Whether a child is diagnosed with Hodgkin Lymphoma (HL), a rare form of cancer, or with another type of cancer, it is important to remember that children can benefit from the latest treatments. There are different approaches to treating HL, including MRI-based screening, treatment of the tumor with a low dose of a chemotherapeutic agent, and treatment of the underlying immune system.
Treatment options for children with HL
Depending on the type of lymphoma, children can receive different treatment options. Treatments may include chemotherapy and radiation therapy. They may also involve a procedure called an ALLO transplant, which involves replacing the blood-forming cells in the body with healthy stem cells from another person.
Children with HL usually receive treatment in a specialized cancer center. These centers have experience treating children with cancer and can provide access to the latest research. Children who participate in clinical trials have the chance to receive new drugs and treatment.
Treatment options for children with HL also depend on the age of the patient. Children younger than age five are often treated with chemotherapy alone. Children older than age five may receive chemotherapy and radiation therapy.
The type of medication that is given depends on the child’s age, general health, and type of lymphoma. Medications can be given by mouth, through the bloodstream, or by an IV.
Hodgkin lymphoma treatment is successful for most children. However, it is not uncommon for children to develop severe late effects.
Early intervention can help reduce the long-term effects of the disease. The longer the child lives with cancer, the more likely the long-term effects will become apparent. These effects may include a change in body weight, drenching night sweats, or weight loss without a known cause.
Treatment options for children with Hodgkin lymphoma may involve chemotherapy or radiation therapy. These treatments destroy the cancer cells and may also help to relieve symptoms.
Predicting prognosis for recurrence
Identifying patient cohorts with a lower risk of recurrence is a key element of current pediatric HL treatment strategies. This approach has been supported by a better understanding of newer imaging modalities and the development of treatment strategies that target toxicity.
The main goal of treatment is to achieve and maintain high survival rates. The establishment of a “standard of care” approach is complicated by the delayed effects of therapy and the need to balance overall survival with minimizing long-term morbidity.
In addition to treatment, there are several prognostic factors that impact outcomes. These include time to relapse, stage, and risk groups.
Early relapse is defined as a relapse between three and 12 months after completion of first-line treatment. In pediatric studies, this is a highly significant prognostic factor.
The recurrence of Hodgkin lymphoma is a significant problem in children. Approximately 80 percent of patients will develop the primary refractory disease. This adversely affects disease-free survival.
Children and adolescents with HL have an estimated five-year survival rate of 94 percent. This rate has increased since 2002. The best treatment for high-risk patients has not been defined. However, treatment failure rates are very low with the most effective pediatric regimens. ICE (ifosfamide, carboplatin, etoposide) with or without bortezomib is being studied for relapsed/refractory Hodgkin lymphoma.
The primary refractory disease has the worst prognosis in children. Consequently, optimal salvage treatment has not yet been defined in children.
In vitro maturation for HL
Using oocytes to stimulate a woman’s fertility is an old-fashioned practice, particularly when transplantation of ovarian tissue is not an option. In the absence of gonadotropin treatment, an oocyte retrieval procedure using the IVM – or a combination of IVM and cryopreservation of cortical ovarian tissue – should be considered as a means to avoid reseeding. Several studies have reported in vitro maturation rates from 3 to 100 percent. Among the oocyte retrieval techniques in use at present, the IVM has been reported to have low operative complication rates. It is thus a viable option for female cancer patients.
The In Vitro Maturation (IVM) procedure is a safe and relatively simple procedure in which oocytes are harvested ex vivo, then incubated in a sterile medium for 48 hours. This procedure has been reported to yield a number of benefits including oocyte retrieval without gonadotropin treatment, avoiding the risk of reseeding the disease, and avoiding the annoyances of oocyte retrieval from a live donor. The resulting oocytes are cryopreserved, and the process is performed under local anesthesia. The IVM has been reported to produce an ovulation rate of around 50 percent, and the procedure may prove to be a viable gamete source in pediatric female cancer patients.
The ovulation rate from the IVM is not a given but is more likely to occur in the event that the ovarian tissue is frozen. This procedure may be more efficient in the event that a patient is already on chemotherapy or radiotherapy.
High-dose ifosfamide and mitoxantrone
Among the various chemotherapy drugs, high-dose ifosfamide and mitoxantrone (HDIM) are used to treat relapsed or refractory Hodgkin lymphoma. This chemotherapy regimen is highly effective in the treatment of relapsed and refractory non-Hodgkin lymphoma. In addition, it is useful in the treatment of refractory juvenile myelomonocytic leukemia.
Ifosfamide-based chemotherapy regimens are used in the treatment of malignant lymphoma and aggressive lymphoma. These regimens are effective and have very limited toxicity. These drugs work in different ways to kill lymphoma cells.
A number of researchers have studied the effects of ifosfamide and other chemotherapy drugs. These drugs are used in combination with each other to mobilize stem cells and reduce tumor burden. Currently, there are several clinical trials evaluating the use of these regimens for newly diagnosed patients. Some of these trials use sequential response-based protocols that combine several non-cross-resistant drugs.
Ifosfamide has been used as a salvage regimen in lymphoma. It has limited toxicity and high response rates. It has been used in combination with other drugs to mobilize peripheral stem cells. It has also been used in combination with other drugs in the treatment of malignant lymphoma.
A number of ifosfamide-based regimens are being evaluated for newly diagnosed patients. In one of these studies, ifosfamide-based chemotherapy is combined with cytosine arabinoside and mitoxantrone. The toxicity was acceptable and the success rate was 96 percent. It has also been used with cladribine and high-dose cytarabine in the treatment of a 33-year-old African gentleman who developed HS after receiving sequential renal transplants.
MRI-based screening reduces BC mortality among women treated with RT for adolescent HL
Among women who were treated with radiotherapy for adolescent Hodgkin lymphoma, the incidence of breast cancer (BC) is significantly lower if women are screened using an MRI compared to screening using mammography alone. This study is the first to examine the feasibility of such a screening strategy in this population.
In this study, women who were treated for adolescent Hodgkin Lymphoma (HL) were enrolled in a screening program. Several screening modalities were evaluated in the trial, including mammography, ultrasound, and MRI. The optimal screening strategy is still unclear, and further investigations are needed.
The primary outcome was the difference in 3-year progression-free survival rates between the randomized groups. The difference between the groups was measured using the Kaplan-Meier method. The estimated 5-year overall survival rate was 62.7 %. The relative risk was calculated as the ratio of the observed to the expected number of secondary BCs.
Among 115 women, 12 BCs were detected during 855 person-years of follow-up. Four of these BCs were in situ carcinomas, and six were invasive ductal carcinomas. The most common site of diagnosis was the parietal region. Five of these tumors were hormone receptor-positive, and all seven tumors had tumor sizes greater than or equal to 1.5 cm. A total of six of these tumors had lymph node metastases.
The median age at diagnosis was 40 years. The interval between HL treatment and the first mammogram was 13 years. Younger age was associated with a higher risk of hospitalization and endocrine disorders.
T-cell therapy is safe for patients with relapsed or refractory HL
Several clinical trials have been published recently to assess the safety and effectiveness of T-cell therapy for patients with relapsed or refractory Hodgkin lymphoma. The results have shown that the combination of anti-CD30 CART-30 cells and nivolumab is safe, feasible, and effective in relapsed and refractory HL patients.
T-cell therapy is now available to patients with relapsed or refractory HL who are at high risk for relapse. CAR T cells have been demonstrated to be effective in other hematologic malignancies. These cells are engineered ex vivo to recognize and attack tumor-associated antigens. In the HL patient, the CAR T cell is transduced with a gammaretroviral vector containing a CD28 co-stimulatory domain.
CART-30 cell therapy was effective and well-tolerated. Patients who achieved complete remission or partial remission were followed up at predetermined intervals. The mean dose of CAR-positive T cells per kg was 1.56 x 107. In addition, a number of CAR-positive T cells developed activity against non-viral tumor antigens.
There were no significant increases in viral infections. However, grade 3/4 thrombocytopenia occurred in 24% of patients. A grade 3/4 neutropenia was present in 10% of patients.
The majority of patients had multiple tumor lesions. The median PFS was 6 months. The overall response rate (ORR) was 43%. The ORR was higher in immunocompetent patients. This suggests that targeting malignant cells is important for successful remission.
In the patients who achieved remission or partial remission, higher levels of circulating LMP-specific T cells were observed. These cells express EBV antigens. This is likely due to the high burden of the disease.
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