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## Complete Summary

#### GUIDELINE TITLE

Pediatric Hodgkin\'s disease.

#### BIBLIOGRAPHIC SOURCE(S)

Constine LS, Hoppe RT, Colman M, Deming RL, Mendenhall NP, Morris DE, Ng
A, Wolkov HB, Yahalom J, Chauvenet AM, Hudson MM, Winter JN, Mauch PM,
Expert Panel on Radiation Oncology-Hodgkin\'s Disease Work Group.
Pediatric Hodgkin\'s disease. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2006. 30 p. \[131 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Constine LS, Wolkov HB,
Yahalom J, Mauch PM, Deming RL, Dosoretz DE, Elman AJ, Hoppe RT,
Pistenmaa DA, Prosnitz LR, Chauvenet A, Connors JM, Glick JH, Leibel S.
Pediatric Hodgkin\'s disease. American College of Radiology. ACR
Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):1225-56.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [January 24, 2008, Leukine
    (sargramostim)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Leukine):
    Voluntary market suspension of the current liquid formulation of
    sargramostim, a granulocyte-macrophage colony-stimulating factor
    (GM-CSF), because of an upward trend in spontaneous reports of
    adverse reactions, including syncope (fainting). The lyophilized
    form of the drug is not affected. See the U.S. Food and Drug
    Administration (FDA) web site for more information.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hodgkin\'s disease

#### GUIDELINE CATEGORY

Treatment

#### CLINICAL SPECIALTY

Oncology\
Pediatrics\
Radiation Oncology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of radiologic treatment procedures for
pediatric patients with Hodgkin\'s disease

#### TARGET POPULATION

Children with Hodgkin\'s disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Chemotherapy, including consideration of type and duration

2.  Radiation therapy, including consideration of volume and therapy
    dose

3.  Combination of chemotherapy and radiation therapy

4.  Observation only

#### MAJOR OUTCOMES CONSIDERED

Overall, relapse-free, and event-free survival rate

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Pediatric Hodgkin\'s Disease**

**Variant 1: 12-year-old boy with CS IA (cervical) NSHD. Patient is
Tanner 3.**

  -----------------------------------------------------------------------------
  **Treatment**          **Appropriateness   **Comments**
                         Rating**            
  ---------------------- ------------------- ----------------------------------
  **Chemotherapy (CT)**                      

  Chemo and radiation    8                    
  therapy                                    

  Alone                  4                    

  **Chemotherapy Type**                      

  ABVD                   8                    

  OPPA (females); OEPA   8                    
  (males)                                    

  VAMP                   8                    

  OPPA/COPP or OEPA/COPP 4                    

  COPP/ABV hybrid        4                    

  COPP/ABVD alternating  4                    

  **Chemotherapy                             
  Duration**                                 

  2 cycles               5                    

  3-4 cycles             8                    

  5-6 cycles             4                    

  \>6 cycles             1                    

  **Radiation Therapy                        
  (RT)**                                     

  Alone                  1                    

  Chemo and radiation    8                    

  **Radiation Volume**                       

  Involved lymph node    2                    

  Involved field (nodal  8                    
  chain)                                     

  Involved field +       4                    
  adjacent site(s)                           

  Mantle                 2                    

  Mantle +               1                    
  para-aortic/spleen                         

  Mantle +               1                    
  para-aortic/spleen +                       
  pelvis                                     

  **Radiation Therapy                        
  Dose**                                     

  15-20 Gy               7                    

  21-25 Gy               8                    

  26-30 Gy               4                    

  31-35 Gy               2                    

  36-40 Gy               1                    

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: 6-year-old girl with CS IIA MCHD, three sites including
mediastinum and bilateral neck, no bulk disease.**

  -----------------------------------------------------------------------------
  **Treatment**          **Appropriateness   **Comments**
                         Rating**            
  ---------------------- ------------------- ----------------------------------
  **Chemotherapy (CT)**                      

  Chemo and radiation    7                    
  therapy                                    

  Alone                  6                    

  **Chemotherapy Type**                      

  ABVD                   8                    

  OPPA (females); OEPA   7                    
  (males)                                    

  VAMP                   8                    

  OPPA/COPP or OEPA/COPP 6                    

  COPP/ABV hybrid        5                    

  COPP/ABVD alternating  5                    

  **Chemotherapy                             
  Duration**                                 

  2 cycles               5                    

  3-4 cycles             8                    

  5-6 cycles             5                    

  \>6 cycles             2                    

  **Radiation Therapy                        
  (RT)**                                     

  Alone                  1                    

  Chemo and radiation    7                    

  **Radiation Volume**                       

  Involved lymph nodes   2                    

  Involved field (nodal  8                    
  chain)                                     

  Involved field +       3                    
  adjacent site(s)                           

  Mantle                 2                    

  Mantle +               1                    
  para-aortic/spleen                         

  Mantle +               1                    
  para-aortic/spleen +                       
  pelvis                                     

  **Radiation Therapy                        
  Dose**                                     

  15-20 Gy               7                    

  21-25 Gy               8                    

  26-30 Gy               4                    

  31-35 Gy               2                    

  36-40 Gy               1                    

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: 12-year-old girl with CS IA (left cervical) LPHD. Node has
been excised. Patient is Tanner 3.**

  -----------------------------------------------------------------------------
  **Treatment**          **Appropriateness   **Comments**
                         Rating**            
  ---------------------- ------------------- ----------------------------------
  **Observation only (no 5                    
  chemo or RT)**                             

  **Chemotherapy (CT)**                      

  Chemo and radiation    7                    
  therapy                                    

  Alone                  4                    

  **Chemotherapy Type**                      

  ABVD                   7                    

  OPPA (females); OEPA   7                    
  (males)                                    

  VAMP                   8                    

  OPPA/COPP or OEPA/COPP 3                    

  COPP/ABV hybrid        2                    

  COPP/ABVD alternating  2                    

  **Chemotherapy                             
  Duration**                                 

  2 cycles               7                    

  3-4 cycles             8                    

  5-6 cycles             2                    

  \>6 cycles             1                    

  **Radiation Therapy                        
  (RT)**                                     

  Alone                  4                    

  Chemo and radiation    7                    

  **Radiation Volume**                       

  Involved lymph nodes   2                    

  Involved field (nodal  8                    
  chain)                                     

  Involved field +       4                    
  adjacent site(s)                           

  Mantle                 1                    

  Mantle +               1                    
  para-aortic/spleen                         

  Mantle +               1                    
  para-aortic/spleen +                       
  pelvis                                     

  **Radiation Therapy                        
  Dose**                                     

  15-20 Gy               6                    

  21-25 Gy               8                    

  26-30 Gy               4                    

  31-35 Gy               2                    

  36-40 Gy               1                    

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: 7-year-old boy with CS IIA LPHD isolated to the right iliac
and inguinal nodes.**

  -----------------------------------------------------------------------------
  **Treatment**          **Appropriateness   **Comments**
                         Rating**            
  ---------------------- ------------------- ----------------------------------
  **Chemotherapy (CT)**                      

  Chemo and radiation    8                    
  therapy                                    

  Alone                  4                    

  **Chemotherapy Type**                      

  ABVD                   7                    

  OPPA (females); OEPA   7                    
  (males)                                    

  VAMP                   8                    

  COPP/ABV hybrid        2                    

  COPP/ABVD alternating  2                    

  **Chemotherapy                             
  Duration**                                 

  2 cycles               7                    

  3-4 cycles             8                    

  5-6 cycles             2                    

  \>6 cycles             1                    

  **Radiation Volume**                       

  Involved field         8                    

  Involved field +       4                    
  adjacent site(s)                           
  (para-aortic)                              

  Mantle +               1                    
  para-aortic/spleen +                       
  pelvis                                     

  Pelvis                 2                    

  **Radiation Therapy                        
  Dose**                                     

  15-20 Gy               7                    

  21-25 Gy               7                    

  26-30 Gy               3                    

  31-35 Gy               2                    

  36-40 Gy               1                    

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: 8-year-old boy with CS IIIA (neck, mediastinum,
para-aortic) NSHD, no bulk disease.**

  -----------------------------------------------------------------------------
  **Treatment**          **Appropriateness   **Comments**
                         Rating**            
  ---------------------- ------------------- ----------------------------------
  **Chemotherapy (CT)**                      

  Chemo and radiation    8                    
  therapy                                    

  Alone                  6                    

  **Chemotherapy Type**                      

  ABVD                   7                    

  OPPA (females); OEPA   4                    
  (males)                                    

  VAMP                   1                    

  COPP/ABV hybrid        6                    

  COPP/ABVD alternating  6                    

  **Chemotherapy                             
  Duration**                                 

  2 cycles               2                    

  3-4 cycles             8                    

  5-6 cycles             7                    

  \>6 cycles             2                    

  **Radiation Volume**                       

  Involved field         8                    

  Involved field +       4                    
  adjacent site(s)                           

  Mantle                 1                    

  Mantle +               2                    
  para-aortic/spleen                         

  Mantle +               1                    
  para-aortic/spleen +                       
  pelvis                                     

  **Radiation Therapy                        
  Dose**                                     

  15-20 Gy               6                    

  21-25 Gy               8                    

  26-30 Gy               3                    

  31-35 Gy               2                    

  36-40 Gy               1                    

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 6: 3-year-old boy with CS IIIB (supraclavicular, mediastinum,
para-aortic + splenomegaly) MCHD.**

  -----------------------------------------------------------------------------
  **Treatment**          **Appropriateness   **Comments**
                         Rating**            
  ---------------------- ------------------- ----------------------------------
  **Chemotherapy (CT)**                      

  Chemo and radiation    6                    
  therapy                                    

  Alone                  8                    

  **Chemotherapy Type**                      

  ABVD                   4                    

  OPPA/COPP (females);   3                    
  OEPA/COPP (males)                          

  COPP/ABV hybrid        7                    

  COPP/ABVD alternating  7                    

  VAMP                   1                    

  **Chemotherapy                             
  Duration**                                 

  2 cycles               2                    

  3-4 cycles             5                    

  5-6 cycles             8                    

  \>6 cycles             2                    

  **Radiation Volume**                       

  Involved field         8                    

  Involved field +       1                    
  adjacent site(s)                           

  Mantle                 1                    

  Mantle +               1                    
  para-aortic/spleen                         

  Mantle +               1                    
  para-aortic/spleen +                       
  pelvis                                     

  **Radiation Therapy                        
  Dose**                                     

  15-20 Gy               8                    

  21-25 Gy               6                    

  26-30 Gy               2                    

  31-35 Gy               1                    

  36-40 Gy               1                    

  ***Appropriateness                         
  Criteria Scale*\                           
  1 2 3 4 5 6 7 8 9\                         
  1 = Least appropriate                      
  9 = Most appropriate**                     
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 7: 10-year-old girl with CS IIIB, MCHD with large mediastinal
mass.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  **Chemotherapy                           
  (CT)**                                   

  Chemo and radiation  8                    
  therapy                                  

  Alone                3                    

  **Chemotherapy                           
  Type**                                   

  ABVD                 4                    

  OPPA/COPP (females); 3                    
  OEPA/COPP (males)                        

  COPP/ABV hybrid      7                    

  COPP/ABVD            7                    
  alternating                              

  VAMP                 1                    

  **Chemotherapy                           
  Duration**                               

  2 cycles             1                    

  3-4 cycles           6                    

  5-6 cycles           8                    

  \>6 cycles           2                    

  **Radiation Volume**                     

  Involved field       8                    

  Involved field +     4                    
  adjacent site(s)                         

  **Radiation Therapy                      
  Dose**                                   

  15-20 Gy             5                    

  21-25 Gy             8                    

  26-30 Gy             4                    

  31-35 Gy             2                    

  36-40 Gy             1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 8: 7-year-old boy with CS IVB NSHD including pulmonary nodules
and enlarged liver with focal defects. No bulk disease.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  **Chemotherapy                           
  (CT)**                                   

  Chemo and radiation  7                    
  therapy                                  

  Alone                6                    

  **Chemotherapy                           
  Type**                                   

  ABVD                 4                    

  OPPA/COPP (females); 3                    
  OEPA/COPP (males)                        

  COPP/ABV hybrid      7                    

  COPP/ABVD            7                    
  alternating                              

  VAMP                 1                    

  **Chemotherapy                           
  Duration**                               

  2 cycles             1                    

  3-4 cycles           4                    

  5-6 cycles           8                    

  \>6 cycles           3                    

  **Radiation Volume**                     

  Involved field       7                    

  Involved field +     1                    
  adjacent site(s)                         

  **Radiation Therapy                      
  Dose**                                   

  10-15 Gy             8                    

  15-20 Gy             1                    

  21-25 Gy             1                    

  26-30 Gy             1                    

  31-35 Gy             1                    

  36-40 Gy             1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 9: 5-year-old girl with CS IVA MCHD with large mediastinal
mass and positive BM.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  **Chemotherapy                           
  (CT)**                                   

  Chemo and radiation  8                    
  therapy                                  

  Alone                4                    

  **Chemotherapy                           
  Type**                                   

  ABVD                 4                    

  OPPA/COPP (females); 3                    
  OEPA/COPP (males)                        

  COPP/ABV hybrid      7                    

  COPP/ABVD            7                    
  alternating                              

  VAMP                 1                    

  **Chemotherapy                           
  Duration**                               

  2 cycles             1                    

  3-4 cycles           4                    

  5-6 cycles           8                    

  \>6 cycles           3                    

  **Radiation Volume**                     

  Involved field       7                    

  Involved field +     1                    
  adjacent site(s)                         

  **Radiation Therapy                      
  Dose**                                   

  15-20 Gy             5                    

  21-25 Gy             8                    

  26-30 Gy             4                    

  31-35 Gy             2                    

  36-40 Gy             1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 10: 16-year-old boy with CS IIA NSHD with small mediastinal
mass.\***

(\*If fully grown, appropriateness criteria guidelines for early stage
favorable disease in adults are appropriate.)

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  **Chemotherapy                           
  (CT)**                                   

  Chemo and radiation  8                    
  therapy                                  

  Alone                4                    

  **Chemotherapy                           
  Type**                                   

  ABVD                 8                    

  OPPA (females); OEPA 7                    
  (males)                                  

  VAMP                 8                    

  COPP/ABV hybrid      4                    

  COPP/ABVD            4                    
  alternating                              

  **Chemotherapy                           
  Duration**                               

  2 cycles             6                    

  3-4 cycles           8                    

  5-6 cycles           3                    

  \>6 cycles           1                    

  **Radiation Volume**                     

  Involved field       8                    

  Involved field +     5                    
  adjacent site(s)                         

  Mantle               2                    

  Mantle + para-aortic 1                    
  spleen                                   

  Mantle + para-aortic 1                    
  spleen + pelvis                          

  **Radiation Therapy                      
  Dose**                                   

  15-20 Gy             6                    

  21-25 Gy             8                    

  26-30 Gy             6                    

  31-35 Gy             4                    

  36-40 Gy             1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

The biology and natural history of Hodgkin\'s disease (HD) in children
are similar to these in adults, but irradiation techniques and doses
suitable for controlling disease in adults produce substantial
morbidities (primarily musculoskeletal growth inhibition) in children. A
desire to reduce morbidity motivated the development of new strategies
for treating pediatric HD. Historically, children were thought to have a
worse prognosis than adults. It is now apparent that the converse is
true.

Please see the original guideline document for information about
epidemiology, clinical presentation, pathologic classification, staging,
diagnostic evaluation, and prognostic factors.

**Selection of Therapy**

HD is one of the pediatric malignancies that has an adult counterpart
with a similar natural history and biology. Devising the optimal
therapeutic approach for children with this disease is complicated by
their increased risk of adverse effects. In particular, radiotherapy
doses and fields used in adults can cause profound musculoskeletal
retardation, including intraclavicular narrowing, shortened sitting
height, decreased mandibular growth, and decreased muscle development in
the treated volume. Therefore, while adults with early stage HD may be
treated with full dose radiation as a single modality, this approach in
prepubertal children, despite a similar success rate, produces
unacceptable sequelae. Further complicating the treatment of children
are gender-specific differences in chemotherapy-induced gonadal injury.

The desire to cure young children with minimal side effects has
stimulated attempts to reduce staging procedures, the intensity and
types of chemotherapy, and the radiation dose and volume. Because of the
differences in the age-related developmental status of children, and the
gender-related sensitivity to chemotherapy, there is no single method of
treatment that is ideal for all pediatric patients. In general, the use
of radiation and chemotherapy broadens the spectrum of potential
toxicities, while reducing the severity of individual (drug or
radiation-related) toxicities. Current approaches, to be discussed
subsequently, entail chemotherapy alone and in conjunction with reduced
radiation doses. The volume of radiation and the intensity and duration
of chemotherapy are risk-adapted or determined by prognostic factors at
presentation, including presence of constitutional symptoms, disease
stage, and bulk. Results for patients with early and favorable and
advanced and unfavorable HD are summarized in Tables 3 and 4 in the
original guideline document, and therapeutic recommendations are
outlined in the Table, below.

**Combination Chemotherapy**

Chemotherapy with mechlorethamine, oncovin, procarbazine, and
prednisolone (MOPP) was the standard regimen used in the United States
for many years. The major toxicities include an associated risk of acute
myeloid leukemia, azoospermia in more than 90% of males treated at any
age, and a risk of sterility in females, which increases with age.
Subsequently, the effectiveness of adriamycin, bleomycin, vinblastine,
and dacarbazine (ABVD) as front-line chemotherapy was established.
Compared to MOPP, second malignancies and sterility were less common.
The predominant adverse effects of ABVD are pulmonary toxicity related
to bleomycin and cardiovascular toxicity secondary to adriamycin. These
side effects may be exacerbated by the addition of mediastinal or mantle
irradiation. Consequently, ABVD and MOPP were combined with the aim of
improving disease control and reducing the risk of leukemogenesis and
sterility related to the alkylating agents in the MOPP regimen. This
alternating combination proved to be more effective than MOPP
chemotherapy alone. Its use in pediatric patients also diminished the
risk of cardiopulmonary dysfunction predisposed by the anthracycline and
bleomycin in the ABVD regimen. Over the years, the MOPP and ABVD
regimens underwent a variety of modifications, but the majority of the
chemotherapeutic regimens used today are derived from these two
combinations.

**Combined Modality versus Chemotherapy Alone**

The arguments that favor treatment with chemotherapy alone for all
stages propose that this treatment approach eliminates the need for
surgical staging and avoids the dysmorphic and carcinogenic consequences
of irradiation. The disadvantages of the use of chemotherapy alone are
the risks of treatment-related fatality, cardiopulmonary toxicity,
infertility, and leukemogenesis due to the higher cumulative doses of
anthracyclines, alkylating agents, and bleomycin, as well as an
increased likelihood of disease recurrence in sites of bulk disease.
Generalization of treatment outcomes after these trials has been limited
because most studies include small numbers of patients assigned to
treatments in a nonrandom fashion. Also, long-term follow-up related to
disease control and late treatment sequelae have not been reported.

Early chemotherapy trials used MOPP or similar regimens derived from
MOPP and prescribed 6--12 months of chemotherapy. The longest follow-up
data are from the Uganda experience, with only a 67% 9-year survival
rate. Subgroups included CS I to IIIA patients with a 75% survival rate,
and CS IIIB to IV patients with 60% and 47% survival rates at 5 and 10
years, respectively. One study reported a 90% 5-year survival rate for
CS I to II children treated with MOPP or a similar program that
substitutes chlorambucil for nitrogen mustard and vinblastine for
vincristine (ChlVPP) (see Table 3 in the original guideline document),
but the disease-free and overall survival rates were 40% and 55%,
respectively, for children with advanced disease. A report from the
Netherlands describes 37 children treated with 6 cycles of MOPP for
\"small\" lymph node disease (defined as less than or equal to 4 cm or
smaller), with the addition of 25 Gy involved-field radiation therapy
for children with \"large\" lymph node disease. The disease-free
survival with a median follow-up of 62+ months were 90% for the former
(21 children) and 85.5% for the latter (16 children).

In an effort to avoid treatment complications associated with alkylating
agent chemotherapy, contemporary chemotherapy alone trials have
alternated MOPP-type regimens with ABVD or similar derivatives
(MOPP/ABVD, COPP-ABV hybrid, CVPP/EBO) or by using combinations without
alkylating agents (ABVD, VEEP, EVAP/ABV). Across all stages, event-free
survival rates after treatment with 6-12 months of alternating MOPP/ABVD
chemotherapy alone ranged from 77% at 4 years to 91% at 10 years;
several of these investigations required pathologic staging to confirm
eligibility for reduced therapy. Across all stages, event-free survival
rates after treatment with 6-12 months of alternating MOPP/ABVD
chemotherapy alone ranged from 77% at 4 years to 91% at 10 years;
several of these investigations required pathologic staging to confirm
eligibility for reduced therapy. Nicaraguan investigators used 8-10
cycles COPP-ABV hybrid chemotherapy alone in clinically staged patients;
3-year event-free survival rates were 100% for the 25 patients with
stages I, II, IIIA, but only 74.9% for the 23 patients with stages IIIB
or IV. Similarly, Costa Rican investigators observed inferior outcomes
for stage IV patients treated with 12 months of cyclophosphamide,
vincristine, procarbazine, and prednisone (CVPP) and epirubicin,
bleomycin, and Oncovin (EBO) chemotherapy (60% 5-year relapse-free
survival rate). The use of ABVD or ABVD-derivative chemotherapy
combinations produced unsatisfactory outcomes in advanced stage patients
treated with 6 cycles of ABVD chemotherapy alone (71% 8-year
disease-free survival rate) and 5-6 cycles of vincristine, etoposide,
epirubicin, and prednisolone (VEEP) chemotherapy alone (78% 5-year
disease-free survival rate).

Only 3 randomized controlled trials have prospectively evaluated
chemotherapy alone versus combined modality therapy in children and
adolescents with HD. The Children\'s Cancer Group compared 12 cycles of
alternating MOPP/ABVD to 6 cycles of ABVD plus low-dose (21 Gy)
radiation. The trend in event-free and overall survival rates suggested
a survival advantage for the combined modality group (90% 4-year
event-free survival rate) over the chemotherapy alone group (84% 4-year
event-free survival rate), but this difference was not statistically
significant (Figures 1A and 1B in the original guideline document). The
Pediatric Oncology Group evaluated the benefit of adding low-dose
radiation to 4 cycles each of MOPP and ABVD (Table 4 in the original
guideline document), the addition of radiation therapy did not improve
disease-free or overall survival rates. However, statistical and quality
assurance issues complicate interpretation of these data. Long term
follow-up will be necessary to assess the toxicity from these 2 trials,
but cardiopulmonary and neoplastic sequelae were observed in early
follow-up and could potentially increase due to the cumulative doses of
alkylating agent chemotherapy, anthracyclines, and bleomycin.

In a recent Children\'s Cancer Group trial, chemotherapy alone using the
COPP/ABV hybrid regimen was compared to combined modality therapy,
including low-dose, involved-field radiation. Treatment assignment was
risk-adapted based on the presence of clinical features, including the
presence of \"B\" symptoms, hilar adenopathy, mediastinal and peripheral
lymph node bulk, and the number of involved nodal regions. Patients with
favorable disease presentations received 4 cycles of COPP/ABV; those
with unfavorable risk features received 6 cycles of COPP/ABV. Stage IV
patients received sequential cycles of high-dose cytarabine and
etoposide, COPP/ABV, and cyclophosphamide, vincristine, doxorubicin, and
methylprednisolone. Patients achieving a complete response to
chemotherapy were eligible for randomization to receive low-dose,
involved-field radiation or no further therapy. The trial was
prematurely terminated because of results indicating a significantly
higher number of relapses among patients treated with chemotherapy
alone. The 3-year event-free survival estimates according to patient
randomization were 92% for patients treated with combined modality
therapy and 87% for those treated with chemotherapy alone; the benefit
of involved-field radiation therapy remained significant in the \"as
treated\" analysis. The difference was most marked in stage IV patients
who had a 90% event-free survival rate if randomized to receive
involved-field radiation compared to 81% in those randomized to receive
chemotherapy alone. Due to successful salvage therapy after relapse,
estimates of overall survival rates are not different between the
randomized groups in early follow-up. However, other investigations of
long-term outcomes after treatment for pediatric HD implicate retrieval
therapy after relapse as a significant risk factor for neoplastic
complications and early mortality. Finally, in the German GPOG-HD 95
trial, the relapse-free survival rate was superior for patients treated
with RT after partial response (93%) than for those without RT after CR
(89%). The difference was significant for patients treated for advanced
stage but not early stage disease.

In summary, numerous investigations have confirmed that chemotherapy
alone is an effective treatment approach for pediatric HD. However, the
higher cumulative doses used in these protocols predispose survivors to
greater risks of acute and late toxicity associated with alkylating
agents, anthracyclines, and bleomycin. Conversely, these protocols avoid
radiation-associated treatment complications, including musculoskeletal
growth impairment, cardiopulmonary dysfunction, and solid tumor
carcinogenesis. Current information suggests that children with advanced
and unfavorable symptomatic or bulky disease at presentation have better
outcomes using a combined modality approach. Identification of the
prognostic features of patients who require radiation to optimize
disease control is a focus of many ongoing pediatric trials.

**Risk-Adapted Therapy**

Numerous investigations published in the 1990s supported the use of a
risk-adapted treatment assignment based on clinical features at disease
presentation. Parameters have varied according to individual studies,
but those most frequently used in risk assessments include the presence
of \"B\" symptoms, mediastinal and peripheral lymph node bulk,
extranodal extension of disease to contiguous structures, hilar lymph
node involvement, number of involved nodal regions and Ann Arbor stage.
These studies uniformly evaluated treatment outcomes using a reduced
number of multi-agent chemotherapy cycles in clinically staged patients
with favorable clinical presentation. Novel treatment approaches have
been explored in patients with intermediate and high risk features in an
effort to improve long-term disease control and reduce late
therapy-related complications. The results of these studies are
summarized in Tables 3 and 4 in the original guideline document.

**Treatment of Early Stage Disease**

Early stage disease may present with favorable or unfavorable features.
A favorable clinical presentation is typically defined as localized
(stage I/II) nodal involvement in the absence of \"B\" symptoms and
nodal bulk. Mediastinal lymphadenopathy is designated as bulky when the
ratio of the maximum measurement of the mediastinal lymphadenopathy to
that of the intrathoracic cavity on upright chest radiograph is 33% or
more. The criterion for peripheral lymph node bulk has varied across
studies from 4 to 10 cm. The presence of extranodal extension to
contiguous sites, hilar lymphadenopathy, or involvement of more than 3
to 4 nodal regions typically moves the patient into an intermediate or
high risk group. Children and adolescents with early stage/favorable
presentations of HD are excellent candidates for reduced therapy.
Several multiagent regimens have proved effective, including MOPP/ABVD,
OPPA or OEPA/COPP, COPP/ABV hybrid, and a variety of non-alkylator
regimens such as ABVD, OEPA, VAMP, VBVP, and DBVE (Table 3 in the
original guideline document). Treatment for patients with a favorable
clinical presentation typically involves 2 to 4 cycles of chemotherapy
and low-dose, involved-field radiation. In some regimens, the dose of
radiation has been reduced based on a favorable response to
chemotherapy.

The German Pediatric Oncology Group (GBOG) pioneered the use of risk-
and gender-adapted therapy featuring the OPPA regimen. Following
demonstration of the efficacy of 2 cycles of OPPA chemotherapy in
combination with 35 Gy involved field radiation in patients with
favorable clinical presentations, the regimen was modified to OEPA for
boys and the radiation dose reduced to 25 Gy for boys and girls
achieving a sufficient remission after 2 cycles of OEPA or OPPA
chemotherapy. The current German Pediatric Oncology Group HD-95 trial is
evaluating if radiation therapy can be omitted in patients achieving a
complete response to chemotherapy. Early results (median follow-up time
of 38 months) indicate a 94% event-free survival rate for favorable risk
patients and no difference in outcome in favorable patients treated with
chemotherapy alone versus combined modality therapy. Notably, bulky
lymphadenopathy is not used in the GPOG risk assessment as bulk has not
influenced outcome in the German trials, which prescribe a 5-10 Gy boost
in cases with an insufficient remission following chemotherapy.

French investigators initially determined that treatment outcomes were
not compromised in patients with early/favorable clinical presentations
who had therapy reduced to 4 cycles of chemotherapy (2 MOPP/2 ABVD or 4
ABVD) plus 20 Gy involved-field radiation. Their next trial evaluated a
novel regimen without alkylators or anthracyclines, VBVP (etoposide,
bleomycin, vinblastine, and prednisone), which produced a 91% 5-year
event-free survival rate in patients achieving a good response following
4 cycles of chemotherapy and 20 Gy to involved fields. Similarly,
Italian investigators demonstrated comparable outcomes (91% 7-year
freedom from progression) using reduced therapy with 3 cycles of ABVD
and 20 Gy involved-field radiation.

Several North American investigators have likewise observed excellent
treatment results in combined modality trials for favorable risk HD.
Pediatric Hodgkin\'s consortium investigators from Stanford, St. Jude,
and Dana Farber recently reported treatment results using a novel
non-alkylator regimen, VAMP for children with clinical I/II, non-bulky
HD. Patients received 4 cycles of VAMP chemotherapy and involved-field
radiation; the radiation dose was determined by early response after 2
cycles of chemotherapy. Patients achieving a complete response received
15 Gy, and those achieving a partial response received 25.5 Gy. At a
median follow-up of 5.6 years (range 1.1-10.4 years) the 5-year
event-free survival rate was 93%. Very good early treatment results have
also been observed by Pediatric Oncology Group investigators using
response-based DBVE (doxorubicin, bleomycin, vincristine, and etoposide)
chemotherapy and low-dose, involved-field 25.5 Gy radiation. The
two-year event-free survival rate for the entire cohort was 91%, with
93% event-free survival for rapid early responders treated with 2 cycles
of DBVE and 89% event-free survival for slower responders treated with 4
cycles of DBVE.

**Treatment of Advanced and Unfavorable Disease**

In risk-adapted treatment regimens, early disease presenting with
unfavorable features are sometimes treated similarly to advanced stage
disease. Alternatively, an intermediate designation is given in some
risk categorizations to patients with localized (stage IA, IIA) disease
presentations that have one or more of the unfavorable features and to
patients with stage IIIA disease. For example, the German Pediatric
Oncology Group studies prescribe 4 cycles of chemotherapy (2 OPPA or 2
OEPA and 2 COPP) for patients with intermediate risk (designated as
stage II~E~A, IIB, IIIA) and 6 cycles (2 OPPA or 2 OEPA and 4 COPP) for
patients with unfavorable and advanced disease. The criteria for
unfavorable clinical presentations vary per investigation, but typically
include the presence of \"B\" symptoms, bulky lymphadenopathy, hilar
lymphadenopathy, involvement of 3 or more nodal regions, extranodal
extension to contiguous structures, or advanced stage (IIIB-IV).
Chemotherapy used for this group includes MOPP and ABVD or derivative
combinations that incorporate etoposide in many cases. As illustrated in
Table 4 in the original guideline document, radiation therapy for
unfavorable and advanced HD is variable and protocol dependent. Although
involved-field radiotherapy remains the standard in patients treated
with combined modality therapy, restricting RT to areas of initial bulk
disease (generally defined as 5 cm or more at the time of disease
presentation), or post-chemotherapy residual disease (generally defined
as 2 cm or more, or residual PET avidity), is under investigation.

Two primary treatment approaches have been used for patients with
unfavorable and advanced disease presentations. A conventional treatment
approach prescribes chemotherapy on a twice-monthly schedule for 6--8
months. An alternative strategy compacts treatment administration into
3--5 months to enhance dose intensity and reduce the risk of developing
resistant disease. This is accomplished by alternating myelosuppressive
and non-myelosuppressive agents in a weekly schedule and using colony
stimulating factor to support neutrophil recovery. A summary of
treatment results of published trials is provided in Table 4 in the
original guideline document, which demonstrates event-free survival
rates ranging from 70%-90%. Long-term follow-up is not yet available to
determine if the abbreviated, dose-intensive treatment approach is
superior to conventional treatment in maintaining disease control.

**Radiotherapeutic Management**

The curability of pediatric HD, the complexity of current treatment
approaches, and the vulnerability of the developing child to both
radiation and chemotherapy require the involved radiation oncologist to
thoroughly understand the role of radiation and to deliver it with
skill. Most newly diagnosed children will be treated with risk-adapted
chemotherapy alone or with combined-modality therapy including low-dose,
involved-field radiation. In the past, fully grown adolescents with
favorable early stage disease were considered for full-dose extended
field radiation therapy, using techniques that are standard for adults.
This approach has been abandoned due to concerns primarily relating to
cardiac toxicity and second malignant neoplasms.

Meticulous and judiciously designed fields are necessary for maximum
success in terms of both disease control and normal tissue damage. The
definitions of such fields depend on the anatomy of the region in terms
of lymph node distribution, patterns of disease extension into regional
areas, and consideration for match line problems should disease recur.
Involved fields typically should include not just the identifiably
abnormal lymph nodes but the entire lymph node region containing the
involved nodes (Table 5 in the original guideline document). The
traditional definitions of lymph node regions can be helpful but are not
necessarily sufficient. For example, the cervical and supraclavicular
lymph nodes are generally treated when abnormal nodes are located
anywhere within this area; this is consistent with the anatomic
definition of lymph node regions used for staging purposes. However, the
hila are irradiated when the mediastinum is involved, despite the fact
that the hila and mediastinum are separate lymph node regions.
Similarly, the supraclavicular (SCV) is often treated when the axilla or
the mediastinum is involved, and the ipsilateral external iliac nodes
are often treated when the inguinal nodes are involved. However, in both
these situations care must be taken to shield relevant normal tissues to
the degree possible, such as the breast in the former situation and
ovaries in the latter. Moreover, a decision to treat the axilla or
mediastinum without the SCV, and the inguinal nodes without the iliacs,
might be appropriate depending on the size and distribution of involved
nodes at presentation. Field definitions are often protocol specific,
but excessively small fields are usually inappropriate. In a very young
child (under 5 years of age), consideration may be given to treating
bilateral areas (e.g., both sides of the neck) to avoid growth
asymmetry. However, this is less of a concern with low radiation doses,
and thus unilateral fields are usually appropriate if the disease is
unilateral.

Efforts to exclude unnecessary normal tissues, (e.g., breast tissue) are
always important in a child with isolated mediastinal disease and no
axillary involvement. Treatment of involved supradiaphragmatic fields or
a mantle field requires precision because of the distribution of lymph
nodes and the critical adjacent normal tissues. These fields can be
simulated with the arms up over the head, or down with hands on the
hips. The former pulls the axillary lymph nodes away from the lungs,
allowing greater lung shielding. However, the axillary lymph nodes then
move into the vicinity of the humeral heads, which should be blocked in
growing children. Thus the position chosen involves weighing concerns
regarding lymph nodes, lung, and humeral heads. Attempts should be made
to exclude breast tissue or position it under the lung/axillary
blocking. When the decision is made to include some or all of a critical
organ in the radiation field, such as liver, kidney, or heart, then
normal tissue constraints, depending on the chemotherapy used and
patient age, are critical.

The most effective sequence of therapy in the setting of combined
chemotherapy and irradiation is not unequivocally established. However,
chemotherapy is usually the first modality. This allows assessment of
drug response, maximization of the amount of drug treatment as well as
shrinkage of disease, and more limited fields of irradiation.
Occasionally, focal irradiation prior to chemotherapy will be necessary
because of airway obstruction. Since most children are treated in
institutional (or multi-institutional) studies, the radiation oncologist
should confirm all aspects of the diagnostic workup and staging and must
also understand study requirements in order to deliver appropriate
radiation.

**Summary Recommendations for Primary Disease**

Optimal treatment planning involves a multidisciplinary approach
beginning at diagnosis. This is best accomplished if the pediatric and
radiation oncologist can meet to review staging studies following
examination of the patient. The treatment approach should consider host
factors such as age and gender that may enhance the risk of specific
treatment complications, as well as disease factors (e. g., presence of
\"B\" symptoms), bulky lymphadenopathy, and stage, and others discussed
above. Recommended treatment approaches for favorable localized,
intermediate, and advanced unfavorable disease presentations are
summarized in the Table below.

See the original guideline document for a discussion of treatment for
refractory and relapsed disease.

**Table. Recommendations for Treatment Approach in Pediatric Hodgkin\'s
Disease**

  -----------------------------------------------------------------------------
  **Clinical Presentation**         **Stage**   **Recommended treatment
                                                approach**
  --------------------------------- ----------- -------------------------------
  **Early/favorable**:\             IA, IIA     **Recommended therapy**:\
  Localized disease involving \<3-4             2-4 cycles non-cross-resistant
  nodal regions in absence of B                 chemotherapy without alkylators
  symptoms, bulk, or extranodal                 (ABVD or derivative) plus
  extension                                     low-dose, involved field
                                                radiation (1500 cGy-2550 cGy)\
                                                **Other considerations**:\
                                                6 cycles non-cross-resistant
                                                chemotherapy alone (alternating
                                                COPP and ABVD or derivative)\
                                                **In clinical trial setting
                                                only**:\
                                                4 cycles of chemotherapy alone

  **Localized                       IA, IIAI\   **Recommended therapy**:\
  unfavorable/intermediate**:\      IB\*\       4-6 cycles (3-5 compacted,
  Localized disease involving       IIIA        dose-intensive cycles)
  [\>]{.underline}3-4 nodal regions             non-cross-resistant
  in presence of bulky                          chemotherapy (alternating COPP
  lymphadenopathy (mediastinal                  and ABVD or derivative
  ratio [\>]{.underline}33%; lymph              [+]{.underline} etoposide) plus
  node mass [\>]{.underline}6-10                low-dose, involved-field
  cm).                                          radiation (1500 cGy-2550 cGy).\
                                                **Other considerations**:\
                                                6-8 cycles (5 compacted,
                                                dose-intensive)
                                                non-cross-resistant
                                                chemotherapy alone (alternating
                                                COPP and ABVD or derivative
                                                [+]{.underline} etoposide).

  **Advanced/unfavorable**:\        IIB\*\      **Recommended therapy**:\
  Stage II patients with            IIIB\       6-8 cycles (5-6 compacted,
  constitutional symptoms of fever  IV          dose-intensive cycles) of
  or weight loss and any patient                non-cross-resistant
  with advanced stage                           chemotherapy (alternating COPP
                                                and ABVD or derivative
                                                [+]{.underline} etoposide) plus
                                                low-dose, involved-field
                                                radiation (organs 1000-1500
                                                cGy, nodes 1500 cGy-2550 cGy).\
                                                **Other considerations**\
                                                8 cycles (6-7 compacted,
                                                dose-intensive cycles)
                                                non-cross-resistant
                                                chemotherapy alone (alternating
                                                COPP and ABVD or derivative
                                                [+]{.underline} etoposide).
  -----------------------------------------------------------------------------

\*Stage IIB patients have been variably treated as intermediate or
unfavorable risk. Some studies use associated factors, e.g., weight
loss, bulk disease, extranodal extension, for further risk
stratification.

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Abbreviations**

-   ABV, Adriamycin, bleomycin, and vinblastine

-   ABVD, adriamycin, bleomycin, vinblastine, and dacarbazine

-   BM, bone marrow

-   CS, clinical stage

-   COPP, cyclophosphamide, oncovin, prednisone, and procarbazine

-   LPHD, lymphocyte-predominant Hodgkin\'s disease

-   MCHD, mixed-cellularity Hodgkin\'s disease

-   NSHD, nodular sclerosis Hodgkin\'s disease

-   OEPA, Oncovin, etoposide, prednisone, and Adriamycin

-   OPPA, Oncovin, procarbazine, prednisone, and Adriamycin

-   VAMP, vinblastine, adriamycin, methotrexate, and prednisone

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate treatment for the management of pediatric
Hodgkin\'s disease

#### POTENTIAL HARMS

-   Use of *chemotherapy alone* is associated with the risks of
    treatment-related fatality, cardiopulmonary toxicity, infertility,
    and leukemogenesis due to the higher cumulative doses of
    anthracyclines, alkylating agents, and bleomycin, as well as an
    increased likelihood of disease recurrence in sites of bulk disease.

-   *Radiation treatment* is associated with musculoskeletal growth
    impairment, cardiopulmonary dysfunction, and solid tumor
    carcinogenesis

-   In general, the use or *radiation and chemotherapy* broadens the
    spectrum of potential toxicities, while reducing the severity of
    individual (drug or radiation-related) toxicities.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Constine LS, Hoppe RT, Colman M, Deming RL, Mendenhall NP, Morris DE, Ng
A, Wolkov HB, Yahalom J, Chauvenet AM, Hudson MM, Winter JN, Mauch PM,
Expert Panel on Radiation Oncology-Hodgkin\'s Disease Work Group.
Pediatric Hodgkin\'s disease. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2006. 30 p. \[131 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Radiation
Oncology -- Hodgkin\'s Work Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Louis S. Constine, MD; Richard T. Hoppe, MD; Martin
Colman, MD; Richard L. Deming, MD; Nancy P. Mendenhall, MD; David Eric
Morris, MD; Andrea Ng, MD; Harvey B. Wolkov, MD; Joachim Yahalom, MD;
Allen R. Chauvenet, MD; Melissa M. Hudson, MD; Jane N. Winter, MD; Peter
M. Mauch, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Constine LS, Wolkov HB,
Yahalom J, Mauch PM, Deming RL, Dosoretz DE, Elman AJ, Hoppe RT,
Pistenmaa DA, Prosnitz LR, Chauvenet A, Connors JM, Glick JH, Leibel S.
Pediatric Hodgkin\'s disease. American College of Radiology. ACR
Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):1225-56.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHodgkinsWorkGroup/PediatricHodgkinsDiseaseDoc4.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 28, 2006. This summary
was updated by ECRI Institute on February 26, 2008 following the U.S.
Food and Drug Administration advisory/voluntary market withdrawal of the
liquid formulation of Leukine (sargramostim).

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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