ABVD Versus VEPEMB in Elderly Hodgkin’s Lymphoma Patients.
Authors: Levis Alessandro , Merli Francesco , Tamiazzo Stefania , Arcari Annalisa , Bellei Monica , Brugiatelli Maura , Federico Massimo , Liberati Marina , Partesotti Giovanni , Pregno Patrizia , Scalabrini Delia Rota , Sabiu Daniele , Salvi Flavia , Stelitano Caterina 
Published: April 2020

BACKGROUND. In advanced age the prognosis of Hodgkin Lymphoma (HL) is poor. Aggressive regimens such as BEACOPP are toxic and difficult to apply in the elderly (Engert et al JCO23, 5052, 2005). Moreover it is not clear if low intensive chemotherapy regimens are better than ABVD. The reduced intensity VEPEMB schedule showed good results in terms of efficacy and tolerance in a phase II multi-centre study (Levis et al Ann Oncol15, 123, 2004).

AIM OF THE WORK. To compare in HL elderly patients the reduced intensity VEBEMP schedule to the ABVD conventional one.

PATIENTS AND METHODS. From June 2002 to December 2006, 54 HL patients older than 65 years entered the study. Frail patients were excluded. Patients were defined frail when present one or more of the following conditions: a) age higher than 80; b) three or more grade 3 comorbidities and/or one or more grade 4 co-morbidities according to the CIRS scale; c) activities of daily living (ADL) score less than 6; d) geriatric syndrome. Early stage (IA-IIA) patients were randomized between 3 courses of ABVD and 3 courses of VEPEMB, both of them followed by IF radiotherapy. Advanced stage (IIB-IV) patients were randomized between 6 courses of ABVD and 6 courses of VEPEMB, with radiotherapy limited to the areas of residual masses or of previous bulky disease. The VEPEMB regimen was as follows: vinblastine 6 mg/sqm i.v. on day 1, cyclophosphamide 500 mg/sqm on day 1, procarbazine 100 mg/sqm p.o. days 1 through 5, prednisone 30 mg/sqm p.o. days 1 through 5, etoposide 60 mg/sqm p.o. days 15 through 19, mitoxantrone 6 mg/sqm i.v. on day 15, bleomycin 10 mg/sqm i.v. on day 15. The regimen was scheduled every 28 days. ABVD was scheduled as usual. Growth factors (G-CSF and erythropoietin) were regularly considered for both regimens.

RESULTS. Mean age was 72 (range 66–80). Seventeen patients (31%) were in early stage and the remaining 37 ones (69%) in advanced stage. One or more comorbidities were present in 26 cases (48%). Twenty six patients were allocated to ABVD and twenty eight to VEPEMB. Significant differences at diagnosis were not seen in terms of sex, mean age, stage, histology, co-morbidity and instrumental activity of daily living (IADL) score between the two arms. Significant differences in grade 3 or 4 toxicities were not seen between ABVD and VEPEMB arms: leucopenia 76% vs 82%; anemia 40% vs. 31%; mucositis 27% vs 19%; neurological toxicity 31% vs. 19%; infections 7% vs 23%. Toxic deaths were not observed. Treatment violations or interruptions were more frequent in the ABVD than in the VEPEMB arm, but this difference was not statistically significant (26% vs. 12%, p=ns). On an intention to treat analysis the final CR rate was slightly better in the ABVD than in the VEPEMB arm, even if this difference was not statistically significant: 86% vs. 77%. The 3-year relapse free survival rates were 57% and 50% (p=ns) for the ABVD and VEPEMB arm respectively. The 3-year overall survival and the event free survival rates for ABVD and VEPEMB were 79% vs. 60% (p=ns) and 52% vs. 24% (p=0.08) respectively.

CONCLUSIONS. The prognosis of this group of elderly HL patients has been confirmed inferior to that observed in younger patients. ABVD is feasible with modest toxic cost in non-frail elderly patients and its results are at least equal, if not better, than those observed with the low intensive VEPEMB regimen.