INTRODUCTION
Hodgkin Lymphoma (HL) is one of the most prevalent tumors (9%) treated
at the Association of Pediatric Hematology-Oncology of Central America
(AHOPCA), a childhood cancer network of pediatric cancer centers from
Central America, Dominican Republic, and Haiti1. This
network designs uniform treatment guidelines, for children with cancer
diagnosed at the individual centers. Over time, AHOPCA has studied
baseline treatment outcomes for different pathologies in the region, and
has addressed unique psychosocial needs in low- and middle income
countries (LMIC)1,2. Because radiation therapy is not
easily accessible in every country in Central America, the AHOPCA Center
in Nicaragua designed a chemotherapy only regimen consisting of four
cycles of cyclophosphamide, vincristine, prednisone and procarbazine
(COPP) for patients with early stage HL and two to four additional
courses of chemotherapy consisting of doxorubicin, bleomycin and
vinblastine (COPP/ABV) for advanced stage HL3. Based
on encouraging results for this regimen, AHOPCA implemented a
chemotherapy-only treatment guideline4: AHOPCA LH-1999
using the same risk assessment and treatment schema for all subjects
presenting to an AHOPCA Center. Castellanos et al reported an event-free
survival (EFS) of 60% regardless of risk assignment4.
However, the EFS for patients with Ann Arbor stage IV HL was only 20%.
This report identified two critical factors that influenced the poor
outcomes: abandonment of therapy (13%), accuracy of diagnosis and
appropriate staging4.
To improve survival, improve diagnostic accuracy and reduce abandonment,
AHOPCA introduced in 2004 three risk groups, low, intermediate, and high
with strict staging and risk assignment criteria, response assessment
and clear radiation therapy guidelines. AHOPCA hypothesized that a
regimen that could be administered over a short period of time (to
prevent abandonment), that had an established low toxicity profile with
lower anthracycline dose (150mg/m2), and low
infertility5, would be effective in a resource-limited
setting. Based on the excellent results reported with the Stanford V
regimen5 6, a short 12-week course
of chemotherapy with doxorubicin, vinblastine, vincristine, bleomycin,
etoposide, prednisone and mechlorethamine and 36 Gy radiotherapy to
bulky sites of disease (> 5cm) at diagnosis. AHOPCA adopted
this regimen as a treatment guideline for children presenting with
pre-defined high-risk HL (HRHL). In 2004 there was a world-wide shortage
of merchlorethamine7, leading AHOPCA to modify the
treatment regimen substituting merchlorethamine with cyclophosphamide at
a dose that was expected to be an equipotent substitution. Furthermore,
radiation therapy was modified to (20-25 Gy) involved field in order to
limit radiation-related long-term effects8-10. We
report here the experience of AHOPCA with this regimen, AHOPCA HRHL 2004
(mStanford V), as applied between August 2004 and August 2009.