Hodgkin's disease in children. A retrospective analysis: 1958-73

Hodgkin's Disease in Children. Pathologic Study of 87 Cases

From 1963 to 1977 at the Istituto Nazionale Tumori at Milan, 112 patients below the age of 16 years with Hodgkin's disease (HD) were observed, representing 13.2 % of all the cases of this disease seen during the stated time interval. Eighty-seven of these cases are the subject of the present study. Fifty-nine patients were males and 28 females (2.1:1 ratio). The age range varied from 2 years 10 months to 15 years 10 months (median 10 years). Forty-three (49.4%) children, of whom 35 were males and 8 females, were below the age of 10 years at the onset of their disease. The clinical staging resulted in 34 patients as stage I, 33 as stage II, 13 as stage III and 7 as stage IV. The histologic type was nodular sclerosis (NS) in 49 cases (56.3 %), lymphocytic predominance (LP) in 15 cases (17.2 %), mixed cellularity (MC) type in 9 cases (10.3 %) and lymphocytic depletion (LD) in 8 cases (9.2 %). In the remaining 6 cases the histologic classification was not applicable. LP type in 15/15 (100 %) patients was associated with stages I and II, and NS in 38/49 (77 %) patients was related to stage I and stage II. The latter was also the istologic type most often encountered in patients with stage II disease (23/33 or 70 %). Eleven patients have died, and their survival varied from 6 to 47 months (median 30 months). The histologic type was LD in 4 cases, NS in 3 cases, MC in 1 case, and LP in 1 case. In the other 2 nonsurvivors, the histologic type was not identifiable. Of the 23 patients with more than a 5-year survival, 14 (60.8 %) had NS HD. As in adults, LP and NS were associated with early stages of the disease and with long survival.

The evolving role of radiation therapy in pediatric Hodgkin's disease

Identifying the optimal treatment of pediatric Hodgkin's disease has been at the forefront of clinical investigation in recent years. Results of a number of large clinical trials have driven paradigm shifts in how physicians approach this often curable disease. In an effort to balance the goals of maximizing survival while minimizing acute toxicities and late complications, the recommended indications, targets, doses and schedules of chemotherapy and radiation have and continue to evolve. Recent attempts to decrease the total volume of tissue receiving radiation without requiring a significant escalation in cytotoxic chemotherapy have shown promise in low, intermediate and high risk patients. Utilizing risk-adapted, response-based treatment, researchers hope to uncover a subpopulation that may not require previously considered standard treatment modalities.

Management and long-term complications of pediatric cancer

The impact of recently intensified and novel therapies for the treatment of childhood cancer has been an increased number of survivors and an increase in the number of treatment complications among survivors. Thus, it is important for the primary care practitioner to be aware of not only acute but chronic complications of therapy, including the possibility of second malignancies. Long-term follow-up is essential, and continuous education of patients and health care personnel is an important aspect for the complete success of treatment. Primary care practitioners also need to incorporate other subspecialties in the management of these patients to ensure that they receive complete evaluation and treatment.

Stage I and II Hodgkin's disease in the pediatric population. Long-term follow-up of patients staged predominantly clinically

Between January 1, 1970, and December 31, 1990, 42 consecutive pediatric patients were treated at the Medical College of Wisconsin Affiliated Hospitals for early-stage Hodgkin's disease. Thirty patients were clinically staged. Twelve underwent staging laparotomy as a part of staging work-up. Thirty-one patients were treated with radiation therapy (RT) alone. Eleven were treated with combined chemotherapy and RT. For the entire group, overall survival at 5, 10, and 15 years was 98, 98, and 92%, respectively. Disease-free survival was 86, 86, and 79, respectively. There was no significant difference in overall survival or disease-free survival comparing clinically versus pathologically staged patients. There was a trend toward improved disease-free survival favoring pathologically staged patients; however, this difference did not reach statistical significance (p = 0.07). The long-term results of this series fail to show statistically significant superior disease-free or overall survival with surgical staging.

MR imaging of infradiaphragmatic lymphadenopathy in children and adolescents with Hodgkin disease: comparison with lymphography and CT

The ability of short-inversion-time inversion recovery (STIR) magnetic resonance imaging to depict infradiaphragmatic lymphadenopathy was evaluated in 25 consecutive patients with newly diagnosed Hodgkin disease. All patients underwent computed tomography (CT) and multiplanar STIR imaging prior to lymphography (LAG). The STIR and CT images were evaluated for paraaortic and parailiac node enlargement. Findings were compared with LAG findings, which showed the architectural pattern of the opacified lymph nodes. In the upper paraaortic region, STIR imaging showed more abnormal nodes than did CT or LAG. In the lower paraaortic and parailiac regions, lymph node enlargement was shown equally well with STIR and LAG, whereas CT showed fewer enlarged lymph nodes. LAG showed paraaortic or parailiac focal tumor infiltration in three patients with normal-size nodes, and hyperplasia in two patients with enlarged nodes. STIR imaging showed more abnormal infradiaphragmatic nodes than did CT because of improved lymph node conspicuity. STIR imaging may be a useful addition to CT for staging pediatric Hodgkin disease.

Hodgkin's disease in children 4 years of age or younger

The natural history of Hodgkin's disease in children younger than 4 years of age is unknown. Thirty-eight patients younger than 4 years of age at the time of diagnosis of Hodgkin's disease were treated at the member institutions of the Pediatric Oncology Group. They were found to be predominantly white and male with early-stage disease. Mixed cellularity and nodular sclerosing histologies were most commonly seen and occurred in equal frequency. They responded to therapy extremely well attaining a complete remission rate of 92% to 94%. Even after relapse, they can be successfully retrieved with salvaging therapy.

The 'urn' portal; an alternative to the 'mantle' portal in the chemoradiotherapy management of paediatric Hodgkin's disease

The experience of St Bartholomew's Hospital with a less than full mantle radiation field in the treatment of 31 children with clinically staged Hodgkin's disease is reported over a ten year period (1977-1987). The major indication for this portal was initial bulk, or residual disease after chemotherapy. Primary treatment consisted of radiotherapy alone (two children) or in combination with chemotherapy (29 children). An 'Urn' radiation portal has been used to encompass mediastinal and neck nodes, but with the aim of reducing radiation doses to lung, breast, axilla, lateral end of clavicle and humeral head. More recently, a further modification has employed partial heart shielding when anthracyclines have been part of the chemotherapy schedule. The majority have received 35 Gy in 20 fractions over 4 weeks with 4-6 Mv photons, and no child received in excess of 35 Gy to the mediastinum. An overall 5-year actuarial survival of 85% was achieved, and a 5-year relapse-free survival of 77%. Seven relapses and five deaths have been reported, all of which occurred in children who presented with nodular sclerosing histology. Six children relapsed within the radiation portals, and one with systemic disease alone. Only a single child relapsed in the unirradiated axilla, and this simultaneously with cervical, mediastinal and paraortic nodes. To date no second malignancies have been reported.

Hodgkin's disease in childhood: the British National Lymphoma Investigation experience (BNLI Report No 27)

The experience of the British National Lymphoma Investigation in the treatment of 68 children with Hodgkin's disease is reported over a 14 year period from 1970. The presenting histology was reviewed by a single histopathologist; 87% of the cases were classified as nodular sclerosis (NS) and further subdivided into NSI (53%) and NSII (35%). Primary treatment consisted of local (involved field) or prophylactic (extended field) irradiation, combination chemotherapy alone or low dose irradiation and chemotherapy. An overall 5 year survival of 87% was achieved and a 5 year relapse-free survival of 64%. Eight deaths were reported during the study, all of which occurred in children who presented with NSII histology. Each child was in relapse and undergoing chemotherapy at the time of death. This histological subtype was also associated with both a lower complete remission rate and a reduced response to second line chemotherapy.

Hodgkin's disease in children in Kuwait

Between 1968 and 1981, 78 children younger than age 15 years were diagnosed, staged, treated, and followed up for a minimum period of 2 years. Most cases (64%) were in their first decade and the male-to-female ratio was 1.9:1. Mixed cellularity type occurred in 49% and nodular sclerosis in 32%. Lymphocytic depletion type was rare and occurred in only 4% of the cases. More than one half (53%) had Stages III and IV at presentation. The mediastinum was involved in 38%. The treatment of Stages I and II was mainly by radiotherapy, and Stages III and IV by combination of radiotherapy and chemotherapy. The total survival was 75% and relapse-free survival was 53%. Since 1975, lymphography became a routine investigation and staging laparotomy was performed in selected case. The mantle field was extended to include the para-aortic bar and spleen in Stage II with enlarged mediastinum, Stage IIIs after laparotomy, and cases in which laparotomy was thought to be indicated but was not performed. The new policy resulted in marked improvement in survival (from 56% to 87%) and relapse-free survival (from 32% to 70%). The stage at presentation was the main prognostic factor, although in the second period of the study, the difference between Stage I and II disappeared.

Malignant lymphomas in children and adolescents

Malignant lymphomas constitute the third most common group of childhood cancers in the United States. Hodgkin's disease (HD) exhibits a bimodal age peak, with the first peak occurring in the 15-34-year age group. Nodular sclerosis is the most common histologic subtype of HD seen in children. The disease tends to be primarily supradiaphragmatic at presentation. Accurate staging is essential for determination of appropriate therapy. Staging laparotomy with splenectomy is indicated for those patients with clinically localized disease whose therapy may be altered by pathologic staging. Radiation therapy is curative in the great majority of patients with localized disease. Multimodality therapy has been employed with increasing success in patients with advanced disease. The late sequelae of therapy must be considered in the design of optimum therapeutic regimens. More than 90% of non-Hodgkin's lymphoma (NHL) in childhood can be grouped into one of three histologic subtypes: lymphoblastic, undifferentiated, and diffuse large cell type. Lymphoblastic lymphomas most commonly present with mediastinal involvement. The majority of nonlymphoblastic lymphomas arise within the abdomen. Because of the tendency of NHL for extralymphatic dissemination, systemic therapy is always required. Treatment is determined by stage and histology. Significant improvements in survival rates have resulted from the development of effective combination chemotherapy programs. Cure rates in excess of 90% can be expected in children with localized disease. The outlook for children with advanced disease of undifferentiated histology remains poor. The presence of central nervous system involvement at diagnosis is a particularly ominous sign.

The incidence of herpes zoster in patients with Hodgkin's disease. An analysis of prognostic factors

The incidence of zoster in 717 patients with Hodgkin's disease was determined by a retrospective chart review. All patients had been treated and followed in one of six cancer centers. Prognostic factors that might predict the subsequent incidence of zoster were examined by univariate and multivariate analytic techniques. Intensity of treatment was a key factor in the incidence of zoster. Thirty-six months after initiation of treatment, patients receiving chemotherapy-radiation-chemotherapy had twice the attack rate (27.3%) of those receiving radiation alone (11.5%). The pediatric age group had a significantly higher attack rate (26.6%) than did adults (18.7%). Stage, histology, and laparotomy did not influence the incidence of zoster.

An evaluation of long-term survival and treatment complications in children with Hodgkin's disease

Between April 1969 and July 1977, 83 patients, 16 years or younger, with pathologically staged IA-IIIB Hodgkin's disease were seen and treated at the Joint Center for Radiation Therapy. The five-year actuarial relapse-free and overall survivals were 82 and 95%, respectively, with a median follow-up from diagnosis of 65 months. Relapse occurred in 6/50 Stage IA-IIA, 2/9 Stage IIB, 4/9 Stage IIIA, and 3/15 Stage IIIB patients. Of patients who relapsed, 11/15 are currently disease-free following retreatment with chemotherapy. Nine patients with Stage IV disease were also evaluated. Four of seven patients initially treated with chemotherapy remain free of disease. Forty-two patients in this study were treated with mantle and para-aortic irradiation alone, thus avoiding the risk of sterility associated with pelvic irradiation or MOPP chemotherapy while retaining a high probability for long-term disease-free survival. Complications of radiation therapy included growth retardation and thyroid function abnormalities in some patients. Standing height measurements were normal regardless of age at initial treatment, however, 16 of 23 patients 3-12 years old at initial treatment had sitting heights measuring more than one standard deviation below the mean. Intraclavicular distances were shortened in some patients and examples are shown. Thyroid stimulating hormone levels were elevated in 21 of 37 patients evaluated. Radiation therapy, without adjuvant chemotherapy remains an important treatment approach for children with early stage Hodgkin's disease.

Hodgkin's disease and non-Hodgkin's lymphoma in children and young adults: a clinicopathologic study of 127 cases

One hundred twenty-seven cases of non-Hodgkin's lymphoma and Hodgkin's disease in children and young adults at the University of Wisconsin Hospital between 1969 and 1980 have been reviewed. Nodular sclerosing was the most frequent histologic type in patients with Hodgkin's disease. Malignant lymphoblastic lymphoma (MLLB) was the most common type of non-Hodgkin's lymphoma. The relationship of the histological pattern to age and sex as well as clinical behavior and survival are discussed.

Hodgkin's disease in children: seventeen years experience at the Instituto Português de Oncologia de Francisco Gentil

The experience of 52 children with Hodgkin's disease was reviewed. Compared with Hodgkin's disease in adults there was an increased incidence among boys. Mixed cellularity (MC) was the most common histologic type (60.5% in boys, and 64.4% in girls) as was also observed in adults (61.1% in men and 63.0% in women). The methods of therapy consisted of three main groups: extended-field radiotherapy (EFRT) + MOPP; involved-field radiotherapy (IVRT) + MOPP, 44.4% for IVRT + Monochemotherapy, and 80% for EFRT alone. The progressive improvement in results was associated with the change from IVRT to EFRT and the introduction of multiagent chemotherapy.

Management of neoplasms of the head and neck in children. II. Malignant tumors

The otolaryngologist who treats children must have knowledge of the neoplasms that can occur in childhood. Such tumors are usually mesenchymal in origin and may be benign or malignant. Diagnosis and management of the more common benign tumors are undertaken by the otolaryngologist because local excision is generally curative. The proper treatment of malignant lesions requires a more extensive, multidisciplinary team, which includes a pediatric oncologist, diagnostic and therapeutic radiologist, and pathologist, in addition to the otolaryngologist. This article outlines the types of malignant neoplasms that occur in childhood and discusses current approaches to therapy.

Lymphoreticular disorders in primary immunodeficiencies: new findings based on an up-to-date histologic classification of 35 cases

A histologic review was undertaken of 35 lymphoreticular disorders that developed in primary immuno-deficiency patients from the Immunodeficiency Cancer Registry. Twenty-one (60%) of the lesions were non-Hodgkin's lymphomas: these included eight B-immunoblastic sarcomas. Eight (23%) of the lesions were Hodgkin's disease, with a high frequency of lymphocytic depletion type in an unusually young age group. Three lesions (8.5%) represented abnormal proliferative processes, which could not be definitely categorized as either benign or malignant. There were only two acute lymphoblastic leukemias (6%). Differences were found between lymphomas arising in Wiskott-Aldrich syndrome and those occurring in ataxia-telangiectasia; this suggests that different pathogenetic mechanisms might operate in their development. The lymphomas in Wiskott-Aldrich syndrome were all of non-Hodgkin's type, predominantly B-immunoblastic sarcomas, and presented as localized extranodal infiltrates. The lymphomas in ataxia-telangiectasia were either Hodgkin's disease, mostly of lymphocytic depletion type, or non-Hodgkin's lymphomas of the histologic subtypes associated with 14q translocations.

Management of stages I to III Hodgkin disease in children

Thirty-seven children, ages 4 through 16 years, presented with clinical stages I, II, or III Hodgkin disease. In nine (24%) patients, laparotomy and splenectomy resulted in a pathologic stage that varied from the clinical stage. Of 36 patients with pathologic stages I, II, and III, 26 have been followed for more than two years from diagnosis. Pathologic stages I and IIA disease were found in 21 patients, and 19 received radiation therapy alone (usually mantle-field), with 90% disease-free survival and 95% overall survival (median follow-up 46 months). Five patients had stage IIB disease; two had progression of disease while received combined modality therapy. Of ten patients with stage III disease, five have had relapses and five have remained in complete remission. All relapses occurred in patients receiving either irradiation or chemotherapy but not both. This experience supports extended-field irradiation alone as adequate treatment for stages 1 and IIA Hodgkin disease in children, but suggests that for stages IIB and III, single modality treatment is not adequate.

Serum immunoglobulin levels in childhood Hodgkin's disease. Effect of splenectomy and long-term follow-up

Children with Hodgkin's disease had significantly elevated serum IgG and IgA levels but normal IgM and IgD levels when compared with healthy age- and sex-matched controls. The increased serum IgG and IgA levels occurred in all four clinical stages of Hodgkin's disease but were not related to histologic cell type. Following staging splenectomy, serum IgG, IgA, and IgD levels fell by 20% in patients who recieved radiation therapy then returned to preoperative levels; by contrast, serum IgM levels fell by 50% and remained there for at least 36 months. Patients who received chemotherapy had a persistent decline in serum levels of all immunoglobulin classes by at least 40%. Thus, staging splenectomy per se appears to be at least partly responsible for the postoperative decline in serum IgM levels and this effect is enchanced by aggressive treatment of the Hodgkin's disease.

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.

The incidence of post-splenectomy sepsis and herpes zoster in children and adolescents with Hodgkin disease

The occurrence of sepsis due to Streptococcus pneumoniae and Hemophilus influenza and of herpes zoster (HZ) was reviewed in a series of 72 consecutive, previously untreated children and adolescents with Hodgkin disease. There was not a statistically significant difference in the risk of developing sepsis within five years of diagnosis between patients who had (16.6%) or had not (6.2%) undergone splenectomy. Sepsis occurred most frequently among patients treated initially with total nodal irradiation and combination chemotherapy. The estimated risk of HZ during the first five years after diagnosis was 34%. Patients treated initially with irradiation and combination chemotherapy had a significantly greater risk of developing HZ than patients treated initially with only irradiation (P less than 0.05). Although trends were present which suggested that splenectomy and the extent of disease at diagnosis may influence the occurrence of HZ, these did not achieve statistical significance. Survival was not influenced by the occurrence of HZ.

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.

MVPP chemotherapy combined with radiotherapy in the treatment of Hodgkin's disease in children

Thirty-four children with Hodgkin's disease were treated during the years 1969--75. After radiotherapy, 7--15 cycles of MVPP were given within 24--53 months. In order to avoid chronic leukopenia, leukocyte counts were made frequently during chemotherapy, and the drug doses adjusted accordingly. A complete remission was obtained in 32 of the 34 children. Two patients died because of progressive disease. Twelve of the 32 survivors have been followed for at least 5 years, and a further 12 for at least 3 years. Three children are still on chemotherapy, whereas the remaining 29 being followed are in continued complete remission.

Combination chemotherapy and radiotherapy for Hodgkin's disease in children

31 children with Hodgkin's disease were treated at the Children's Hospital, University of Munich, between 1963-1976. Before 1971 the diagnosis of abdominal involvement was based solely on physical findings and radiological studies. Treatment consisted of involved-field radiation; chemotherapy was added in selected cases. Of 15 children treated between 1963-1971, 5 are still in their first remission and 2 in their second remission. Since 1971 exploratory laparotomy and splenectomy have been performed. Radiation therapy was changed from involved- to extended-field therapy and combination chemotherapy was added in all the children. No patient from this group of 16 children relapsed during a median observation time of 24 months (range 12-55 months). The toxicity of the combined treatment does not seem to be prohibitive.

The team approach to the management of pediatric cancer

The last 20 years have witnessed remarkable improvements in the prognosis of children with many forms of malignant disease. The reasons for these improvements relate not only to the development of better drugs and more effective radiotherapy, but also to the multidisciplinary approach involving surgeon, chemotherapist, radiotherapist and immunotherapist in providing optimum treatment for the child with a particular cancer. In this paper, the changing role of the pediatric oncologist, surgeon and radiotherapist in improving the management of pediatric cancer is discussed.

Hodgkin's disease in children

Fifty-nine children with Hodgkin's disease were seen over a 34-year period. Compared with Hodgkin's disease in adults, there was an increased male incidence, especially in the younger children. This was associated with an increased male incidence of lymphocyte-predominant histology. Forty-six patients underwent lymphography as part of their staging, and 13 had staging laparotomies. The 5-year survival for the entire group was 85%, with a median survival of 10 years. Response to radiotherapy in children with Stages I-IIIA disease was: 12 children treated with involved-field radiotherapy after inadequate clinical staging had a 3-year remission rate of 13%, and a median length of remission of 18 months; 24 children treated with extended-field radiotherapy after adequate clinical staging, including lymphography, had a 3-year remission rate of 72%, and a median duration of remission not yet reached; 3 children treated with elective local radiotherapy for Stage IA disease after intensive clinical staging remain in complete remission for periods of up to 34 months. Eight out of 10 children with Stages IIIB-IV disease, treated with combination chemotherapy, achieved complete remission with a 3-year remission rate of 70%; 7 children treated with combination chemotherapy following relapse after radiotherapy all achieved complete remission with a 3-year complete remission rate of 66%. Thirteen children underwent laparotomy and splenectomy as a staging procedure. Five were found to have intra-abdominal disease, including 4 with splenic involvement. These results show that there is no place for involved-field radiotherapy after inadequate clinical staging, in the management of childhood Hodgkin's disease. Extended-field radiotherapy after adequate staging, and combination chemotherapy, produce results which are as good as those for adults, but the benefits of these treatments and of staging laparotomy must be balanced against the possible complications when they are used in children. These problems are discussed and a scheme of management is proposed.

Stages I--III Hodgkin's disease in children: results of staging and treatment

Fifty-two children with clinical stages I-III Hodgkin's disease were evaluated for disease extent between April 1969 and March 1975. All underwent laparotomy and splenectomy. Two patients with liver involvement were excluded. Thirty of 31 patients with pathologically staged IA-IIA disease have been continuous complete remission after mantle and para-aortic irradiation. There have been no extensions into the untreated pelvis. Fourteen of 15 patients with pathologic stages IIB and IIIB disease show no evidence of relapse after TNI and MOPP. Three of four patients with stage IIIA disease developed nodal relapse after irradiation; all are alive without evidence of disease after re-irradiation (3) and MOPP (2). Thus 45 of 50 patients (90%) have remained continuously free of disease after completion of the planned treatment, and overall 49 of 50 (98%) are alive, without evidence of disease. Such results justify continuation of our staging and treatment philosophy in children with Hodgkin's disease.

Pediatric Hodgkin's disease. I. Radiographic evaluation

The pretreatment roentgenographic evaluation of 105 consecutive patients less than 16 years of age with Hodgkin's disease was reviewed. The patients were divided into groups aged 1-10 years (37%) and 11-15 years (63%). All patients had chest roentgenograms, of which 36% were abnormal in the younger group and 77% abnormal in the older group. Full-lung tomography was helpful only when the chest film was abnormal or equivocal. Foot lymphography was performed in 103 patients with 20% positive for Hodgkin's disease. Lymphographic-histologic correlation was 98% in the 62 patients undergoing laparotomy. Routine skeletal surveys, as well as examinations of the urinary tract and gastrointestinal tract, were not rewarding.

Involved field radiation therapy for early stage Hodgkin's disease in children: preliminary results

Twenty Stage I and II children with Hodgkin's disease were treated with involved field radiation therapy. Twelve patients were Stage I. The histologic types were:nodular sclerosis(seven cases), mixed cellularity (two) and lymphocyte predominant (three). There were eight Stage II patients (six nodular sclerosis and two of mixed cellularity). One Stage I and 4 Stage II patients had class B disease. Involved field irradiation was used in these children after staging laparotomy showed no disease below the diaphragm. Eight of the 20 patients relapsed, five in lymph nodes adjacent to the primary site, two in areas across the diaphragm; the other had both local and distant extension. The median time to relapse after completion of radiation therapy for Stage I and II were 15 and 5 months, respectively. Two of the eight children with recurrent disease are dead. The other six were retreated and are alive and free of disease for periods ranging from 24 to 68 months after original treatment (median, 36 months). Two of the six survivors in this group received irradiation to the site of the recurrent disease only, one was given total nodal irradiation, and three had chemotherapy. The other 12 patients are in continuous first remission. They have been followed for a median time of 26 months. The actuarial relapse-free survival and survival rates at 3 years are 57 and 89%, respectively.