Late effects after therapy of Hodgkin's disease: Update 2003/04 on overwhelming post-splenectomy infections and secondary malignancies

Background: For a long time, a main focus of paediatric therapy studies for Hodgkin's disease (HD) has been on diminishing adverse late effects. Consequently, the long-term follow-up of patients after HD is very important. The HD late effects project of the GPOH, which evolved from 5 consecutive German-Austrian DAL therapy studies, was aimed at establishing a basis for the further improvement of therapy concepts and of long-term surveillance. Patients and Methods: The original cohort consisted of 1245 study patients from 92 centres enrolled in the DAL studies HD-78 to HD-90 between 1978 and 1995. Initially, follow-up data were submitted by the participating study centres. When the majority of the patients had reached adult age and were no longer seen by the originally treating paediatric colleagues, we contacted them directly by mail every 2-3 years. At the time of analysis (March 2004) information from the preceding 6 years was available in 78.6% of the patients alive. Results: The median follow-up period of patients at the date of last information was 11.1 years (max. 25.5 years), the median age was 23.7 years (max. 41.1 years). The present report is focused on three out of a wide range of problems evaluated, namely cause of death in 14 patients expired after 10-21 years' follow-up, overwhelming post-splenectomy infections (18 events, 11 fatal), and 46 secondary malignancies. The CS rate after 24 years is 87% (SE 3%) in the total group, 83% (SE 3%) in 335 asplenic patients, and 93% (SE 2%) in 910 non- or partially splenectomised patients. We have initiated activities to improve the prophylactic measures against overwhelming infections in this risk group of asplenic patients. The cumulative incidences of secondary malignancies (SM) after 22 years is 11% (SE 2%) for all SM, 10% (SE 2%) for solid tumours, 0.8% (SE 0.5%) for NHL, and 0.6% (SE 0.3%) for leukaemias. The cumulative incidence of breast cancer in female patients at the age of 35 years is 4.0% (SE 2%). The effect of reducing the radiotherapy doses in the studies HD-87/HD-90 will become evident within the next years.