and can prolong life or improve its quality in patients who have other malignancies. Mortality has declined significantly in recent years, especially for autologous transplantation. [ABSTRACT FROM AUTHOR]

The initial signs and symptoms of Hodgkin's disease and the non-Hodgkin's lymphomas have not changed, but their assessment has become streamlined. Staging is the key to treatment. In some cases, delaying therapy is advised; in others, chemotherapy, irradiation, or both are recommended. [ABSTRACT FROM AUTHOR]