TREATMENT OF CHILDHOOD HODGKINS-DISEASE WITH COPP OR COPP-ABV (HYBRID) WITHOUT RADIOTHERAPY IN NICARAGUA

Background: Childhood Hodgkin's disease (HD) in low-income countries h as been reported to have distinct presenting features, including a hig h prevalence of the mixed cellularity subtype. which also seems to be associated with poorer prognosis. Further investigations are needed to evaluate these issues. Another controversial aspect of childhood HD i s the use of radiotherapy (RT) in its treatment and the growing concer n about its serious adverse side effects. In this paper, data on the d iagnosis and outcome of children treated without RT in a low-income co untry (Nicaragua) are reported. Patients and methods: Forty-eight cons ecutive children aged 0-15 years, diagnosed at 'La Mascota' Hospital o f Managua (Nicaragua) from January 1990 to October 1995, entered this study. Follow-up was updated in May 1996. Clinical and histopathologic al staging was performed according to Ann Arbor and Rye criteria, resp ectively. Treatment consisted of COPP (six cycles) for stages I or IIA , or COPP-ABV (hybrid): eight cycles for stages IIB or III, and 10 cyc les for stage IV. Total cumulative doses of adriamycin and bleomycin i n this protocol are, respectively, 200 and 80 mg/sqm for stages II B o r III and 250 and 100 mg/sqm for stage IV, Results: The median age of the 48 patients at diagnosis was seven years, and the mean age was 7.9 years (range 3-15 years). Clinical stages were IA in 5, IIA in 9, IIB in 6, IIIA in 5, IIIB in 14, and IVB in 9, Histopathologically, 25 ca ses presented with mixed cellularity, 15 with nodular sclerosis, 5 wit h lymphocytic predominance and 3 with lymphocytic depletion. Four pati ents did not proceed with treatment and were lost to follow-up. Two pa tients (stages IIIB and IVB), who never achieved complete remission (C R) during treatment, presented progressive disease at the end of the s cheduled chemotherapy. The remaining 42 patients were in complete remi ssion at the end of chemotherapy. Following discontinuation of therapy , one patient (stage IA) was lost to follow-up and two patients with s tage IIIB, who were in CR after the second chemotherapy cycle, relapse d 20 and 9 months following the diagnosis. EFS at three years is 100% for the 25 patients with stages I, II: IIIA and 74.9% for the 23 patie nts with stages IIIB or IV. Conclusion: The presenting features found in these patients are similar to those reported from other low-income countries. In our experience, however, the high prevalence of the mixe d cellularity subtype was not associated with poorer prognosis. Satisf actory results have been achieved in patients with stages I, II or III A HD using COPP or COPP-ABV (hybrid) regimens without RT. The treatmen t was also well tolerated and can thus be recommended for these patien ts in low-income countries, where RT facilities may be scarce or unava ilable. The use of more aggressive treatment schedules and/or RT on in volved fields in front-line treatment may, however, be needed for the more advanced stages IIIB or IV. Large studies with adequate follow-up are needed to evaluate whether, if RT is omitted, higher cumulative d oses of more toxic drugs are required and thus compare the long-term t oxic effects of different treatment modalities.