Long-term side effects in irradiated patients with Hodgkin's disease

Primary hypothyroidism as a complication after treatment of tumours of the head and neck

In 100 successive patients treated for tumour in the head and neck region, the function of the thyroid gland was evaluated during follow-up by determination of the serum levels of thyroid stimulating hormone and thyroxine. Radiation therapy alone did not lead to hypothyroidism, 4 patients had no dysfunction after laryngectomy for recurrent tumour after irradiation. Ten of 17 (59%) patients treated with irradiation and surgery including hemithyroidectomy and with a follow-up period of more than one year developed functional disturbance; in the absence of hemithyroidectomy one of 10. In patients who underwent hemithyroidectomy and developed hypothyroidism, the interval between surgery and postoperative irradiation was shorter than in those who did not develop functional disturbance (31 versus 49 days).

The effects of cancer and cancer therapy on male fertility

Multimodality treatments have increased the survival of cancer patients in recent years. With cure the quality of life also should be taken into consideration. Maintenance of the reproductive capacity is of great concern to many young patients. Until now the cause of sterility was attributed to the long-term side effects of treatment when recovery could not be predicted. Pre-treatment sperm banking is advised routinely for many of these patients. Our own observation as well as a few other reports show that cancer itself seems to have an adverse effect on fertility before any form of treatment. As assessed by semen quality the majority of our patients were subfertile when first seen. Hence, sperm banking may be a poor guarantee for future reproduction in these patients.

The effects of postoperative adjuvant chemotherapy and radiotherapy on testicular function in men undergoing treatment for soft tissue sarcoma

Testicular function was studied in 26 men with sarcoma who received adjuvant treatment with doxorubicin, cyclophosphamide, and high-dose methotrexate (with or without radiotherapy). Testicular size, sperm output, and serum FSH, LH and testosterone levels were assessed after treatment. Five of 17 men who received chemotherapy or chemotherapy with radiotherapy to the neck, arm, chest, or leg, had normal testicular function. Eight of the remaining 12 men who provided ejaculates were oligospermic or azoospermic and serum FSH was increased threefold and LH twofold; testosterone levels were normal. In the five men with normal testicular function, FSH was increased fourfold during therapy but returned to normal six to 21 months after treatment. In men less than 40 years old, the mean FSH was less than that of men over 40 years of age (P = to 0.05), suggesting that recovery from the injury was age-related. By contrast, all nine men who received chemotherapy plus radiotherapy to the abdomen or thigh had decreased testicular size, azoospermia, fourfold increase in FSH, and twofold increase in LH levels; but testosterone concentration was normal. These data increase in FSH, and reversible testicular injury occurs after treatment with doxorubicin, cyclophosphamide, and high-dose methotrexate; recovery is age-related. However, these agents in combination with use of adjuvant radiotherapy to the thigh or abdomen may produce permanent testicular injury even in young patients.

[Treatment results of Hodgkin's disease, stages I and II (author's transl)]

The results obtained in the treatment of Hodgkin's disease, stages I and II, are discussed comparing survival data of the literature after various radiotherapy programs and after combined modality using additional chemotherapy. In stage IA 90 to 97% and in stage IIA 75 to 80% of patients are not prone to relapse after extended-field irradiation. In stage IIB 0 to 80% long-lasting remissions are reported after radiotherapy. Additional chemotherapy improved relapse-free survival, but not overall survival in stages I and II. Subgroups are discussed which bear a high risk of relapsing disease (big mediastinal masses, E-lesions of the lungs, histological findings with lymphocyte depletion).

Cyclical combination chemotherapy and thyroid function in patients with advanced Hodgkin's disease

Clinical and biochemical assessment of thyroid function was undertaken in patients with Hodgkin's disease at designated points following diagnosis. At diagnosis, two of 20 patients had either abnormally low routine thyroid indices, or elevated thyroid stimulating hormone (TSH) levels that were not due to iodine-based investigations. Following lymphography, 76.5% of patients had TSH levels that remained elevated for a median period of 3 months. No detectable thyroid dysfunction was induced during chemotherapy. Fifty-four patients were studied at a median time of 35 months after chemotherapy. One euthyroid patient had a nodular goitre, and one had abnormal thyroid indices. Tsh levels were elevated in 44% of patients, although the median TSH level for the group was normal. Half the patients had abnormal TRH stimulation tests. Sixty patients were studied after irradiation and chemotherapy. Four patients had clinical thyroid dysfunction, and 10% of routine thyroid indices were abnormal. TSH levels were abnormal in 80%, with a markedly elevated median level. All thyroid releasing hormone stimulation tests were abnormal.

Thyroid carcinoma after high-dose external radiotherapy for Hodgkin's disease: report of three cases

Three patients (two female and one male), who had received mantle irradiation for Hodgkin's disease eight, ten, and twelve years previously, developed papillary thyroid carcinoma. The radiation doses to the necks overlying the site of thyroid cancers were 3000, 4000, and 4100 rads, respectively. It has been stated that there is no risk of developing thyroid cancer with such high doses of external irradiation but apparently this complication will be encountered in a small number of patients.

Feasibility of Different Combinations of Chemotherapy (6 MOPP) plus Radiotherapy in Hodgkin's Disease

During a preliminary clinical experience (1973-1977) we experimented three different sequences in associating 6 MOPP cycles (CT) with radiotherapy (RT) for the treatment of stage II and III Hodgkin's disease. A total of 55 consecutive previously untreated patients can be estimated to contribute in defining feasibility, immediate results and toxicity of the combined treatment. In this group of patients RT preceded CT in 20 cases (RT-6 MOPP), the opposite sequence (6 MOPP-RT) was preferred in 16 cases, whilst a split-course CT fitting in the RT (3 MOPP-RT-3 MOPP) was employed in 19 cases. Except for the sequence used with respect to irradiation, the CT was carried out in all the cases according to the classical scheme proposed by De Vita et al. (11). RT was effected with 60Co-teletherapy and a wide field or segmental sequential fields, having variable extension depending on the stage (« extended nodal irradiation » for stage II and III cases with lymph node involvement not below L3; « total nodal irradiation » for the remaining cases in stage III). The programmed doses were 45.0 Gy to the involved areas and 40.0 Gy to the clinically uninvolved regions for the RT-6 MOPP and 6 MOPP-RT groups. Doses of 35.0/30.0 Gy were planned for the 3 MOPP-RT-3 MOPP group. The three different groups are not homogeneous with regard to certain important clinical and pathological characteristics; in fact, a higher quota of stage III patients, with systemic symptoms and spleen positivity is present in the 6 MOPP-RT and 3 MOPP-RT-3 MOPP groups. The combined treatment has achieved a complete clinical remission in 18/20 patients in the RT-6 MOPP group (90.0 %), in 12/16 patients of the 6 MOPP-RT group (75.0%), and in 17/19 cases in the 3 MOPP–RT-3 MOPP « sandwich » combination (89.5%). The average overall duration of the treatment was 48 weeks for the sandwich combination, 50 weeks for the RT-6 MOPP group, and 56 weeks for the 6 MOPP-RT association. As regards the sandwich combination, both CT and RT took a reasonable length of time to complete. On the contrary, both the medical treatment and irradiation required an excessively long time and were not well tolerated when preceded by either RT or CT in full doses. In particular, myelosuppression was less acute and prolonged in the 3 MOPP-RT-3 MOPP group, whereas the actual doses of CT and RT were higher than those which can be reached with respect to other groups. Three preliminary cycles of CT considerably reduce the target volumes and complications arising from RT. The first CT time gave an objective response ≥ 50 % in 9/9 cases of the 3 MOPP-RT-3 MOPP group with mediastinal involvement. In this group, rather considerable pulmonary complications were observed in 3/9 patients (33.3 %) with respect to the 40 % found for the 6 MOPP-RT group (2/5 cases) and the 67.7 % for the RT-6 MOPP group (6/9 cases).

Hodgkin's disease

During the past two decades, new approaches to the diagnosis and treatment of Hodgkin's disease have contributed to improved rates of survival and probable cure. Currently, patients with Hodgkin's disease are treated according to the stage and symptoms of their disease. The degree of certainty necessary for determining stage depends on the potential effectiveness of the therapeutic options available in a given case. Certain cases have been identified where treatment with a single modality has been disappointing, and the use of both radiotherapy and chemotherapy may be considered for these. Such decisions can be made only by evaluating the effectiveness of salvage after relapse following single-modality treatment and assessing the added hazards of initial treatment with both modalities.

Hodgkin's disease in children: treatment with low dose radiation and MOPP without staging laparotomy: a preliminary report

Twenty-seven children with previously untreated Hodgkin's disease (CS I-2, II-13, III-3, IV-9) were given three cycles of MOPP to induce a remission which was consolidated with extended field radiation (2000--3500 rad) and three cycles of MOPP. Surgical staging was discontinued. Twenty-five of 27 children have not relapsed (range 15+--64+ months; median 39+ months); two children have died, one of uncontrolled Hodgkin's disease and one of acute infection while in complete remission. Actuarial 3 and 5 year survival rates and relapse-free rates are 91%. The merits of this treatment approach are discussed.

An evaluation of total nodal irradiation as treatment for stage III A Hodgkin's disease

Between April 1969 and December 1974, 37 patients with surgically staged III A Hodgkin's disease were treated with total nodal irradiation (TNI). Their probability of relapse-free survival at 7 years is 51% and overall survival 82% with the majority of patients remaining disease free after retreatment with MOPP (10 of 16). In contrast, 21 stage III B patients treated with TNI and MOPP chemotherapy over the same time period have a relapse-free survival of 74% and overall survival of 91%. Because of superior results in treating stage III B patients with combined modality treatment, we fell that a relapse-free survival of 51% may not justify continuation of TNI as the only modality of treatment for patients with stage III A disease, and we have initiated a trial of combined radiation therapy and MOPP chemotherapy in these patients. The most effective treatment of stage III A Hodgkin's disease, however, remains uncertain and depends both on the ultimate risk of combined modality treatment and the success of retreatment following relapse after radiation.

Hodgkin's disease, stages I and II: relationship of recurrence to size of disease, radiation dose, and number of sites involved

A total of 57 patients with Hodgkin's disease limited to above the diaphragm (Stages I and II, A and B) were treated with radiation therapy alone at the University of Florida between 1964 and 1974. Staging laparotomy was done on 24 patients (42%). A total of 16 patients have relapsed, 4 within the treatment fields, 3 marginally, and 9 as extensions. Analysis of dose vs. size showed no in-field failure with disease less than 6 cm in size, with a range of doses. Massive disease continued to recur occasionally, even with higher doses. Most of the massive disease was mediastinal or hilar; the risk of lung or pleural involvement as determined by x-ray and/or biopsy showed a dramatic increase with size of mediastinal/hilar disease. Only 2 (5%) of 43 patients with mediastinal disease less than 6 cm in size had lung or pleural involvement, compared with 10 (71%) of 14 patients with disease greater than 6 cm in size. Both in-field recurrence and generalized relapse were closely related to the number of anatomical sites involved. Treatment programs need to consider tumor size, particularly in the mediastinum, and the number of sites involved.

Cyclical combination chemotherapy and gonadal function. Retrospective study in males

The effect of cyclical chemotherapy on fertility and gonadal function was investigated in seventy-four male patients who had been treated for advanced Hodgkin's disease. All patients were azoospermic after therapy, and, with a median follow-up period of 27 months (range 1--62 months), only four patients have regained spermatogenesis. Testicular biopsy showed an absence of germinal epithelium without other gross architectural changes. Despite this high degree of infertility, 60% of patients were practising contraception. A decline in libido and sexual performance with frequent long periods of sexual inactivity was noted by most men during therapy. Although some recovery was apparent once therapy was stopped, this was incomplete in approximately half of the patients. Follicle-stimulating-hormone levels were consistently raised after therapy at all periods of study. Median luteinising-hormone levels were at, or just above, the upper limit of normal, and median testosterone levels were normal. Increased prolactin levels were noted in 42% of patients, of whom about a half had an identifiable cause for hyperprolactinaemia. Return of spermatogenesis could not be predicted by serial hormone assessment. Because of the guaranteed infertility and the low frequency and unpredictability of recovery of spermatogenesis, sperm storage should be available for male patients undergoing cytotoxic therapy, since most of these patients may enjoy prolonged survival. Hormone-replacement therapy will usually be unnecessary. However, the probability of major changes in libido and sexual performance should be discussed with patients so that additional stress can be avoided. Contraceptive advice should be available to those who require it.

Complications of treatment encountered in lymphoma-leukemia long-term survivors

Potential posttreatment complications for patients with the lymphomas and leukemia include: 1) impairment of growth and development in children, 2) CNS disturbances encompassing psychologic, intellectual and neurologic expressions, 3) gonadal effects--endocrine, reproductive, teratogenic and genetic, 4) dysfunction of other organs and structures, such as the thyroid, lung and heart and 5) oncogenesis. Many of these adversities are occasioned by radiation therapy, but chemotherapy also can be responsible for some long-term deleterious consequences. The results of combined chemo- and radiaton therapy are becoming better understood, and require further elucidation because earlier stages of the disease are being managed by combined chemo- and radiation therapy regimens.

Pregnancy outcome of patients treated for Hodgkin's disease: a controlled study

Normal reproduction prosepcts for Hodgkin's disease patients are unknown. This study compares the outcome of 93 pregnancies in 48 patients with 228 pregnancies in 69 sibling controls. No statistically significant differences for spontaneous abortions or abnormal offspring were noted comparing all patients with all controls or 35 irradiated patients with all controls. Pregnancy outcome of 13 patients who received both irradiation and chemotherapy prior to pregnancy appeared to be compromised compared to controls. Wives of male patients in this category were more likely to have spontnaeous abortions than wives of male controls; female patients in this category were significantly more likely to produce abnormal offspring than were female controls (p = 0.047). In this series of patients therapeutic irradiation alone did not appear to jeoparadize posttreatment reproduction in fertile Hodgkin's disease patients but in the smaller group of patients who received both irradiation and chemotherapy the reproduction picture was statistically not as good.