treatment of limited stage of hodgkin lymphoma by introducing new chemotherapy regimens and combining radiotherapy and chemotherapy has significantly evolved in recent years and failure in treatment is seen only in 10 to 20% of patients . recently , there are tangible improvements in advanced stages of hodgkin lymphoma but 10% of patients failed to achieve complete response with combined modality therapy , and 20 to 40% of patients suffered from recurrence or progressive disease . salvage chemotherapy and autologous bone marrow transplant has become the standard of treatment in recurrence or refractory hodgkin 's lymphoma . different regimens of salvage chemotherapy have been introduced in literature , with the goal of attaining a higher response rate , least side effects , and least damage to bone marrow cells in order to avoid distortion in next phase of treatment which needs mobilization and harvesting stem cells . considering acceptable progression free survival following this treatment , proper chemotherapy before autologous bone marrow transplant is a critical step . the two main salvage chemotherapies vastly implemented are gdp ( gemcitabine , dexamethasone , and cisplatine ) with less hospitalization introduced by baetz , and eshap ( etoposid , methyl prednisolone , cisplatine , cytarabine ) introduced by aparicio et.al . the latter needs at least five days of hospitalization   and has been used as the standard protocol in our institute over the last few years . although several studies have been performed to demonstrate the efficacy of these protocols , no comparison has been made between these two treatment regimens . in order to compare the efficacy of these two protocols the study included 50 patients with recurrent of hodgkin lymphoma between jan 2010 and dec 2011 . all patients received standard protocol of abvd ( doxorubicin , bleomycin , vinblastine and dacarbazine ) as the first - line of treatment . disease recurrence was histopathologically confirmed in patients with recurrence one year after their primary diagnosis , or there was radiologic evidence of recurrence in any organ in the body other than primary site . no histopathologic study was done on patients with recurrence disease in less than one years of diagnosis and radiologic evidence of recurrence in primary site . other inclusion criteria were : age 16 years ' old , eastern cooperative oncology group performance states of 02 , creatinine<1.4 mg / dl , serum aspartate or alanine aminotransferase<2.5 upper limit of normal and bilirubin<1.5 uln . patients with inclusion criteria were randomly assigned into two treatment groups : gdp and eshap ( block randomization ) . complete physical examination , cbc with differentials , and biochemistry profile ( bun , cr , and liver function tests ) were conducted before starting treatment in each cycle and one week after chemotherapy . this study was approved by the institutional review board and medical ethics committee of shiraz university of medical science ( sums ) . chemotherapy in gdp group consisted of gemcitabine 1000 mg / m2 on days 1 and 8 ; dexamethasone 40 mgiv on days 1 to 4 , and cisplatin 75mg / m . in order to reduce the risk of cisplatin - induced nephrotoxicity , patients were hospitalized for a maximum of 36 hours and hydrated with normal saline 12 hours prior to chemotherapy that was continued 8 hours after introduction of cisplatin . dexamethasone and granisetron were used intravenously as anti - emetic agent . in eshap group , patients were hospitalized during chemotherapy and the protocol included the followings : etoposide 40mg / m on days 1 to 4 , methylprednisolone 500mgiv on days 1 to 4 , cytarabine 2000mg / m on day 5 , and cisplatin 25mg / m on days 1 to 4 . courses were repeated every 3 weeks and anti - emetic agents used for treatment were the same as gdp protocol . treatment cycles were delayed by 1 week for garnulocytopenia of < 1.0  10 or thrombocytopenia of < 100  10/l , or attenuation schedule was implanted . all patients were evaluated during 3 weeks of third course of chemotherapy with complete physical examination and chest , abdomen and pelvis ct - scan . the primary objective of this study was to evaluate the response rate according to the national comprehensive cancer network ( nccn ) guide line version 1 - 2011 . chemotherapy side effects were evaluated based on national cancer institute common toxicity criteria version 4.0 . pet scan or gadolinium scan was not done for patients . the study included 50 patients with recurrent of hodgkin lymphoma between jan 2010 and dec 2011 . all patients received standard protocol of abvd ( doxorubicin , bleomycin , vinblastine and dacarbazine ) as the first - line of treatment . disease recurrence was histopathologically confirmed in patients with recurrence one year after their primary diagnosis , or there was radiologic evidence of recurrence in any organ in the body other than primary site . no histopathologic study was done on patients with recurrence disease in less than one years of diagnosis and radiologic evidence of recurrence in primary site . other inclusion criteria were : age 16 years ' old , eastern cooperative oncology group performance states of 02 , creatinine<1.4 mg / dl , serum aspartate or alanine aminotransferase<2.5 upper limit of normal and bilirubin<1.5 uln . patients with inclusion criteria were randomly assigned into two treatment groups : gdp and eshap ( block randomization ) . complete physical examination , cbc with differentials , and biochemistry profile ( bun , cr , and liver function tests ) were conducted before starting treatment in each cycle and one week after chemotherapy . this study was approved by the institutional review board and medical ethics committee of shiraz university of medical science ( sums ) . chemotherapy in gdp group consisted of gemcitabine 1000 mg / m2 on days 1 and 8 ; dexamethasone 40 mgiv on days 1 to 4 , and cisplatin 75mg / m . in order to reduce the risk of cisplatin - induced nephrotoxicity , patients were hospitalized for a maximum of 36 hours and hydrated with normal saline 12 hours prior to chemotherapy that was continued 8 hours after introduction of cisplatin . dexamethasone and granisetron were used intravenously as anti - emetic agent . in eshap group , patients were hospitalized during chemotherapy and the protocol included the followings : etoposide 40mg / m on days 1 to 4 , methylprednisolone 500mgiv on days 1 to 4 , cytarabine 2000mg / m on day 5 , and cisplatin 25mg / m on days 1 to 4 . courses were repeated every 3 weeks and anti - emetic agents used for treatment were the same as gdp protocol . treatment cycles were delayed by 1 week for garnulocytopenia of < 1.0  10 or thrombocytopenia of < 100  10/l , or attenuation schedule was implanted . all patients were evaluated during 3 weeks of third course of chemotherapy with complete physical examination and chest , abdomen and pelvis ct - scan . the primary objective of this study was to evaluate the response rate according to the national comprehensive cancer network ( nccn ) guide line version 1 - 2011 . chemotherapy side effects were evaluated based on national cancer institute common toxicity criteria version 4.0 . pet scan or gadolinium scan was not done for patients . a total of 44 patients who met the inclusion criteria were entered into the study . mean age of patients was 29.73(rang : 17  56 ) in gdp group and 26.5(rang : 18  56 ) years old in ehsap group . no statistically significant difference was observed between the two treatment groups ( mann - whitney test , p value = 0.655 ) . in gdp group , disease stage was stage ii in 45% , stage iii in 45.5% and stage iv in 9.1% of patients . in eshap group , these proportions were 54.6% , 22.7% and 22.7% , respectively , suggesting the equal distribution of patients in both groups with respect to disease stage . in gdp group , 77% of patients had first relapse , 9.1% had second relapse and 13.6% of them had primary refractory disease . in eshap group , these values were 72.2% , 4.5% and 22.7% , respectively ( fisher 's exact test , p - value : 0.546 ) . therefore , no difference was observed in disease stages between two groups . the mean time to relapse was 20.42 and 16.35 months in gdp and eshap groups , respectively and there was no statistically significant difference between the two groups ( mann - whitney sig : 0.247 ) . considering the aforementioned factors , it can be concluded that patients were equally distributed in both groups with respect to age , sex , stage and time to relapse ( s1 ) . 27.3% of patients in gdp group had complete response , 31.8% had more than 50% response , and 40.9% had no response . statistical analysis with the chi - square test showed that response rate was identical in both groups ( sig 0.578 ) . overall response rate in gdp and eshap groups was 54.1% and 50% , respectively ( sig 0.763 ) ( s2 ) . of two patients with thrombocytopenia in gdp group , one ( 4.5% ) developed grade two patients were experienced thrombocytopenia in gdp group , one patient grade i ( 4.5% of patients in this group ) and another one grade iii . this event in eshap group was seen in 9.1 % ( grade ii ) . in gdp group , grade iii neutropenia was seen in one ( 4.5% ) patient and two ( 9.1% ) patients experienced grade ii neutropenia in eshap group creatinine in eshap group was raised from 1.8 to 2 mg / d in one patient and remained in this level after one - year follow - up period . ast and alt also rose to greater than 2 times about 2xuln ( upper normal limit ) during chemotherapy and returned to normal levels after two weeks in this patient . ( s3 ) in gdp group , one patient suffered from hyperglycemia in the last cycle of treatment and blood sugar was not corrected after termination of treatment . of two patients with thrombocytopenia in gdp group , one ( 4.5% ) developed grade i and one ( 4.5% ) developed grade iii . two patients were experienced thrombocytopenia in gdp group , one patient grade i ( 4.5% of patients in this group ) and another one grade iii . this event in eshap group was seen in 9.1 % ( grade ii ) . in gdp group , grade iii neutropenia was seen in one ( 4.5% ) patient and two ( 9.1% ) patients experienced grade ii neutropenia in eshap group creatinine in eshap group was raised from 1.8 to 2 mg / d in one patient and remained in this level after one - year follow - up period . ast and alt also rose to greater than 2 times about 2xuln ( upper normal limit ) during chemotherapy and returned to normal levels after two weeks in this patient . ( s3 ) in gdp group , one patient suffered from hyperglycemia in the last cycle of treatment and blood sugar was not corrected after termination of treatment . because achievement to adequate response to salvage chemotherapy before bone morrow transplantation is important this influences transplantation 's results and progression free survival of patients . in this study the researcher attempted to compare the results of two methods of treatments : eshap vs. gdp . the former has been used as a common treatment regimen at our center over the last few years and needs 5 days of hospitalization . hospitalization with another method which had acceptable effectiveness with far less side effects and hospitalization required i.e. gdp . baetz introduced gdp protocol ( gemcitabine , dexamethasone , cisplatin ) and evaluated patients after 2 cycles of chemotherapy . among his patients , 4 had complete response , had partial response and 7 had stable disease ( without progression on treatment ) . in the study conducted by aparicio , 22 patients were treated with eshap ( etoposid , methyl prednisolone , cisplatin and cytarabine ) protocol and were evaluated after 3 cycles of chemotherapy . at the end of the study , 9 patients had complete response and 5 patients had partial response ( overall response : 73% ) . chemotherapy regimen in gdp group of the current study was slightly different from baetz study . in this study , patients were hospitalized at least 36 hours in order to hydration in order to reduce the risk of cisplatin - related nephrotoxicity , while in baetz study this protocol was prescribed as outpatient and manitol was used in addition to dextrose / saline before cisplatin . due to lack of response to initial salvage treatment protocol ( gdp or ehsap ) ; cross - over trial was performed in three patients in two groups at the beginning of our study . none of these patients showed response to second - line salvage chemotherapy ( either gdp or eshap ) , therefore , this trend was stopped . one of the significant findings was that none of the patients with primary refractory disease responded to protocols used in this study , but all responded to iev ( ifosfamide , epirubicin , etoposide ) . none of the patients with recurrent stage iv disease in both groups reached complete response . in baetz study , 52% of patients treated with gdp protocol had stage iii and iv diseases and 48% had stage i and ii . in the current study , these rates were 45.5% and 54.5% , respectively . in this study , 13.6% of patients in gdp group had primary refractory disease , while only 26% of patients had primary refractory disease in baetz study . compared to baetz study in which patients received 2 cycles of chemotherapy , in this study patients received 3 cycles of chemotherapy . in the current study , overall response rate in gdp group was 54.1% , while it was reported 69.5% in baetz study . in the present study , overall response rate was 50% in eshap group , while it was 73% in patients treated with similar protocol in aparicio study . here , we present the results of comparison on side effects between the two treatment groups and with previous studies ( s4 , s5 ) : in aparicio study , 59% of patients developed myelotoxicity ( grades iii and iv ) and one patient died of neutropenic fever , while in the present study side effects were significantly lower and there were no mortality . in baetzstudy , four patients needed hospitalization , 8.6% in the present study , 4.5% of patients showed grade iii neutropenia and 4.5% of patients showed grade i and iii thrombocytopenia . , there was no significant difference in response rate between the two salvage regimens , but gdp regimen can be used as an outpatient regimen with low toxicity . based on this study , these two regimens were not suitable options for primary refractory hodgkin lymphoma as salvage treatment . there is no significant difference in overall response rates between the two protocols but due to least toxicity and lower health care costs result from less hospitalization , gdp could be considered as the better option for salvage regimen .