XVI. Early stage Hodgkin lymphoma

In the 1960s and 1970s, patients with clinical stage IA or IIA disease HL apparently confined to the thorax, axillae or neck underwent staging laparotomy with lymph node and liver biopsies and a splenectomy; if histological assessment confirmed the absence of disease below the diaphragm, wide field radiotherapy was recommended [1]. This approach led to prolonged disease-free survival in a significant number of patients and represented a major step forward. What soon became apparent, however, was recurrence of disease outside the radiation field in some patients as a result of false negative histological assessment of biopsy specimens taken at staging laparotomy. This led to studies of adjuvant chemotherapy designed to determine whether a combined modality approach could prevent recurrence in patients with seemingly early stage HL. A clear benefit for patients receiving adjuvant treatment was observed in terms of progression-free survival (PFS), but there was no survival advantage because patients developing recurrent disease after radiotherapy alone were very efficiently salvaged by chemotherapy [2]. Furthermore, the benefit of fewer relapses after combined modality therapy was at the expense of patients receiving the highly emetogenic MOPP chemotherapy or a close variant at a time when anti-emetic medication was in its infancy. It also became evident that MOPP and its relations caused permanent azoospermia in a high proportion of men [3] and premature menopause in women [4] and, rarely, acute leukaemia or myelodysplasia in both sexes [5]. These studies highlighted the benefits of chemotherapy in terms of disease control but also showed that there were undesirable long-term consequences to treatment in addition to the immediate toxicity with which Hodgkin patients were already well acquainted. The replacement of