LAPORAN KASUS
ABVD versus Stanford V Regimen in Unfavorable
Classical Hodgkins Lymphoma
TOMMY SUPIT1 DAN ZULKIFLI AMIN2
1
Faculty of Medicine, Universitas Indonesia
Department of Internal Medicine, Pulmonology Division, Cipto Mangunkusumo Hospital
2
Diterima 3 Oktober 2013; Direview 10 Januari 2014; Disetujui 7 Februari 2014
KORESPONDENSI:
Tommy Supit
Hp. 0857 1013 1316
Jl. Senen Raya No.
135 137, Apartemen
Mitra Oasis Tower C-904,
10410, Jakarta Pusat
Email: tommy.supit@gmail.
com;
tommy_supit@yahoo.com
ABSTRACT
Background: The patient presented in this case report was diagnosed with stage IIB unfavorable classical Hodgkins
lymphoma. Major oncology guideline includes doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) and
Stanford V as a treatment option. Presently, there is no systematic review or meta-analysis published on comparing
both regimens specific for this case. This case study analyzed published clinical trials and assessed whether one of the
regimen is superior to the other, based on their clinical efficacy and toxicity profile.
Method: Systematic search was conducted through EMBASE and Cochrane databases. Selected publications were
randomized controlled trials (RCT) published in English with direct relevance on answering the question of this case
report.
Results: Three RCTs with full-text availability were evaluated. Two studies have shown the superiority of ABVD over the
modified Stanford V regimen, while the other RCT have showed slight lead of the ABVD regimen. However, all three
trials were more restrictive on the radiotherapy component that differs from the standard Stanford V protocol.
Conclusion: We concluded that both ABVD and Stanford V remained to be a valid option for treating classical HL.
Keywords: Hodgkins lymphoma, ABVD, versus, Stanford V, comparison, clinical efficacy, toxicity, NCCN, ESMO
ABSTRAK
Latar belakang: dilaporkan pasien yang terdiagnosis unfavorable limfoma Hodgkin klasik stadium IIB. Pedoman terapi
onkologi memasukkan regimen doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) dan Standford V sebagai
pilihan pengobatan. Namun, sampai saat ini tidak ada tinjauan sistematis atau analisis-meta yang membandingakan
kedua rejimen tersebut yang spesifik untuk kasus ini. Studi kasus ini akan menganalisis hasil uji klinis untuk mengetahui
apakah salah satu dari rejimen yang tersebut lebih unggul berdasarkan efikasi klinis dan profil toksisitas.
Metodologi: pencarian sistematis dilakukan melalui database EMBASE and Cochrane.
Laporan kasus ini menelaah beberapa publikasi dalam bahasa Inggris yang berdasarkan uji klinik acak terkendali.
Hasil: tiga hasil uji klinik acak terkendali dengan ketersediaan teks lengkap dievaluasi dalam laporan ini. Dua penelitian
telah menunjukkan keunggulan ABVD dibandingkan dengan rejimen Standford V yang dimodifikasi, sementara studi
lain menunjukkan keunggulan ABVD yang tidak signifikan. Namun, komponen radioterapi regimen Standford V yang
digunakan dalam ketiga penelitian tersebut lebih restriktif dibanding dengan rejimen Standford V yang standar.
Kesimpulan: ABVD dan rejimen Standford V merupakan dua pilihan yang dapat digunakan untuk mengobati limfoma
Hodgkin klasik.
Kata Kunci: limfoma Hodgkin, ABVD, Stanford V, perbandingan, efikasi klinik, toksisitas, NCCN, ESMO
Indonesian Journal of Cancer Vol. 7, No. 4 October - December 2013 159
 Case Report: ABVD versus Stanford V Regimen in Unfavorable Classical Hodgkins Lymphoma
INTRODUCTION
H odgkins lymphoma (HL) is one of the most
treatable malignancies with high long-term cure
rates even in advanced stage. Chemotherapy (CT)
consisting of doxorubicin, bleomycin, vinblastine
and dacarbazine (ABVD) is currently considered the
standard treatment for HL worldwide. Santoro and
colleagues first introduced the ABVD regimen in
the late 1980s as an alternative to MOPP
(mechlorethamine, vincristine, prednisone, and
procarbazine) the previous standard.1 The newer
regimen was proven to be at least comparable at
disease control and was superior in toxicity profile
compared to its predecessor. 2,3 Two major oncology
guidelines; National Comprehensive Cancer Network
(NCCN) and European Society for Medical Oncology
(ESMO) currently list ABVD to be one the main therapy
for both intermediate and advanced stage HL.4,5
Patients treated with ABVD were able to achieve
complete response rate of 82%, 5-year failure-free
survival rate of 61% and 5-year overall survival rate
of 73%, with minimal occurrences of acute and late
toxicity. 1-3 Superiority of the ABVD regime is a result
from these profiles. New therapy regimens for HL
have been developed in search for better clinical
outcomes, shorter duration of treatment and minimal
long-term toxicities. Novel regimens who came to
highlights showed promising preliminary results,
including MOPP/EBV/CAD (MEC), escalated BEACOPP,
and Stanford V.6,7,8
Several trials was designed to test the combination
of mechlorethamine,vincristine, procarbazine,
prednisone (MOPP) with epidoxorubicin, bleomycin,
vinblastine, lomustine, doxorubicin, and vindesine
(MOPP/EBV/CAD [MEC]). The MEC regimen attempts
to hybridize and intensify some baseline-effective CT
to increase their efficacy. One trial conducted by Gobbi
et al. showed 5-year survival rates of 89% using MEC
CT with optional limited radiotherapy (RT).6 Escalated
BEACOPP comprises of bleomycin, etoposide,
doxorubicin, cyclophosphamide, vincristine,
procarbazine, and prednisone. A large prospective
randomized trial by the German Hodgkins Lymphoma
Study Group (GSHG) showed a 5-year failure-free
survival rate of 85% and 5-year overall survival of 90%.7
Integrated with two cycles of ABVD, this regimen was
recently included in the NCCN guideline as one option
for treating main unfavorable classical HL. BEACOPP
was associated with more toxicity than ABVD.4
One promising novel treatment is the Stanford
V. It is one of the three main regimens listed in the
NCCN guideline for treating stage I-II unfavorable
160 Indonesian Journal of Cancer Vol. 7, No. 4 October - December 2013
159-166
(bulky) classical HL (HODG4).4 The therapy course
consists of doxorubicin, vinblastine, mechlorethamine,
etoposide, vincristine, bleomycin, and prednisone that
are administered weekly for 12 weeks followed by
radiotherapy (RT) with 36 Gy to the initial site of
tumor bulk. The Stanford V regimen was initially
developed for patients with early stage bulky and
advanced stage HL. This preliminary study shows
freedom from progression (FFP) of 89% and overall
survival (OS) of 96% with no record of treatment-related
infertility, secondary leukemia or mortality.9 In a more
mature phase II clinical trial Stanford V regimen showed
promising results of 91% of 5-year freedom from
progression and 96% of 5-year overall survival. 10
Stanford V regimen involves intensive-dosing
therapy that is given on a weekly basis, shortening
the duration of CT to only 3 months. The procedure
incorporates radiotherapy (RT) to the sites of tumor
bulk or regions with the highest probability for
relapse limiting the field of RT side effects. RT is
commonly incorporated with the main CT, unless
in nodular lymphocyte predominant Hodgkins
lymphoma (NLPHL). All RT techniques used in
treating HL are all ISRT, as opposed to involved
field radiation therapy (IFRT) where the radiation
involves larger target area. Modern CT-based imaging
is needed prior to the initiation of RT. This
conjunctive therapy is directly given for tumors that
respond well to the main CT. On the other hand,
refractory tumors are given second-line CT, restaged,
before concomitant ISRT.
Cumulative doses of the drugs in Stanford V
regimen are less than those in MOPP, ABVD, escalated
BEACOPP or other hybrid regimens, thereby reducing
the risks for chemotherapy-related infertility, secondary
malignancies, and other systemic toxicity. Such
features of Stanford V are particularly suitable for
women in reproductive year, such as the patient
presented in this paper. Latest recommendations in
the HODG4 include the combination of two cycles
of escalated BEACOPP, two cycles of ABVD and
involved site radiation therapy (ISRT). Special interests
are put in this paper to explore the potential
superiority of Stanford V over ABVD per se because
of its promising safety profile and thus will limit the
scope of the discussion to such.
Current consensus was made based on long-term
follow-up of major randomized trials that are still
underway, such as the intergroup trial E2496 and
HD9601.11,12-14 Presently, there is no systematic review
or meta-analysis made comparing ABVD and Stanford
V, specifically for the diagnosis and staging of our
TOMMY SUPIT DAN ZULKIFLI AMIN 159-166
patients HL. This evidence-based case report will
evaluate published clinical trials by assessment of
clinical efficacies and toxicity of the treatment. This
report will answer the question: which of the
following regimens; ABVD and Stanford V provide
better clinical outcome and toxicity profile?
CASE RESUME
A 23-year-old Indonesian woman presented with
a two month-long breathing difficulty with increasing
severity. The breathing difficulty worsened with
physical exertion and orthopnea was present.
Constitutional symptoms; unexplained weight loss,
fever and night sweats were also reported. The
patient noticed growing painless lumps on both
side of her neck since 12 months ago. Over the past
2 months she noticed significant enlargement and
swelling of her face, neck, and both arms. Physical
examination revealed bilateral palpebral, face, neck,
and upper extremities swelling. Painless
lymphadenopathy with rubbery consistency of the
submental, bilateral submandibular, cervical,
supraclavicular and left axillar were noted. Liver,
spleen and inguinal lymph node enlargement were
not palpable. Overall vesicular breathing sound was
diminished on all lung fields, with reduced vocal
fremitus and dullness over the left-lung field.
Multislice computed tomography (MSCT) confirmed
the presence of superior, anterior and medial
mediastinal masses measuring 15,38 10,16 7,67
centimeter with superior vena cava compression and
collateral vein distention. Histopathological analysis
of an excisional biopsy sample revealed a fibrous
tumor composed of atypical cells and small
Hodgkin's Lymphoma AND ABVD AND Stanford V
Figure 1: Flowchart of article selection
Indonesian Journal of Cancer Vol. 7, No. 4 October - December 2013
lymphocytes, consistent with nodular sclerosis type
Hodgkins lymphoma (HL). Reed-Sternberg cells were
present. Immunohistochemistry (IHC) analysis was
conducted for CD3, CD20, CD 15 and CD30; however
with inconclusive CD15 and CD30 staining. The patient
was diagnosed with superior vena cava syndrome
(SVCS) and stage IIB unfavorable nodular sclerosis
Hodgkins lymphoma.
The SVCS was initially treated with five cycles
of radiotherapy (RT) to a total dose of 30 Gy,
complemented with high dose corticosteroid therapy.
There was no resolution of symptoms or observable
mass reduction by the end of 5 RT cycles. The
patient has subsequently undergone chemotherapy
(CT) with doxorubicin, bleomycin, vinblastine, and
dacarbazine (ABVD) for 1 cycle and treated as an
out-patient for the rest of CT regimen.
METHOD
Literature Search and Study Selection
Electronic search was conducted through EMBASE
and Cochrane library, using the search terms:
Hodgkin Lymphoma, ABVD and Stanford V, with
AND in between search terms as the Boolean
operator. Manuscripts written in language other
than English and overlapping publications from the
two databases were primarily excluded. Seven
publications were initially selected because of their
direct relevance to the clinical question. Two articles
limited to conference abstracts were excluded. Finally,
three RCT results with full text availability were
selected to be evaluated (Figure 1). The three articles
were written by Gobbi et al. (2005), (14) Hoskin et
al. (2009), (15) and Chisesi et al. (2011).12,14,15
161
 Case Report: ABVD versus Stanford V Regimen in Unfavorable Classical Hodgkins Lymphoma 159-166

Two articles written by Gobbi et al and Chisesi Table 2: Assessment of importance

et al were based on an ongoing large Italian
Gobbi et al. Hoskin et al. Chisesi et al.
intergroup trial.12,14 The trial compared ABVD to
Stanford V and MEC. The treatment groups were Number of patients 335 500 335
independent from each other, thus enabling us to ABVD: 94%, ABVD: 92%, ABVD: 89%,
Complete remission
extract data only from the ABVD and Stanford V StV: 76% StV: 91% StV: 76%
treatment wings. ABVD: 8%, ABVD: 7%, ABVD: 24%,
Failure rates
StV: 16% StV: 6% StV: 51%
Critical Appraisal ABVD: 90%, ABVD: 90%, ABVD: 87%,
Overall survival rate
Appraisal of selected articles was principally StV: 82% StV: 92% StV: 78%
based on evidence-based medicine toolkit (16) and ABVD: 92%, ABVD: 88%,
Relapse free survival N/A
Grading of Recommendation Assessment Develop StV: 73% StV: 67%
ment and Evaluation (GRADE) guidelines. They were 5-year progression-free ABVD: 85%, ABVD: 76%,
N/A
assessed based on validity as evidence-based survival StV: 73% StV: 74%
publications (Table 1), importance of clinical results 10-year progression-free ABVD: 84%,
N/A N/A
was in Table 2 and applicability of study results to survival StV: 68%
our clinical setting in Cipto Mangunkusumo hospital 5-year failure-free ABVD: 78%,
N/A N/A
eas in Table 3. This EBCR only analyzed RCTs with survival StV: 54%
full-text availability. Such approach will allow us to 10-year failure-free ABVD: 75%,
N/A N/A
be most critical on evaluating the validity and overall survival StV: 49%
quality of the publications. Currently ongoing Grade 3 to Same
unpublished studies and abstracts will also be 4 non- occurrences
discussed within the discussion section. pulmonary of late
toxicity: toxicities in
Table 1: Assessment of validity Hematologic ABVD (8%) each group:
toxicities: StV (19%); FLNHL and
Gobbi Hoskin Chisesi mild for ABVD, pulmonary acute ITP in

et al. et al. et al. moderate toxicity: ABVD ABVD; B-cell
Toxicity profile for StV; Non- (10%) StV CLL in StV; no
Clearly defined research
Yes Yes Yes hematological (2%); 8 cases late cardiac
questions
toxicities: of secondary toxicities; 3
moderate in malignancies: events of fatal
Concealed randomization N/A N/A N/A
both arms 4 patients in pulmonary
each group; toxicities - 2
Drop-out rates 5,60% 4,60% 5,60% 1 treatment- PE in ABVD
related death and 1 PE in
in ABVD arm StV
Length of study 8 years 8 years 14 years
Abbreviations: ABVD, doxorubicin, bleomycin, vinblastine, dacarbazine; StV
Median follow-up 61 months 52 months 86 months (Stanford V), doxorubicin, vinblastine, mechloretamine, etoposide, vincristine,
bleomycin, prednisone; FLNHL, follicular non-Hodgkins lymphoma; ITP,
autoimmune thrombocytopenic purpura; CLL, chronic lymphocytic leukemia;
Intention-to-treat analysis Yes Yes Yes PE, pulmonary embolism; N/A, not available, no answer or not applicable.

Table 3: Assessment of Applicability

Blinded participants N/A N/A N/A
Gobbi et al. Hoskin et al. Chisesi et al.
Equality of treatment between
Yes Yes Yes Similarity of patient Similar Similar Similar
different therapy groups
Study effect for patient Significant Significant Significant
Homogenecity of treatment
Acceptable Acceptable Acceptable
groups Feasibility for adapting
Feasible Feasible Feasible
intervention
Overall Validity Valid Valid Valid Similarity of intervention to
Similar Similar Similar
current practice
Abbreviation: N/A, not available, no answer or not applicable.
Assessment of clinical importance are based on complete remission (CR), Usefulness of outcome Appropriate Appropriate Appropriate
failure rate, overall survival rate (OS), relapse free survival (RFS), 5 or 10-year
Explanation on similar: diagnosis of the clinical case stage IIB unfavorable
progression-free survival (PFS), failure-free survival (FFS) and every treatment-
(bulky) nodular sclerosis (classical) Hodgkins lymphoma was included within
induced toxicities (Table 2).
the study groups of presented publications.

162 Indonesian Journal of Cancer Vol. 7, No. 4 October - December 2013

TOMMY SUPIT DAN ZULKIFLI AMIN 159-166

DISCUSSION Table 4: Comparison between the original Stanford V protocol and the
The optimal CT regimen can be defined by the Radiotherapy guidelines adopted in the HD9601 study (adapted from
combination of high survival rate, response rate, Chisesi et al.)
progression and failure-free survival with low toxicity
level. For such reasons, newer therapeutic regimens Variable Standard V protocol# HD9601 guidelines
for HL are being explored to fulfill those criteria. Radiotherapy All patients in combination To sites of initial bulky
Out of the numerous novel regimens, the 12-week administration with CT, without restaging disease and to sites partially
CT program Stanford V has gathered international in between responding to CT, providing
interests for its promising early results and that no more than two sites
were to be irradiated
significantly shorter course of therapy. A major
feature of the regime includes high-intensity, Dose 36 - 44 Gy 36 - 42 Gy
abbreviated individual drug dosing and involved-
field radiotherapy (IFRT) that are restricted to sites Tumor Diameter 5 cm Diameter 6 cm
of bulky disease ( 5 cm) or macroscopic splenic bulk (to be
disease. irradiated)
Multicenter Italian RCT conducted by Gobbi et Spleen When showing nodularity Not specifically codified, but
al. showed similar OS rate between ABVD and irradiation or to nodal sites not excluded either
Stanford V.14 Complete remission of ABVD and that showed residual
abnormalities after CT
Stanford V were 94% and 76%, 5-year PFS and FFS
rates were 85%, 73% and 78% and 54%, respectively Radiotherapy Within 2 weeks from the From 4 - 6 weeks after the
start end of CT end of CT to allow restaging in
(P<0,01). Treatment failure rates of Stanford V between
doubled those in AVBD arm. The Stanford regime
also showed inferior hematology toxicity profile, Abbreviations: CT, chemotherapy; cm, centimeter; Gy, gray unit.
#
Barlett et al.17
with comparable non-hematological side effects
Gobbi et al. 14
(Table 2). These results were markedly different from
the original Stanford results, thus questioning the Article written by Chisesi et al. was based on a
reproducibility of the Stanford method.9,10,17 longer term follow-up of the same HD9601 trial that
However, it is must be noted that the Stanford included Gobbi and colleagues, within the Intergruppo
V regimen adapted by this trial differs in from the Italiano Linfomi.12 The study shows 10-year clinical
original protocol in terms of RT. Radiation following results and late-onset toxicities of the ABVD versus
the end of first CT was largely based on the judgment Stanford V regimen. Ten-year OS rate were 87% and
of clinicians, who decide whether to irradiate patient 78% for ABVD and Stanford V, respectively (P=0.04).
or not. The overall application of RT in this trial is Similarly, 10-year PFS rates of ABVD and Stanford
far less and more restrictive compared to that in V were 84% and 68%, 10-year FFS rates were 75%
the original study (Table 4). Thus, results of the and 49%, respectively (P=0.001). Failure rates were
Stanford V arm may not reflect actual efficacy of higher within the Stanford V group and there was
the standard course of therapy. The authors defense a significant difference of 10-year disease-free survival
regarding this issue was that the team was exploring (DFS) rates; ABVD 76% and Stanford V 33% (P=0,004)
the ability of Stanford V regimen to remain effective (Table 2).
in lower dose of RT, since it may cause significant Longer ten-year follow-up showed similar clinical
toxicities. results with previous study.14 Under the study
Another confounding factor that might the overall conditions, ABVD were superior in terms of response
inferiority of the Stanford arm was patient rate PFS and FFS, although OS rates between the
characteristics. Six percent of the 142 patients in two regimens were equivalent. Late toxicities were
the original Stanford study were 45 year old, similar; two cases of metachronous tumors were
whereas 25% of the patients in the study conducted reported in each group. As previously discussed,
by Gobbi et al.14 were 45 years old or older. At its the restrictive use RT within the Stanford V arm in
conclusion, Gobbi and colleagues acknowledged this trial may have been the major cause of the
that the original Stanford V regimen is inseparable decreased efficacy of the regimen (Table 4).
from subsequent RT and that technical reproducibility The author acknowledged and further emphasized
of the technique may be an issue when applied in the inseparability of RT from the Stanford V
other institutions. procedure. IFRT to bulky sites is mandatory, as

Indonesian Journal of Cancer Vol. 7, No. 4 October - December 2013 163

 Case Report: ABVD versus Stanford V Regimen in Unfavorable Classical Hodgkins Lymphoma
suggested in the original Stanford series and
recently confirmed by a retrospective study conducted
at the Memorial Sloan-Kettering Cancer Center.9,17,18
As a conclusion of the study, Chisesi et al. still
suggest that ABVD possess the best balance between
efficacy and toxicity in treating HL.
Comparisons of ABVD and Stanford V made by
Hoskin et al. were based on a large multicenter
trial in The United Kingdom (UK).15 The results were
different compared to the Italian study. Stanford V
showed comparable CR, failure rates, OS rates, and
PFS with ABVD regimen after 5 years of follow-up.
With a median follow-up of 52 months, CR was 92%
for ABVD and 91% for Stanford V. OS rate and 5-year
PFS were 90% and 76%, respectively for ABVD and
92% and 74%, respectively for Stanford V. There was
no difference of failure rates between the two
treatment wings (Table 2). Non-pulmonary toxicities
were more prevalent in the Stanford V group, while
pulmonary toxicities are more affiliated with ABVD.
Both groups have similar secondary malignancies
and 1 treatment-related death was reported in ABVD.
The results for Stanford V were not as good
compared to the original North American Series.
RT involvement in this study was lower than in the
original protocol, but higher compared to the Italian
trial. In the discussion, the author acknowledged
the possibility the lower use of RT in this trial than
in the original series could have affected the
outcomes. The results of the study might also be
affected by the difference of granulocyte colony-
stimulating factor (GCSF) administration in both
groups. Seventy-five percent of patient in the ABVD
arm received GCSF, while only 41% in Stanford V
arm. Such intervention may affect the clinical
outcome of the study, especially late-toxicity
occurrences. The investigators did not provide
detailed explanations regarding this matter.
It is also must be noted that his trial was
prematurely ended, because of drug supply
limitations. Thus, the study obtained the initial
recruitment target. However, this shortcoming was
partially covered by the study long-term follow-ups.
The authors concluded that ABVD was not bettered
by Stanford V. However, they did not reject Stanford
V as a main stray therapy for HL for some patients,
where Stanford V may be the first-line therapy due
to its brief treatment duration and no pulmonary
toxicity.
Concerns were raised regarding the reproducibility
of the Stanford V regimen when the Italian Group
published their clinical trial results. Since then,
164 Indonesian Journal of Cancer Vol. 7, No. 4 October - December 2013
159-166
several non-comparative clinical trials have been
conducted to put Stanford V regimen to the test.
The Stanford V regime was proven to be highly
effective in treating locally extensive and advanced
HL by Bennet and colleagues.18 The regimen was
similarly favorable in treating early-stage HL while
showing good tolerance and no treatment-related
death, based on a mature G4 trial.19
A large United States based HL intergroup
trial (E2496), recently completed a phase III clinical
trial.11 The study compared ABVD plus RT with
Stanford V regimen for the management of stage
I-IIA/B and bulky mediastinal disease and stage
III-IV disease. With a median follow-up of 5.25 years,
there was no difference in response rates between
the two arms (72% CR, 7.7%PR for ABVD; 69% CR,
7% PR for Stanford V). There were no significant
differences of the 5-year FFS: 73% for ABVD and
71% for Stanford V (p=0.29) and 5-year OS: 88% for
ABVD and 87% for Stanford V (p=0.87).
A subset analysis of the same E2496 trial failed
to detect statistically significant differences between
the two treatment arms.20 The trial results showed
ABVD versus Stanford V: 5-year OS were 95% and
92 % (p=0,31) and 5-year FFS were 85% and 77%
(P=0,13). There was also no difference in hematologic
toxicity between the two regimens. The overall
response was 82% in ABVD and 86% in Stanford V.
The Stanford V showed more acceptable results
in the E2496 trial compared to those in the Italian
studies. This partly confirmed our initial analysis
about the shortcomings of the three RCTs discussed
earlier. Overall, these findings showed that both
ABVD and Stanford V are at most comparable to
each other. Without obvious advantage of Stanford
V over the ABVD regimen; ABVD remains to be a
valid standard of therapy for our patient with
classical HL.
Recent investigations were performed in the past
years on the role of positron emission tomography
(PET) as a strong predictive tool for HL therapy
outcome.21,22 The use of this radiologic modality
plays a detrimental role in the overall success of
HL treatment. Initial staging and treatment response
assessment after both primary ABVD and Stanford
V regimen with PET-CT is an integral part of the
therapy algorithm. PET scans are interpreted based
on fludeoxyglucose (FDG) uptake by the cancerous
sites defined by Deauville criteria.23 Initiation of RT
after preliminary CT is decided based on the results
of Deauville PET criteria. ISRT are usually reserved
for Deauville 1-4 subsequent to either one the
TOMMY SUPIT DAN ZULKIFLI AMIN 159-166
three main CT in HODG4. Such advances allow
clinicians to tailor therapy to the best risk-adapted
treatment. However, the role of PET-CT is not
recommended for post-therapy or routine surveillance
due to risk of false positive findings.
CONCLUSION AND RECOMMENDATION
Two follow-up studies based on a large Italian
intergroup trial showed the superiority of the ABVD
regimen over Stanford V in terms of clinical outcome
and toxicities. However, the Stanford V regimen in
these studies was modified, differing on the RT
applications which were more restrictive compared
to the original protocol designed by the Stanford
group. Hence, the results presented by the two trials
were not representative of the standard Stanford V
protocol. The UK-based intergroup trial showed
better clinical outcomes from the Stanford V regimen,
however still inferior compared to its counterpart
and those from the original studies. Similarly, the
authors acknowledge the diminution of RT in their
modified Stanford V.
We conclude that results from the 3 RCTs
appraised in this EBCR were not significant enough
to show an absolute superiority of a single regimen,
because of several limitations of each trial discussed
previously. Hence, both ABVD and Stanford V
remained to be a valid therapy option for treating
classical HL.
Considering of the absence of obvious advantage
of the Stanford V over ABVD regimen for our patient,
she is to continue her planned ABVD regimen. It
is also recommended for our patient to undergo
restaging with PET-CT after 4 cycles of ABVD,
following the NCCN guideline for stage I-II
unfavorable HL. With such approach, we are able
to adjust and tailor therapy specifically to the
patients needs while minimizing treatment side
effects.
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