Survival and complications of radiotherapy following involved and extended field therapy of Hodgkin's disease, stages I and II. A collaborative study

Treatment of Early Stage Hodgkin's Disease with Radiation Therapy plus Short-Cycle (3 MOPP) Adjuvant Chemotherapy

Eighty-four consecutive, previously untreated patients with stage I, II A-B and IIIA Hodgkin's disease were treated with combined modality therapy including subtotal or total nodal irradiation, followed by three cycles of MOPP. MOPP was administered before radiotherapy in patients with systemic symptoms or with bulky disease. Seventy-six of 84 patients (90.5%) achieved complete remission, and 8 died from disease progression after a variable period of incomplete remission. Three of 76 (3.9%) relapsed, and 2 of them have been subsequently salvaged. Up to the present time, 70 patients are alive, without evidence of disease; 9 have died from Hodgkin's disease, 2 from acute non-lymphoblastic leukemia, and 3 from inter-current causes. No death occurred from acute toxicity due to chemotherapy. Actuarial overall survival is 82.3% and freedom from relapse is 81.8% after 48 months’ median observation (range: 12–111 months). No significant difference in survival and freedom from relapse has been observed with respect to age, sex, stage, presence or absence of unfavorable prognostic factors. The role of adjuvant chemotherapy and its use in a reduced number of cycles in early stage Hodgkin's disease are discussed.

The impact of protocol assignment for older adolescents with hodgkin lymphoma

BACKGROUND AND PURPOSE

Hodgkin lymphoma (HL) treatment has evolved to reduce or avoid radiotherapy (RT) dose and volume and minimize the potential for late effects. Some older adolescents are treated on adult protocols. The purpose of this study is to examine the protocol assignment of older adolescents and its impact on radiation dose to relevant thoracic structures.

MATERIALS AND METHODS

Cooperative group data were reviewed and 12 adolescents were randomly selected from a pediatric HL protocol. Treatment plans were generated per one pediatric and two adult protocols. Dose volume histograms for heart, lung, and breast allowed comparison of radiation dose to these sites across these three protocols.

RESULTS

A total of 15.2% of adolescents were treated on adult HL protocols and received significantly higher radiation dosage to heart and lung compared to pediatric HL protocols. Adolescents treated on either pediatric or adult protocols received similar RT dose to breast.

CONCLUSION

Older adolescents treated on adult HL protocols received higher RT dose to thoracic structures except breast. Level of nodal involvement may impact overall RT dose to breast. The impact of varying field design and RT dose on survival, local, and late effects needs further study for this vulnerable age group. Adolescents, young adults, Hodgkin lymphoma, RT, clinical trials.

Coronary heart disease--a possible risk in megavoltage therapy?

A 21-year old man died of an extensive anteroseptal myocardial infarction 16 months after receiving megavoltage radiotherapy to a mantle field for Hodgkin's disease stage PS IA confined to the midcervical lymph nodes on the left side of the neck. Post mortem findings revealed severe atherosclerotic changes in the coronary arteries. This case and a review of the literature suggest that irradiation to the heart may induce or accelerate atherosclerosis of the epicardial vessels. This should be taken into consideration when starting prophylactic irradiation to the mantle field in patients with Hodgkin's disease stage IA without obvious involvement of the mediastinun. Histologic examination of the heart and coronary vessels should be performed in any fatal case after megavoltage therapy involving the heart.

Hodgkin's disease: historical perspective and clinical presentation

In conclusion, emphasis has shifted from a progressive increase in the weight of treatment to the reduction of management aggressiveness for some subsets of patients by taking advantage of clinical presentation and risk factors. The first period was based on the philosophy that extensive work-up can help to minimize treatment. The goal has become to avoid unnecessary invasive techniques. With better knowledge of the late effects and causes of death, there is now a consensus that management should be modulated according to the individual characteristics of the patient. The aim of further studies will be to progress in the identification of the various subsets of HD and to introduce new therapeutic modalities as effective but less toxic than the present ones. This approach requires for each subset of patients a rigorous assessment of the long-term cost and benefit of the various therapeutic modalities used for treatment of HD.

Radiotoxic model for three-dimensional treatment planning. Part 1: Theoretical basis

Since recent treatment planning systems calculate volumetric dose distribution, an objective evaluation of potential toxicity in the main critical organs may be helpful in treatment optimization. Modeling the toxicity of radiotherapy must at least account for: (a) specific risks in every critical organ; (b) total dose and dose per fraction; (c) partial irradiation of critical organs; (d) heterogeneous dose distribution. The Radiation Damage Factor formula is aimed at estimating the delayed toxicity of a given treatment plan on every critical organ concerned. The formulation uses a double exponential function: RDF = 100 e-Ke-(a+bd)DVc, where: D is the total dose, and d the dose per fraction; a and b are coefficients representing the radiosensitivity of the critical organ, according to the linear-quadratic model, with a/b = alpha/beta. K represents the theoretical critical unit content of the organ, these critical units being groups of functionally related stem cells. The avoidance of a complication depends on the ability of surviving critical units to preserve organ function. V is the ratio:irradiated volume/total volume of the organ. Exponent c accounts for tissue organization: c is equal to or near 1 in "parallel organs" like the liver or the lung, where localized hot spots are tolerated; c is lower in "series organs" like the spinal cord where hot spots, even in a small portion, are dangerous. Heterogeneous irradiation, summarized by dose cumulative-volume histograms, is accounted for by calculating step by step the dose D' considered as having an equivalent effect when given in the largest irradiated volume ratio. Preliminary calibration of the RDF formula is attempted for radiation myelitis and radiation hepatitis.

Radiation therapy in clinical stage I and II Hodgkin's disease. The Princess Margaret Hospital Lymphoma Group

A review of the Princess Margaret Hospital experience over the last 20 years in treating clinically staged patients with stage I and II Hodgkin's disease was performed to analyse the impact of patient selection and extended field radiation on relapse and survival. Of the 878 patients with stage I and II Hodgkin's disease, 521 with clinical stages I and II received radiation alone as the initial treatment. The actuarial survival for all stage I and II patients was 85.1% at 5 years and 76.2% at 10 years, and for clinically staged patients treated with radiation alone, 87.2 and 77.6%, respectively. The relapse-free rate (RFR) for all clinical stage I and II patients treated with radiotherapy (RT) alone was 70.1% at 5 years and 65.8% at 10 years. Significant prognostic factors for RFR and survival included age, stage and histology. In addition, the extent of radiation was identified as an independent prognostic factor for survival as well as for relapse. The RFR for those treated with involved field RT was 58.4% at 5 years and 50.5% at 10 years; for patients treated with mantle RT, 69.9 and 65.6%, and those treated with extended field RT 77.4 and 75.8%, respectively. In a highly selected group of patients with no adverse features, i.e. with stages IA-IIA, lymphocyte predominant or nodular sclerosis histology, erythrocyte sedimentation rate < 40, age < 50, no large mediastinal mass, and no E-lesions--the policy of mantle RT (M) and extended field RT (EF) produced comparable 5-year relapse-free rates (M, 84.9%; EF, 87.1%; P = 0.53). We conclude that a policy of treatment selection based upon clinicopathological prognostic factors and the use of extended field RT confers excellent results in the treatment of clinical stage I and II Hodgkin's disease.

On the significance of Lhermitte's sign in oncology

We present three cases of Lhermitte's sign out of twenty consecutive cases of epidural spinal cord compression due to metastatic cancer. The three patients were diagnosed with epidural thoracic compressions. The literature on Lhermitte's sign is reviewed with emphasis on the differential diagnosis of this symptom in oncological patients.

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.

The intergroup Hodgkin's disease in children. A study of stages I and II

A total of 228 previously untreated and eligible children with pathologic Stage I or II Hodgkin's disease were registered in the Intergroup Study of Hodgkin's Disease in Children between February 1977 and April 1981. Patients were randomized in the Southwest Oncology Group (later the Pediatric Oncology Group [POG] to involved-field (IF) radiotherapy alone or IF radiotherapy followed by six courses of mechlorethamine, vincristine, prednisone, and procarbazine (MOPP) chemotherapy; patients in the Children's Cancer Study Group (CCSG) and Cancer and Leukemia Group B (CALGB) were randomized to receive extended-field (EF) radiotherapy or IF radiotherapy followed by six courses of MOPP. An estimated 97% of patients receiving IF + MOPP were relapse-free and surviving (RFS) at 5 years, which was significantly better than 41% for patients receiving IF alone; however there was essentially no overall difference in survival experience between groups. Patients in CCSG and CALGB receiving IF + MOPP had significantly superior RFS at 5 years than patients receiving EF. Survival rate was not different between these two groups, an estimated 93% of patients surviving 5 years or longer. Although patients were not randomized between IF or EF radiotherapy, they were similar with respect to patient characteristics. There was some statistical evidence that RFS was superior at 5 years for patients receiving EF than for IF; however, there was no evidence of a difference in survival experience. The percentages of patients with late effects of therapy were not significantly different by treatment. The most common types of late effects were endocrine dysfunction and impaired resistance to infection. Overall, the response rate to therapy for relapse patients was good, being 83% among all patients who relapsed. Patient characteristics related to poor prognosis were the presence of constitutional (B) symptoms (fever, night sweats, and weight loss) and poor performance status.

Treatment of stages I and II Hodgkin's disease with three different therapeutic modalities

Since 1969, 184 previously untreated and evaluable adult patients with Hodgkin's disease, staged as I (43) or II (141), have been treated. Eighty patients were part of the National Hodgkin's Disease Study, randomly assigned to receive radiotherapy to either an involved (39) or extended field (41). In a subsequent single-arm study, 104 patients were treated with involved-field radiotherapy preceded and followed by three cycles of MOPP chemotherapy. Median durations of follow-up have been 172, 172, and 92 months, for the involved-field radiotherapy, extended-field radiotherapy, and MOPP plus involved-field radiotherapy treatment groups, respectively. Although significant differences among the three treatment groups were observed with respect to disease-free survival (p less than 0.001), only the group of patients treated with involved-field radiotherapy had a statistically significant decline in overall survival as compared with the two other treatment groups (p less than 0.001). Moreover, patients who underwent clinical staging and were treated with MOPP plus involved-field radiotherapy had significantly prolonged disease-free survival compared with those who underwent surgical staging and were treated with extended-field radiotherapy (p less than 0.001). One of the patients who received MOPP plus involved-field radiotherapy had subsequent development of acute monocytic leukemia, and another had refractory anemia with excess blasts. One instance of diffuse poorly differentiated lymphocytic lymphoma was also observed. Acute monocytic leukemia developed in another patient treated with involved-field radiotherapy. The rates of amenorrhea in the group treated with MOPP plus involved-field radio-therapy were 9.6 percent and 78.5 percent for female patients younger and older than 30 years of age, respectively. Despite the universal azoospermia ensuing after MOPP plus involved-field radiotherapy, in three patients whose sperm counts were checked sequentially for 26 to 53 months after treatment, evidence of spermatogenesis was observed. Three patients with remission of Hodgkin's disease after involved-field (two) and extended-field (one) radiotherapy died from cardiovascular disease that could only be attributed to the prior radiotherapy. Although further follow-up evaluation will be required to determine the impact of the three different treatment modalities on survival and long-term toxicity, MOPP plus involved-field radiotherapy appears to be superior to involved-field or extended-field radiotherapy alone in achieving prolonged disease-free survival without significant leukemogenic potential.

MOPP chemotherapy plus irradiation for Hodgkin's disease, stages IA to IIIB. Long-term results of the prospective trial H72 (1972-1976, 334 patients)

From April 1972 to December 1976, 334 patients with Hodgkin's disease, CS IA-IIIB, were prospectively treated with combined chemotherapy and radiation. The 166 stages IA and II2A were clinically staged only; the 168 other patients were randomized to clinical or pathological staging. All patients received 3 or 6 cycles of MOPP followed by Mantle field with or without mediastinal irradiation and/or inverted Y or lumbo-aortic field according to initial stage, presentation and protocol. At completion of therapy, 317 patients were in complete remission. Twenty-six patients relapsed and 43 died including 5 with leukemia and 6 with infection. Overall 12-year survival and relapse-free rates are 86.6 +/- 3.08 per cent and 91.5 +/- 3.2 per cent respectively (IA: 95.3 and 95.3 per cent; IIA: 87.8 and 92.1 per cent; IIIA: 83.3 and 100 per cent; IB, IIB: 81.7 and 89.2 per cent; IIIB: 67.8 and 73.7 per cent). The randomized comparison between clinical staging plus 6 cycles of MOPP and laparotomy staging plus 3 cycles of MOPP in final stage II3+A, IB, IIB patients showed no significant 12-year survival differences (90.8 versus 85.6 per cent). With this combined modality treatment policy, high survival rates are obtained using only 3 cycles of MOPP and radiotherapy in CS IA, II2A and in PS II3+, IB, IIB. Laparotomy staging may be unnecessary if 6 cycles of MOPP are employed before irradiation in CS IIA, IB, IIB disease and if 3 cycles of MOPP are followed by irradiation in CSIA and II2A disease. Mediastinal irradiation can be avoided in patients with supradiaphragmatic disease without mediastinal involvement.

Radiotherapy of stage I and II Hodgkin's disease. A collaborative study

Four hundred sixty patients enrolled in a randomized trial of involved field (IF) and extended field (EF) radiotherapy for Hodgkin's disease Stages I and II in the years 1967 to 1973 have been followed to a maximum of 13 years. Minimum time at risk is 6 years, and median follow-up is 8 years. Actuarial survivals are 85% IF and 87% EF at 5 years. The overall standardized risk ratio comparing IF with EF is 1.3, implying a 30% excess mortality in IF, a nonsignificant difference. For males the risk ratio is 1.7 and significant, whereas for females it is 0.6, a nonsignificant reduction in risk with IF therapy. Extension-free survival was significantly better in the EF group than in the IF within 2 years after treatment, and that benefit persists to the current follow-up, with extension-free survivals of 42% IF and 64% EF at 5 years. The risk ratio is 1.7. Favorable survival is significantly correlated with initial characteristics of female sex, age younger than 40 years, and histologic type nodular sclerosis or lymphocyte predominance. Histologic type is the most powerful predictor in the total series, but its prognostic value is not seen in patients staged with laparotomy. Six cases of leukemia have been reported in this series, among whom less than one case would be expected at general population rates. All leukemias have occurred in 167 patients who required chemotherapy for extension of Hodgkin's disease after initial radiotherapy, implying an increased risk following chemotherapy of more than 200-fold.

Involved field (IF) irradiation with or without chemotherapy in the management of children with Hodgkin's disease

The present policy at Memorial Sloan Kettering Cancer Center (MSKCC) of treating children with Hodgkin's disease [HD] is as follows: involved field (IF) irradiation only (3,600 rad) for Stages IA and IIA; IF irradiation (2,400 or 2,000 rad) combined with multidrug chemotherapy (MDP) protocol for all other stages. A somewhat higher recurrence rate is accepted for Stages IA and IIA in view of the good salvage rate for these recurrences and in view of side effects of more aggressive types of radiation treatment. One hundred forty-two patients with HD, 2-19 years of age, were treated at MSKCC between 1970 and 1981; 98 of these were treated according to the present policy (SP group), and 44 (NP group) were treated differently. All SP patients underwent staging laparotomy. The follow-up time was 12 to 146 months with a median of 65 months; two patients were lost to follow-up. For the SP group, all stages, 10-year disease-free survival is 77%, and 10-year survival is 93%. By comparison, in the NP group 10-year disease-free survival is 64%, and 10-year survival is 80%. The disease-free survival of SP patients in Stages IA and IIA treated with IF radiation alone is 72%, and survival is 95%. The disease-free survival of SP patients in advanced stages treated with combined radiation and chemotherapy is 87%; the salvage rate of recurrent disease in these stages is poor. The survival was apparently better (P = 0.07) in the SP group as compared to the NP group. All 6 patients of the SP group who died had a nodular sclerosing type of HD. None of the patients in the SP group have developed secondary malignancies, and no severe bone growth retardations or late effects to other organs were observed. In our opinion, IF irradiation alone might at present be suitable treatment for children in Stages IA and IIA of Hodgkin's disease, and addition of IF radiation with low doses of MPD improves the survival of patients in advanced stages.

Treatment of patients with stages I and II nonmediastinal Hodgkin's disease

In this study, 95 patients with laparotomy-staged I and II nonmediastinal Hodgkin's disease were treated with involved fields (41 patients), mantle (17), extended fields (26), or involved fields followed by 6 cycles of MOPP (11). Eighty-five patients had upper torso presentations. Seventy had Stage I disease and 25 had stage II. Pathologic findings were nodular sclerosing, 33; mixed cellularity, 41; lymphocyte predominance, 20; and unclassified, one. Five-year overall survivals were excellent regardless of stage, pathologic findings, or treatment: 98% for involved fields or mantle, and 100% for both extended fields and involved fields followed by 6 cycles of MOPP. Corresponding disease-free survivals were 77%, 82%, and 86%, respectively. For patients with upper torso presentations, disease-free figures for the mantle (94%) were better than those for involved fields alone (67%). In addition, regression analysis proved involved fields to be a prognostic factor for a lower disease-free survival. No difference between extended fields or mantle radiotherapy could be detected using this model. Relapses usually occurred in nonirradiated upper torso sites. Only three of the 36 patients treated with involved fields and one of 21 treated with extended fields relapsed in the abdomen alone. Most patients in relapse were salvaged. Rescue treatment was most often radiotherapy and adjuvant combination chemotherapy. Based on this study, the use of mantle radiotherapy is recommended in treating laparotomy-staged I and II patients with nonmediastinal presentations, and the use of extended fields or adjuvant chemotherapy as primary prevention is not recommended.

[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).

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.

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.

Pathologic stage I and II Hodgkin's disease, 1968--1975: relapse and results of retreatment

Sixty-seven previously untreated patients with Hodgkin's disease, pathologic stages I and II, seen during a 7-year period were evaluted with respect to initial staging and treatment, as well as relapse and retreatment results. The initial treatment consisted of radiation therapy (RT) to an involved field (IF) or an extended field (EF) for patients with stages IA and IIA, or RT and, in recent cases, combination chemotherapy [cyclophosphamide, Oncovin, procarbazine, and prednisone (COPP)] for patients with stages IB and IIB. Nineteen of the 67 patients relapsed (28%), including 11 of 56 patients with stages IA and IIA (20%) and 8 of 11 patients with stages IB and IIB (73%). Seventeen of the 19 relapses occurred within 24 months after completion of the initial therapy (89%). The relapse-free survival at 5 years was 75% for the A patients and 25% for the B patients. The actuarial survival of stage IA and stage IIA patients at 5 years was 91%; there was no significant difference between patients treated initially with either IF or EF. The actuarial survival at 5 years for the patients with stages IB and IIB was 88%, as most responded to a second program of induction therapy. No correlation could be found between the pattern of relapse and the initial pathologic stage or the mode of treatment.

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.

Morbidity of staging laparotomy in Hodgkin's disease

The morbidity of exploratory laparotomy and splenectomy in Hodgkin's disease was determined at three institutions--a university hospital, a major university affiliated hospital and a large community hospital. Of the 90 patients who underwent exploratory laparotomy, 33 (37%) sustained a major or minor complication within two weeks of surgery. Seventeen patients (19%) sustained a minor complication and 16 patients (18%) a major complication. There was no mortality. A higher complication rate occurred in patients more than 28 years of age (p = 0.01), and in patients with advanced clinical stage when age was controlled (p = 0.05). We suggest that prior to performing an exploratory laparotomy in a given patient, the necessity of the procedure be weighed against its potential hazards.

Hodgkin's disease stage I and II. A comparison between two different treatment policies

A retrospective analysis was performed on 145 patients with Stage I and II Hodgkin's disease treated over an 11-year period. Sixty-two patients (Group I) received a mantle field without systematic irradiation of the para-aortic lymph nodes. Eight-three patients (Group II) received radiotherapy according to the folowing policy: all Stage IB and IIB and all mixed cellularity and lymphocytic depletion types received total nodal irradiation while stage IA and IIA nodular sclerosing and lymphocytic predominance cases received irradiation to a mantle field and to the para-aortic lymph nodes. The characteristics of the two groups were roughly comparable in age range, sex, staging, histopathologic subtypes and total irradiation doses. All patients had lymphangiograms although not all underwent staging laparotomies. The staging laparotomy did not appear to have an influence within each group. The extent of irradiation did significantly affect both the incidence of further manifestation of disease as well as survival rates. The frequency of lymph node extension, organ extension and local recurrence for Group I was 24%, 14%, and 3%, while for Group II it was 4%, 6%, and 6%, respectively. The seven-year absolute survival rate for Group I was 57% while for Group II it was 93%.