Exploring the Outcomes of Hodgkin Lymphoma in Pediatric Patients: A Systematic Review from India

Abstract

Hodgkin lymphoma (HL) has emerged as one of the most curable pediatric cancers globally. However, in low- and middle-income countries like India, the treatment landscape is shaped by various biological, social, and resource-related factors, leading to variability in management approaches and outcomes. This systematic review aims to bring together the available data to provide an integrated overview of current management practices and outcome of childhood HL in India. Thirteen studies were reviewed, including 3 multicenter studies, with a total cohort of 1,766 children. The median age at diagnosis ranged from 7 to 10 years, with male-to-female ratios between 2.8:1 and 10.5:1. A significant proportion (70–80%) of children presented with advanced stages of the disease. Utilization of positron emission tomography-computed tomography for assessment was inconsistent across centers, and the use of radiotherapy (RT) varied widely. Most centers have reported 5-year overall survival and 5-year event-free survival of approximately 90% and above and 75 to 85%, respectively. Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) was the most widely used regimen; however, recent studies have used vincristine, etoposide, prednisolone, doxorubicin (OEPA)/cyclophosphamide, vincristine, prednisolone, dacarbazine (COPDAC) with the intent to reduce long-term side effects associated with radiation exposure. Treatment-related mortality of around 5% was noted with OEPA/COPDAC in Indian setting in contrast to ABVD, which is close to 1%. Feasibility and long-term benefits of the former chemotherapy need further follow-up. Challenges such as treatment abandonment and toxic deaths remain significant, and there is a notable lack of data on long-term outcomes and late effects, necessitating further research in these areas.

Keywords

abandonment - Hodgkin lymphoma - pediatric - overall survival

Introduction

The evolution of treatment over the past 4 to 5 decades has altered the outcome of pediatric Hodgkin lymphoma (HL) such that the majority of patients are cured. The inclusion of HL as one of the six index cancers in the World Health Organization-Global Initiative for Childhood Cancer initiative launched in 2018,[1] emphasizes the need to discuss and increase the awareness about it, especially in low- and middle-income countries (LMICs). Multiple collaborative trials in the West have come up with various treatment regimens based on risk-stratified and response-based approach with the aim of prevention of long-term side effects while maintaining the excellent cure rates.[2] [3] [4] Although LMICs, like India, have kept pace with changes in management of HL globally, there are significant variables that might affect outcome. The biologic and demographic differences observed in pediatric HL between the West and India include a higher male preponderance, poor nutritional status, younger age at presentation, and increased incidence of a mixed cellularity pathologic subtype in India.[5] With heterogeneity in the treatment approach and variable resource availability in India,[6] a systematic review is needed to understand the current management and outcome of childhood HL in India. The purpose of this review was to summarize and integrate the published literature on reported current management practices and outcome of pediatric HL from India. Recent collaborative efforts with prospective multicenter studies under the aegis of the Indian Pediatric Oncology Group (InPOG, which has recently been renamed the Indian Pediatric Hematology Oncology Group) has proven a crucial step toward a more streamlined approach in pediatric oncology in our country where resource limitation is a major determinant of outcomes.[7] [8] This review is an effort which will provide useful baseline information and overview of treatment strategies for HL across the country.

Materials and Methods

A search of Medline (via PubMed) using keywords “Hodgkin lymphoma,” “pediatric,” and “India” was done in January 2023. The search was limited to studies published from the year 2000 onward. Studies which reported outcomes on survival, related to pediatric HL (age < 18 years) were included. Title and abstracts of the search results were independently screened by two investigators (K.T. and R.S.A.) to identify potentially eligible studies. Full text of these was then screened to make the final decision. Analysis of the articles was done by two independent reviewers (C.V. and R.S.A.). Retrospective case–control studies, randomized control trials, and retrospective cohort studies were included in the review. Manual examination of reference lists as well as of citations (through Google Scholar) of included studies were done to identify any additional studies which may not have been identified in Medline. [Fig. 1] depicts the flow diagram for study selection approach.

Fig. 1 Flow diagram for study selection.

The results of the searches were compared and merged. Any single or multicenter study from India was eligible for inclusion. If there were more than one study from the same institute, only the most recent was included. Case reports and studies reporting less than 20 cases were excluded. Where available, data for early stage (stage 1 and 2A) and advanced stage (stage 2B, 3, and 4) was also examined separately. Demographic and clinical variables were collected from the shortlisted studies. Chemotherapeutic and radiotherapy (RT) strategies used were also included. Key outcomes of the review included survival rates, mortality, relapse rates, disease progression, and treatment abandonment. The key features and outcomes of the selected studies were summarized in tabular form, and an overall narrative presentation synthesized the findings to provide insights into the current landscape of pediatric HL management in India.

Results

The studies included[5] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] for this review along with their clinical and demographic details have been summarized in [Table 1]. Thirteen studies were included, which covered variable time periods (range 1988–2019). While most were single-center studies, three recent studies were multicenter studies including two InPOG collaborative studies with 27 participating centers across the country.[13] [19] [20] Together, they constituted 1,766 children with HL with the median age of children ranging from 7 to 10 years. There was male preponderance (majority of centers reported ratio of > 4:1) in all studies with male-to-female ratio ranging from 2.8:1 to 10.5:1. Most common histology noted was mixed cellularity followed by nodular sclerosis. A significant proportion of patients, approximately 70 to 80%, presented with advanced-stage disease, a finding that showed little variation between earlier and more recent studies, highlighting the persistent burden of advanced presentations. B symptoms were present in approximately half of the patients while bulky disease was present in a quarter of children. Most centers utilized contrast-enhanced computed tomography (CECT) for staging and response assessment; however, the increasing availability and affordability of positron emission tomography-CT (PET-CT) in recent times have led to its use for this purpose.

Table 1 Clinical, demographic, and treatment details of the included studies

Study details	Study period	No. of patients	Age group (y)	M:F	Advanced stage (≥ 2b)	B symptoms	Bulky disease	Histology	Chemotherapy[a]	Staging and response assessment modality	Indication and dose (in parenthesis) of radiotherapy	Radiotherapy
Chandra et al, 2008[9]	1988–2004	35	< 18	10.5:1	83%	NM	NM	MC 50.5%, NS 23.7%, LP 20%	COPP X 6: 83%, COPP X 3 + ABVD X 3: 11.4%, ABVD X 6: 2.9%	CT	Bulky disease; (NM)	11%
Trehan et al, 2013[10]	1990–2006	206	3–16	10.5:1	52% (≥ 3)	54%	NM	MC 69.6%	ABVD/ ABVD-COPP/ MOPP-COPP/OEPA	CT	No routine RT, Individualized decision; (NM)	1.44%
Verma and Kumar, 2015[11]	1994–2012	184	< 15	7.4:1	82%	79%	19.10%	MC 38%, NS 32%, LP 13.7%	ABVD, COPP, COPP/ABV	CT	Incomplete or no response; (NM)	6.5%
Jain et al, 2016[12]	1996–2013	167	< 18	9.4:1	31.80%	43%	16.70%	MC 49.8%, NS 25.8%, LR 10.8%	ABVD	CT (PET in few)	Bulky disease/PR; (20–36 Gy)	30.50%
Radhakrishnan et al, 2016[5]	2001–2010	172	< 18	2.8:1	40%	32%	27%	MC 45%, NS 35%, LP 2%, LD 1%	ABVD (70%), ABV/COPP hybrid	CT	Bulky disease or PR; (bulky 20–30 Gy; PR 30–36 Gy)	19%
Bhethanabhotla et al, 2017[13]	2003–2013	186	< 18	4.6:1	100%	74.20%	44.6%	MC 44.1%, NS 32.2%, LR 2.7%	ABVD	CT/PET	Bulky disease/PR/ extranodal disease; (25 Gy)	40.30%
Seth et al, 2015[14]	2005–2010	35	< 13	7.7:1	65.70%	60%	25.70%	MC 25.7%, NS 28.6%, LP 25.7%	ABVD, BEACOPP in progression (2 cases)	CT (PET in 10)	PR; (20–30Gy)	11.40%
Gupta et al, 2019[15]	2005–2014	90	< 15	7.2:1	87.80%	87.80%	15.60%	MC 44.4%, NS 26.7%	ABVD, COPP/ABVD, COPP	CT	Bony involvement; (NM)	2.20%
Jayabose et al, 2016[16]	2010–2014	26	4–18	4.2:1	100%	NM	NM	NM	HR: mBEACOPP + ABVD, IR: ABVE-PC/ ABVE-PC + ABVD	CT (PET in 7)	PR; (NM)	7.60%
Palayullakandi et al, 2022[17]	2010–2019	143	< 13	5.8:1	74% (TG2 and 3)	46.2%	58.9%	NM	OEPA/COPADAC	PET-CT	Inadequate PET response; (NM)	21%
Parambil et al, 2020[18]	2013–2016	126	< 15	4.7:1	90.40%	65.80%	86.80%	MC 27.2%, NS 19.3%, LR 7%, NS 46.5%	LR: ABVD IR + HR: OEPA + COPDAC	PET	Bulky sites and ERA < CR; (19.8 Gy in bulky and 30.6 Gy in ERA < CR)	76%
Mahajan et al, 2021[19]	2015–2018	134	< 18	5.7:1	0%	NM	39.50%	NM	ABVD X 4 cycles	PET (49.2%) Rest CT	Bulky sites, suboptimal ERA; (21Gy)	39%
Jain et al, 2022[20]	2015–2018	262	< 18	5.2:1	100.00%	75.50%	50.30%	NM	ABVD X 6 cycles	PET (44.6%) Rest CT	Bulky sites, suboptimal ERA; (21Gy)	42.30%

Abbreviations: CR, complete response; CT, computed tomography; ERA, early response assessment; HR, high risk; IR, intermediate risk; LD, lymphocyte depleted; LP, lymphocytic predominance; LR, low risk; LR, lymphocyte rich; MC, mixed cellularity; NA, not applicable; NM, not mentioned; NS, nodular sclerosis; NS, not specified; PET, positron emission tomography; PR, partial response; TG: treatment groups as per Euronet-PHL-C1-protocol.

^a Chemotherapy abbreviations: COPP, Cyclophosphamide, Oncovin [Vincristine], Procarbazine, Prednisolone; ABVD, Adriamycin [Doxorubicin], Bleomycin, Vinblastine, Dacarbazine; MOPP, nitrogen mustard, vincristine, procarbazine, prednisolone; ABV, Adriamycin, bleomycin, vinblastine; BEACOPP, bleomycin, etoposide, adriamycin, COPP; mBEACOPP, modified BEACOPP; ABVE-PC, Adriamycin, bleomycin, vincristine, etoposide, prednisone, cyclophosphamide; OEPA, vincristine, etoposide, prednisolone, doxorubicin; COPDAC, cyclophosphamide, vincristine, prednisolone, dacarbazine.

Chemotherapy

The most frequently employed chemotherapy regimen was Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD), either alone or in combination with cyclophosphamide, Oncovin [vincristine], procarbazine, prednisolone (COPP), used by most centers. The same backbone was also used for the InPOG studies.[19] [20] Palayullakandi et al[17] and Parambil et al[18] have reported outcomes with Euronet-PHL-C1-protocol using OEPA-COPDAC-based chemotherapy.

Number of cycles and intensification by addition of other drugs was based on stage at presentation and early response assessment by CECT/PET. Number of ABVD cycles varied from 4 to 8 depending upon the stage of disease and individual institutional protocols. Early-stage disease received 4 to 6 cycles and advanced stage disease received 6 to 8 cycles. The treatment details have been described in [Table 1].

Radiotherapy

RT was incorporated in nearly all centers, with involved field radiation therapy being the preferred modality. The most common indications had been bulky disease and partial or no response on reassessment. Study by Bhethanabhotla et al involving patients from three centers have additionally given radiation to extranodal disease.[13] Two centers were not using radiation routinely and given radiation to occasional patients on individualized basis.[10] [15] In three studies[13] [16] [20] involving only advanced stage cases, indications were bulky disease/partial response/extranodal disease. Regardless of indication, in several studies, the proportion of children receiving radiation was around 10% or lower. On the other end of the spectrum, in one study, three out of four children with HL received RT.[18] Six studies have mentioned the dose of radiation given, which were 20 to 30 Gy in bulky disease and ranged from 25 to 36 Gy for partial response as shown in [Table 1].

Survival Outcomes

The survival outcomes as well as the events occurred have been outlined in [Table 2]. The median follow-up period ranged from 17 months to 5 years. For HL all stages combined, most of the centers have reported 5-year overall survival (OS) of around 90% and above except one center which has reported approximately 80% survival. Five-year event-free survival (EFS) reported by five studies has ranged from 75 to 85% with one outlier at the lower end of 53%.[11] Seven studies have also reported OS and EFS separately in early and advanced-stage disease. OS ranged from 90 to 100% in early stage and 70 to 95% in advanced-stage disease. Likewise, EFS ranged from 70 to 100% and 50 to 94% in early and advanced stage, respectively.

Table 2 Events and survival outcomes

Study	Progression on treatment/relapse/both (%)	TRM	Abandonment	Overall OS	Overall EFS	Early stage OS	Early stage EFS	Late stage OS	Late stage EFS
Chandra et al, 2008[9]	2.8/11.4/14.2	8.50%	5.7%	NM	80% (5 y)	NM	NM	NM	NM
Trehan et al, 2013[10]	2.8/11.1/13.9	NM	7.7%	92.7% (5 y)	77.5% (5 y)	97.7%	90.2%	88.2%	73.2%
Verma and Kumar, 2015[11]	4.8/9.7/14.5	6.5%	20%	79.4% (5 y)	53.1% (5 y)	90.1%	70.7%	77%	49.6%
Jain et al, 2016[12]	2.4/11.3/13.7	NM	1.1%	95.9% (5 y)	79.1% (5 y)	97.2%,	93.9%	94.3%	63.7%
Radhakrishnan et al, 2016[5]	1.7/16/17.7	1.16%	2.90%	92.9% (5 y)	83.1% (5 y)	96% (stage I), 94.7% (stage II)	91.7% (stage I), 86.6% (stage II)	84% (stage III), 69.8% (stage IV)	78.3% (stage III), 57.1% (stage IV)
Bhethanabhotla et al, 2017[13]	4.8/8/12.8	1%	4.2%	95.3% (5 y)	84.4% (5 y)	NM	NM	95.30%	84.40%
Seth et al, 2015[14]	5.7/11.4/17.1	None	0	100% (5 y)	76.7% (5 y)	NM	NM	NM	NM
Gupta et al, 2019[15]	1.1/12.2/13.3	None	5.50%	88.80%	84.50%	90.0%	90.0%	89.0%	83.8%
Jayabose et al, 2016[16]	3.8/0/3.8	None	None	NM	100%	NM	NM	NM	NM
Palayullakandi et al, 2022[17]	0/6.3/6.3	5.3%	9.1%	93.5 ± 2.2% (4 y)	86.2 ± 3.4% (4 y)	100% (4 y; TG1)	93.2 ± 4.6% (4 y; TG1)	92.1 ± 4.5% (4 y; TG2) 88.1 ± 4.6% (4 y; TG3)	84.7 ± 6.5% (4 y; TG2) 82 ± 6% (4 y; TG3)
Parambil et al, 2020[18]	1.5/2.6/4.1	3.9%	NM	NM	NM	100% (LR, 3 y)	100% (LR, 3 y)	94.4% (IR), 92.6% (HR)	94.4% (IR), 90.3% (HR)
Mahajan et al, 2021[19]	1.5/2.2/3.7	0.75%	0.75%	NM	NM	97.7% (5 y)	95.5% (5 y)	NM	NM
Jain et al, 2021[20]	4.2/10.7/14.9	1.14%	3.43%	NM	NM	NM	NM	90.8% (5 y)	81.1% (5 y)

Abbreviations: EFS, event-free survival; NM, not mentioned; OS, overall survival; TG, treatment groups as per Euronet-PHL-C1-protocol; TRM, treatment-related mortality.

Causes of treatment failure included progression/relapse, toxic deaths, and abandonment. The largest proportion of treatment failure was due to progression/relapse, which was around 15% in most studies, but has been close to 5% in the most recent studies.[17] [18] [19] Toxicity-related mortality (TRM) was generally 0 to 1%, except for two of the earliest studies (8.5 and 6.5% by Chandra et al[9] and Verma and Kumar,[11] respectively) and more recently around 5% in two studies, which used the more intensive OEPA/COPDAC chemotherapy backbone.[17] [18] Abandonment data has been provided in seven studies, which ranged from 0 to 8% in six studies with one study reporting exceptionally high abandonment rate of 20%.[11]

Discussion

The findings of this systematic review highlight the evolving landscape of pediatric HL management in India, reflecting both progress and persistent challenges characteristic of LMICs. While factors such as the simplicity of treatment protocols, favorable tumor biology, and lower toxicity from less myelosuppressive chemotherapy will contribute to better outcomes, issues like high rates of treatment abandonment, advanced disease at presentation, and resource limitations hinder outcomes. Analyzing the data of 13 included studies across the nation published over a period of last three decades and comparing these studies in two cohorts of recent era (group 1) and earlier era (group 2) as shown in [Table 3] highlights some noteworthy details. To facilitate comparison, the year 2010 was chosen as a convenient cutoff for commencement point of studies to categorize them into earlier and recent era phase.

Table 3 Key differences observed between recent-era (group 1) and earlier-era (group 2) studies in pediatric HL in India

Parameter	Group 1 (n = 5)	Group 2 (n = 8)
Study years	Studies commenced from 2010 onwards (last 5 studies from Table 1)	Studies commenced prior to 2010 (first 8 studies from Table 1)
Chemotherapy backbone	OEPA/COPDAC, modified regimens	ABVD/COPP-based regimens
Imaging modality	High PET-CT use	Predominantly CT-based
Sample size	26–262	35–206
Male:Female ratio	∼5:1	7–10:1
Advanced stage at presentation	74–100%	31–88%
Bulky disease	39–87%	15–45%
Radiotherapy use	Moderate–high, PET-guided	Low–variable
Abandonment	0.75–9.1%	0–20%
Treatment-related mortality	0.75–5.3%	0–8.5%
Relapse rates	3.7–6.3%	12–18%

Abbreviations: ABVD, Adriamycin [Doxorubicin], Bleomycin, Vinblastine, Dacarbazine; COPDAC, cyclophosphamide, vincristine, prednisolone, dacarbazine; COPP, Cyclophosphamide, Oncovin [Vincristine], Procarbazine, Prednisolone; CT, computed tomography; OEPA, ; PET, positron emission tomography.

The epidemiologic patterns seen across the included studies—particularly younger age at presentation, male predominance, and a higher frequency of mixed cellularity histology—are consistent with previously published LMIC data sets, including the Indian Council of Medical Research (ICMR) 2017 Pediatric Lymphoma Guidelines and recent global LMIC-focused reviews.[21] [22] [23] [24] These patterns contrast with high-income countries (HICs), where nodular sclerosis is more common and peak age is slightly older.[25] The contrasting biology in LMIC suggests that environmental, socioeconomic, and infection-related exposures may contribute.

Delayed diagnosis and high rates of advanced-stage presentation continue to be major concern in LMICs contributing to treatment complexity. Nearly 70 to 80% of Indian children were diagnosed at stage IIB to IV, markedly higher than in HIC cohorts.[25] System-level delays including referral lag, limited awareness at primary care level, and constrained access to pediatric oncology services remain important barriers.

The transition in chemotherapy protocols from predominantly ABVD-based regimens to risk- and response-adapted strategies such as OEPA/COPDAC in contemporary study cohorts mirrors global trends but requires judicious adaptation in our setting. While OEPA/COPDAC has been associated with lower relapse rates internationally, Indian centers reported higher TRM (up to 5%), likely reflecting limited supportive care capacity. Adoption of such intensive protocols should be in alignment of supportive care infrastructure. In the era of adapted treatment regimens,[26] this observation provides a guidance to achieve a balance between reducing progression/relapse rates and the need for strengthening supportive care to bring down TRM rates to reach the ultimate goal of improved survival rates.

Another interesting observation is PET-CT–based response assessment, which is currently the backbone of modern HL management internationally, remains inconsistently accessible across India. However, uniform use of PET-CT in recent studies is a notable advancement.[27] [28] Limited availability, cost, and uneven infrastructure remain barriers. Both ICMR[24] and recent LMIC reviews[25] recommend PET-CT where feasible, but also call for validated CT-based early response criteria for resource-limited settings.

RT practices, an integral treatment modality in HL, remain heterogeneous, with some centers using RT in < 10% and others in > 70% of cases as tabulated in [Table 1]. Variation arises from inconsistent access to RT facilities, differing oncologist preferences, lack of standardized national protocols, and differing levels of PET integration. Recent InPHOG trials aim to harmonize RT decision-making.[20]

Comparing the survival outcomes from past epidemiological data, there has been constant improvement in survival rates in LMICs in current time.[29] [30] However, the obstacles still persisting common to LMICs are treatment abandonment, socioeconomic disparity for treatment access, and compromised nutrition. Abandonment rates have improved over time (from 20% in older studies to < 10% in recent cohorts) ([Table 3]), reflecting expansion of government and nongovernmental supporting funds, public insurance schemes, increased awareness, and increasing participation of centers in prospective collaborative trial in India.

This systematic review summarizes the ongoing practices in pediatric HL in the country; however, this study is limited by the lack of access to individual patient data. There has been paucity of data on long-term outcomes as well as late effects.

Conclusion

Although high abandonment, advanced disease at presentation, and a significant TRM are roadblocks in the stride of optimal outcomes of pediatric HL, consistent and fairly good outcomes have paved the way to focus on reducing long-term effects also. Higher male predisposition in HL is a unique biological feature noted in all studies. Conventional approach of chemotherapy with ABVD backbone seems to yield reasonable outcomes with acceptable TRM. There is heterogeneity for RT use with variable indications and individualized approaches across various centers. As we transition toward approaches that further reduce long-term treatment-related toxicities including alternative intensive chemotherapy protocols, more focused radiation techniques, and attention to robust supportive care, the collaborative trials seem the way forward in near future. As of now, there is limited data on late effects but this is now being increasingly considered an important area to focus on. By far, we seem to be doing well in terms of favorable outcomes. The gap between treatment and overtreatment has the answer to avoid long-term side effects, which reinforces the strong need of working together, which can mitigate not only treatment-related factors but various social impacts also. Need to monitor late effects cannot be overemphasized.

Conflict of Interest

None declared.

Authors' Contributions

R.S.A. conceptualized the study, supervised the work, and critically reviewed the manuscript. K.T. collected the data, searched literature, and analyzed the data. Analysis of the articles was done by two independent reviewers (C.V. and R.S.A.). K.T. and C.V. integrated and interpreted the data and cowrote the manuscript. All authors discussed the results and approved the final draft.

Patient Consent

Patient consent is not required.

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Publication History

Article published online:
20 January 2026