Reassessment of prognostic factors in stage IIIA and IIIB Hodgkin's disease treated with MOPP and radiotherapy

Hodgkin's lymphoma in the elderly: The results of 10 years of follow-up

Elderly patients with Hodgkin's lymphoma carry a worse prognosis than younger patients because of a higher incidence of advanced stages, a worse performance status and the intolerance of full-dose curative treatment. A retrospective analysis of patients treated at our institution was performed. Our retrospective study summarizes the treatment results for 52 Hodgkin's lymphoma patients aged older than 60 years between 1973 and 1993. These patients were treated with combination of less toxic chemotherapy schedule (cyclophosphamide, vincristine, procarbazine and prednisone) and/or involved-field radiotherapy. The aim was to maintain an acceptable quality of life in spite of lower remission rate. The 5- and 10-year overall survival rates were 48% and 33%, respectively. We found two independent prognostic factors for overall survival: (i) stage of the disease and (ii) accomplishment of the treatment. Combined modality treatment yielded better results than chemotherapy. Tolerance of the treatment was acceptable. The present study demonstrates that a combination of mild chemotherapy with limited radiotherapy is a feasible way of treating elderly patients with Hodgkin's lymphoma.

Bystander cells and prognosis in Hodgkin lymphoma. Review based on a doctoral thesis

Hodgkin lymphoma (HL) is characterised histologically by a minority of malignant Hodgkin and Reed-Sternberg (HRS) cells surrounded by benign cells, and clinically by a relatively good prognosis. The treatment, however, leads to a risk of serious side effects. Knowledge about the biology of the disease, particularly the interaction between the HRS cells and the surrounding cells, is essential in order to improve diagnosis and treatment. HL patients with abundant eosinophils in the tumours have a poor prognosis, therefore the eosinophil derived protein eosinophil cationic protein (ECP) was studied. Serum-ECP (S-ECP) was elevated in most HL patients. It correlated to number of tumour eosinophils, nodular sclerosis (NS) histology, and the negative prognostic factors high erythrocyte sedimentation rate (ESR) and blood leukocyte count (WBC). A polymorphism in the ECP gene (434(G>C)) was identified and the 434GG genotype correlated to NS histology and high ESR. The poor prognosis in patients with abundant eosinophils in the tumours has been proposed to depend on HRS cell stimulation by the eosinophils via a CD30 ligand (CD30L)-CD30 interaction. However, CD30L mRNA and protein were detected in mast cells and the predominant CD30L expressing cell in HL is the mast cell. Mast cells were shown to stimulate HRS cell lines via CD30L-CD30 interaction. The number of mast cells in HL tumours correlated to worse relapse-free survival, NS histology, high WBC, and low blood haemoglobin. Survival in patients with early and intermediate stage HL, diagnosed between 1985 and 1992, was generally favourable and comparatively limited treatment was sufficient to produce acceptable results for most stages. The majority of relapses could be salvaged. Patients treated with a short course of chemotherapy and radiotherapy had an excellent outcome. In conclusion prognosis is favourable in early and intermediate stages and there are possibilities for further improvements based on the fact that mast cells and eosinophils affect the biology and prognosis of HL.

Prognostic factors in Hodgkin's lymphoma

Risk-adapted treatment strategies have constituted a major issue since the beginning of clinical research into Hodgkin's disease (HD). Various prognostic factors have been identified and several of those considered for staging procedures, resulting in strictly stage-dependent treatment recommendations for patients suffering from HD. These factors may be subdivided in host-related (e.g. age, sex) and tumour-related (e.g. number of tumour cells, growth characteristics, spread of tumour cells, resistance to apoptosis) factors. Owing to the striking improvement of the overall prognosis in HD patients it may be difficult to identify novel prognostic factors analysing the minority of patients with a fatal outcome. However, especially in advanced-stage disease, improved treatment results were achieved by the introduction of more aggressive treatment regimens, resulting in an increased toxicity rate. Thus, partially in contrast to earlier work in this field, future prognostic factors are needed for identification of those patients that have a good prognosis and might be susceptible to overtreatment. During the Fifth International Symposium on Hodgkin's Lymphoma, promising results on several new prognostic markers were presented. Furthermore, a joint effort to design new studies on large, well characterised patient groups has been initiated.

Laparotomy versus no laparotomy in the management of early-stage, favorable-prognosis Hodgkin's disease: a decision analysis

PURPOSE

To perform a decision analysis that compared the life expectancy and quality-adjusted life expectancy of early-stage, favorable-prognosis Hodgkin's disease (HD) managed with and without staging laparotomy, incorporating data on treatment outcomes of HD in the modern era.

METHODS

We constructed a decision-analytic model to compare laparotomy versus no laparotomy staging for a hypothetical cohort of 25-year-old patients with clinical stages I and II, favorable-prognosis HD. Markov models were used to simulate the lifetime clinical course of patients, whose prognosis depended on the true pathologic stage and initial treatment. The baseline probability estimates used in the model were derived from results of published studies. Quality-of-life adjustments for procedures and treatments, as well as the various long-term health states, were incorporated.

RESULTS

The life expectancy was 36.67 years for the laparotomy strategy and 35.92 years for no laparotomy, yielding a net expected benefit of 0.75 years for laparotomy staging. The corresponding quality-adjusted life expectancies for the two strategies were 35.97 and 35.38 quality-adjusted life years (QALYs), respectively, resulting in a net expected benefit of laparotomy staging of 0.59 QALYs. Sensitivity analysis showed that the decision of laparotomy versus no laparotomy was most heavily influenced by the quality-of-life weight assigned to the postlaparotomy state.

CONCLUSION

Our model predicted that on average, for a 25-year-old patient, proceeding with staging laparotomy resulted in a gain in life expectancy of 9 months, or 7 quality-adjusted months. These results suggest that a role remains for surgical staging in the management of early-stage HD.

Treatment of early and intermediate stages of supradiaphragmatic Hodgkin's disease: the Swedish National Care Programme experience. Swedish Lymphoma Study Group

PURPOSE

Since 1985 a Swedish National Care Programme has provided tailored principles for the staging, treatment and follow-up of patients with Hodgkin's disease (HD). This report presents treatment results for all patients below 60 years of age who were diagnosed with early and intermediate stages, between 1985 and 1989.

PATIENTS AND TREATMENT

During that period, 210 patients with supradiaphragmatic HD in clinical (CS) and pathological (PS) stages IA+IIA, PS IB+IIB, and PS III1 A were diagnosed in five Health Care Regions in Sweden. In patients with CS IA, staging laparotomy was not recommended provided that the radiological assessment of the abdomen was adequate, whereas this procedure was recommended in stages CS IB, IIA and IIB in order to minimize treatment. In the absence of bulky mediastinal disease, patients with CS+PS IA and PS IIA were treated with mantle (occasionally mini-mantle) irradiation alone, while patients with bulky disease, as well as those with stages PS IB+IIB+III1 A, were treated with one cycle of MOPP/ABVD prior to mantle (PS III1 A sub-total nodal) irradiation. Full chemotherapy followed by radiotherapy to initial sites with bulky disease was recommended for patients with CS IIA who did not undergo laparotomy.

RESULTS

After a median follow-up in excess of five years, treatment results are 'favourable' for all stages, provided the recommendations were followed. In patients with CS+PS IA treated according to the recommendations, recurrence rates were 14% (9/65) with all but one patient (64/65, 98%) remaining in continuous first or second remission. These figures were worse in patients treated inadequately (9/26 [35%] and 22/26 [85%], respectively). In PS IIA, adequately-treated patients had a recurrence rate of 13% (7/52) whereas 5/7 (71%) of those with bulky disease who received only mantle irradiation developed recurrences. Similar patterns also emerged in patients with CS IIA, PS IB+IIB and PS III1 A.

CONCLUSIONS

The tailored principles, which usually entail less staging and/or treatment than is generally the case, produced favourable results when applied to an entirely unselected group of patients with early and intermediate stages of HD.

Chromosomal damage in sperm of patients surviving Hodgkin's disease following MOPP (nitrogen mustard, vincristine, procarbazine, and prednisone) therapy with and without radiotherapy

Following fusion with hamster eggs, human sperm chromosomes from six Hodgkin's disease patients were analyzed to determine the genotoxic effects of therapy. Each patient had received two to six cycles of MOPP (nitrogen mustard, vincristine, procarbazine, and prednisone), with or without radiotherapy, from 3 to 20 years before the study. A total of 571 cells from the six patients were analyzed; 9.8% of the cells had structural aberrations, and 1.6% were hyperhaploid. Analysis of 5998 metaphases from a control group of 24 male donors revealed only 6.9% of cells with structural aberrations and 0.8% aneuploidy. The increase in hyperhaploidy in the patients was statistically significant. Thus, results of this study suggest that the MOPP regimen, with or without radiotherapy, is capable of causing chromosome abnormalities in the sperm of Hodgkin's disease patients.

A new chemotherapy regimen for treatment of Hodgkin's disease associated with minimal genotoxicity

Recently, the combination chemotherapy Novantrone, Oncovin, Velban, Prednisone [NOVP] was developed by The University of Texas M. D. Anderson Cancer Center for treatment of Hodgkin's disease [HD]. Preliminary clinical results show that NOVP is as effective as the traditional Mechlorethamine, Oncovin, Procarbazine, Prednisone [MOPP] regimen in achieving remission, but with fewer side-effects. To determine if NOVP is genotoxic, we studied the induction of chromosome breaks and sister chromatid exchanges [SCEs] in lymphocytes of 42 HD patients both before and during NOVP treatment. Furthermore, in vitro bleomycin treatment was used to unmask potential single-stranded DNA breaks inducted by the therapy. Our results showed that NOVP did not cause elevated levels of chromosome or single-stranded DNA breaks, or SCEs. These results together with previous findings that NOVP caused minimal acute and gonadal toxicities suggest that NOVP is less toxic than MOPP. Therefore, this new regimen shows promise as an effective and minimally toxic regimen for treatment of HD.

Are alkylating agents a necessary component in the therapy of Hodgkin's disease

Management of early stages of Hodgkin's disease requires development of treatment programs that are nominally toxic, with a low likelihood of sterility and secondary malignancies, both associated with alkylating agents. Although patients with laparotomy-staged disease without B symptoms or large mediastinal masses have good results when treated with radiotherapy alone, patients with adverse features need chemotherapy for optimal disease-free survival results. MOPP and its variants have been studied extensively for adjuvant therapy of patients with early staged disease but are associated with the development of secondary malignancies, including acute leukemia and solid tumors. ABVD has been compared with MOPP in combination with radiation therapy for patients with stages IIB and IIIB, and ABVD is not associated with a high risk of acute leukemia; however, cardiac and pulmonary toxicities have been reported, and there may be long term complications following ABVD in combined modality programs. In 1988, we developed NOVP [mitoxantrone (Novantrone), vincristine, vinblastine, prednisone], designed as adjuvant chemotherapy to treat patients with clinically staged I-II Hodgkin's disease who had unfavorable features, including B symptoms, large mediastinal masses, and hilar lymph node involvement. We also included patients with peripheral masses > or = 10 cms and those with stage III disease. In the second phase of this study, we treated patients without adverse features, in order to avoid laparotomy. The treatment plan included three cycles of NOVP, followed by radiotherapy to the mantle and the abdomen, with fields depending upon disease presentation. Patients with large mediastinal masses or hilar involvement also received low dose lung radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

NOVP and radiotherapy for early-staged Hodgkin's disease: an interim analysis

Modern treatment plans for early staged Hodgkin's disease must focus on optimal disease-free survival results without laparotomy, minimal acute toxicity, and reduced long-term complications. We have treated 69 adult patients with stage I-II Hodgkin's disease, 40 of whom had bulky disease, B symptoms, or hilar disease, and 22 with stage III disease with 3 cycles of NOVP (Novantrone, vincristine, vinblastine, prednisone) and radiotherapy. Only patients with stage III1 disease involving the celiac axis without para-aortic or pelvic involvement, had to undergo laparotomy prior to treatment. Three patients did not respond to NOVP: two of these did not respond to MOPP or ABDIC, and two are currently without relapse following bone marrow transplant. With a median follow-up of 18 months, 62 with stage I-II and 19 with stage III remain without relapse, and 91 patients are alive. Tolerance to therapy was excellent with minimal nausea, myalgias, and alopecia. We conclude that this regimen for Hodgkin's disease provides good results for clinically staged I-III disease, but longer follow-up may demonstrate prognostic factors which will influence our results.

The role of radiation therapy in Hodgkin disease: experience and controversy. The 54th annual Janeway Lecture: 1989

BACKGROUND

Beginning in 1970, a series of patients with Hodgkin disease were treated at the University of Minnesota, after staging laparotomy, with radiation therapy (RT) for Stage I, II, and IIIA Hodgkin disease. This report is an analysis of the results of the treatment and of treatment modifications.

METHODS

From 1970 to 1974, all patients were treated with standard RT. In 1975, an analysis of these patients indicated that patients with large mediastinal mass (LMM) and patients with Stage IIIA spleen-positive (IIIAS+) disease had a higher recurrence rates than patients without these factors. Subsequently, a schema of radical radiation therapy (RRT) was devised, which included low-dose lung RT for patients with LMM and low-dose liver RT for patients with IIIAS+ disease.

RESULTS

Analysis of the results of the two treatments indicates that the use of low-dose lung RT in patients with LMM and low-dose liver RT in patients with IIIAS+ Hodgkin disease produced survival and recurrence-free survival results equivalent to those achieved by use of combined modality treatment (CMT) or chemotherapy (CT) alone.

CONCLUSIONS

The use of RT with whole lung and liver irradiation for patients with LMM and IIIAS+ Hodgkin disease, respectively, produces results that are equivalent to those of CMT or CT alone with the advantage of a decreased incidence of second malignant neoplasms. In addition, patients who do not respond to initial RT have a greater chance of being saved with chemotherapy than do patients initially treated with CMT of being saved with RT. The authors suggest that radical RT is the treatment of choice for patients with LMM and/or IIIAS+ Hodgkin disease.

Computer-aided individual prognoses of squamous cell carcinomas of the lips, oral cavity and oropharynx

Computer-aided individual prognoses (CIP) is a software-package developed on the basis of an empirical study and can be installed on any IBM-compatible personal computer. The project which went into the making of CIP was called "Prospective DOSAK-study on squamous cell carcinomas of the lips, oral cavity and oropharynx". In the course of the study 1485 patients were treated between 1977 and 1982, and followed up through 1985. CIP facilitates individual prognoses and comparisons of independent patient groups with parallel groups from the data of the above-mentioned study. In practical clinical work individual prognoses allow exact and reliable judgements on individual patients. In clinical cancer research it provides the information about prognostic factors required for controlled clinical studies. The comparison of independent patient populations allows for an ongoing qualitative control of the patients in each clinical institution. In clinical cancer research such a comparison means that certain characteristics of the patient, the tumor and of the disease can be given higher prognostic value. The same is true of the clinical testing of therapeutic measures which is typically carried out during phase-II-studies. Due to its menu-based organization CIP does not presuppose any specialist knowledge on the part of its users and can be regarded as particularly user-friendly.

Tumour burden as the main indicator of prognosis in Hodgkin's disease

A method of estimating the total tumour burden in patients with Hodgkin's disease was devised, combining the number of involved regions with the tumour size in each region. Further, a method of estimating the total tumour cell burden was devised, combining the estimate of the total macroscopic tumour burden with an estimate of the concentration of tumour cells in the tumour tissue. The prognostic significance of the total tumour burden was examined in multivariate studies of 300 patients in pathological stages I and II treated in the Danish National Hodgkin Study and 506 patients in all stages treated at the Finsen Institute, Copenhagen, Denmark, during a 15-year period. The total tumour burden turned out to be the most important prognostic factor in Hodgkin's disease. Most of the hitherto known prognostic factors were shown to be correlated with the total tumour burden and to lack independent prognostic significance.

An analysis of prognostic factors in stage III and IV Hodgkin's disease treated at a single centre with MVPP

Two hundred and twenty seven patients with stage IIIA-IVB Hodgkin's disease have been treated at a single centre with MVPP chemotherapy followed by radiotherapy to sites of previously bulk disease. The median follow up is 58 months. 119 patients (52%) had stage IV disease. Overall complete remission (CR) rate was 72%. Discriminant analysis of factors predictive for complete remission showed that low albumin was the only independent factor that predicted a significantly lower chance of CR. Overall five year survival was 73%. A Cox multivariate analysis demonstrated that age greater than 40 years, stage IV disease, presence of bulk disease, low serum IgG and male sex to be variables which independently predicted poorer prognosis in terms of overall survival. Stage IV and lymphocyte depleted or unclassified histologies were independently predictive for poorer progression-free survival. Patient weight greater than 70 kg and stage IV disease were adverse prognostic factors for relapse free survival. Results are compared to other published multivariate analyses of prognostic factors in advanced Hodgkin's disease.

Chemotherapy of Hodgkin's disease

An overall perspective of chemotherapy for Hodgkin's disease has been presented with particular emphasis on the treatment options to be considered at each stage of the disease. In 1950, M. Vera Peters ended her paper on the 'radiological' treatment of Hodgkin's disease thus: 'In the light of present knowledge the diagnosis of Hodgkin's disease should not be regarded with despair and the patient treated as incurable.... If a single ray of hope emerges from this analysis, the treatment of the individual concerned is a challenge to the combined efforts of the radiotherapist, the physician and the surgeon' (Peters, 1950). Over the ensuing 40 years, substantial progress has been made, but any further improvement must begin with an increase in the proportion of patients for whom complete remission is achieved. Prospective comparisons of hybrid regimens against standard chemotherapy are in progress and the results of these trials will hopefully answer the question as to which is the optimal regimen in the primary treatment of advanced Hodgkin's disease. The advent of growth factors may allow for an increase in dose intensity, possibly improving the results further. The role of very intensive therapy with autologous bone marrow support remains to be defined and is currently being evaluated in different trial settings. Meanwhile, the quest for alternative, less toxic compounds goes on. The challenge continues.

Two cycles of MOPP and radiotherapy: effective treatment for stage IIIA and IIIB Hodgkin's disease

Two cycles of MOPP (mechlorethamine, vincristine (Oncovin), procarbazine, prednisone) and radiotherapy were used to treat 197 patients with stage III Hodgkin's disease. Prior to 1980, radiotherapy was delivered to the mantle, abdomen and pelvis; thereafter, pelvic irradiation was deleted for patients with stage III1 disease. Complete remission rates for IIIA and IIIB presentations were 91% and 89%. The 10-year freedom from tumor mortality (FTM) rate for all patients was 81%; for IIIA, it was 87% and for IIIB, it was 72%. Results were not significantly affected by gender, age, pathology, or deletion of pelvic radiotherapy. However, a subgroup of 28 patients with a tumor burden that included pelvic disease who also had B symptoms was identified as having a poor prognosis. Their FTM was 43%, compared with 87% for all other patients combined (P = 0.002). Based on this analysis, we conclude that limited chemotherapy in combination with radiation therapy can yield results similar to programs that use more chemotherapy for all patients with IIIA disease and for most patients with stage IIIB. However, patients with tumor burdens which include pelvic disease and B symptoms require a different approach.

Grades of nodular sclerosis (NSI-NSII) in Hodgkin's disease. Are they of independent prognostic value?

Subclassification of the nodular sclerosis (NS) type of Hodgkin's disease in Grade 1 and 2 was reported for the first time by the British National Lymphoma Investigation (BNLI). Three groups, the BNLI, Gärtner et al. and the current authors, found clearly different survival rates between Grade 1 and 2 NS patients. The authors studied retrospectively if this NS grading has an independent prognostic value in 90 NS patients, diagnosed in ten hospitals in the southeastern part of the Netherlands (1972-1983). In this study there is no significant difference in sex, age, B-symptoms, erythrocyte sedimentation rate (ESR), stage, positive laparotomy, involvement of mediastinum or spleen, lymphocyte count, and percentage of complete remissions between the NS subgroups. Multivariate analysis suggests that the subclassification of NS in Grades 1 and 2 is a prognostic factor in survival independent of age, stage and ESR. This finding and the high relative frequency of NS makes application of this NS subdivision probably clinically useful to identify patients for a risk-adapted therapy.

Prognostic factors for survival in stage IIIB and IV Hodgkin's disease: a multivariate analysis comparing two specialist treatment centres

A multivariate analysis of prognostic factors was carried out on 301 patients with clinical or pathological stage III/IV Hodgkin's disease treated using the same combination chemotherapy (MVPP) at two centres (Christie Hospital, Manchester, 151 patients, St. Bartholomew's Hospital, London, 150 patients). There were no significant difference in CR or relapse free and overall survival at 5 and 10 years between the two groups. Cox analysis of the Christie data alone produced four significant factors for survival - age, sex, lymphocyte count and stage. The latter three factors showed the same trend for the St. Bartholomew's Hospital patients but failed to reach statistical significance. Analysis of the combined data showed all four factors to be of importance in predicting survival. Three different prognostic groups were identified which separated patients with good, intermediate or poor prognosis in both centres. The good prognostic group included patients aged less than 45 years, lymphocyte count greater than 0.75 x 10(9) l-1 and female patients with stage IIIB disease (5 year survival 85%). The rest were of poorer prognosis with male stage IV patients faring particularly badly (5 year survival 40%). Problems associated with the use of multivariate analysis to produce useful prognostic groupings in patients from different centres, are discussed.

Prognostic factors in Hodgkin's disease stage III with special reference to tumour burden

143 patients with Hodgkin's disease stage III (65 PS III, 78 CS III) were treated with radiotherapy alone (33 patients), combination chemotherapy alone (56 patients), or radiotherapy plus combination chemotherapy (54 patients). They were followed till death or from 7 to 191 months. Prognostic factors including treatment, peripheral + intrathoracic tumour burden (assessed by combining tumour size in each involved region with number of involved regions), intraabdominal tumour burden (assessed by combining size of lymphographically involved lymph nodes in each region with number of lymphographically involved regions), histologic subtype, B-symptoms, number of involved regions, mediastinal involvement, pretreatment ESR, sex, age, laparotomy, and substage were examined in multivariate analysis. With regard to disease-free survival, total tumour burden (intraabdominal and peripheral + intrathoracic) emerged as the only pre-treatment factor of independent prognostic significance. With regard to overall survival the only factor of independent significance apart from age turned out to be intraabdominal tumour burden. The results of the present study thus support recently published findings regarding early stage disease to the effect that tumour burden is the single most important prognostic factor in Hodgkin's disease.

The adjuvant role of two cycles of MOPP and low-dose lung irradiation in stage IA through IIB Hodgkin's disease: preliminary results

Fifty-eight laparotomy-staged I and II patients with upper torso presentations of Hodgkin's disease and 8 patients with lymphangiogram-staged lower torso disease were treated with radiotherapy alone or with 2 cycles of MOPP and radiotherapy. Patients with upper torso disease with either no mediastinal or only small mediastinal disease without hilar involvement and with no "B" symptoms were treated with mantle radiotherapy alone. Patients with large mediastinal masses or hilar disease were treated with 2 cycles of MOPP followed by definitive mantle irradiation and low dose lung irradiation. Those for whom "B" symptoms were the only adverse prognostic feature received 2 cycles of MOPP and mantle radiotherapy. Patients with lower torso disease were treated with radiotherapy alone if the disease was limited to the pelvis. Those with more extensive disease received 2 cycles of MOPP prior to radiotherapy. The 4-year survival for all 66 patients was 97%. The corresponding disease-free and freedom from second relapse figures were 77% and 92%. Survival for the patients with unfavorable presentations who received 2 cycles of MOPP and radiotherapy was 100%. It was 92% for the group with favorable presentations who were treated with radiotherapy only.

Results of treatment of stage 3A Hodgkin's disease

From 1975 to 1981, 38 patients with Stage 3A Hodgkin's disease (35 patients pathologically staged) underwent mantle and para-aortic irradiation, and in 36 patients this was preceded or followed by at least six cycles of multiagent chemotherapy. Both the 5-year actuarial survival and disease-free survival for all 38 patients were 83%. There have been six treatment failures: two patients have relapsed within irradiated nodal groups, one patient in apical pericardial lymph nodes as a marginal recurrence, one patient concurrently infield and in unirradiated nodal groups, and two patients systemically (concurrently in unirradiated nodal groups). Of these six relapses, three patients have died of Hodgkin's disease, one patient has been salvaged, and two patients currently are under treatment for salvage. One patient has developed acute nonlymphocytic leukemia and died of this disease. Extensive disease, as estimated by the number of sites of involvement at presentation, degree of splenic involvement, extent of intra-abdominal disease or mediastinal involvement, did not reveal statistically significant prognostic subgroups for relapse. It is currently recommended that patients with Stage 3A Hodgkin's disease receive six cycles of multiagent chemotherapy and mantle and para-aortic irradiation.

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.

The prognostic significance of mediastinal bulk in patients with stage IA-IVB Hodgkin's disease: a report from the Manchester Lymphoma Group

Three hundred and two previously untreated patients with Stage IA-IVB Hodgkin's disease were reviewed to determine the prognostic significance of mediastinal involvement. Mediastinal bulk disease was defined as either a maximal mediastinal width of 7.5 cm or more, or a ratio of the maximum width of mediastinal disease to the maximum chest diameter of greater than or equal to 0.33, or a ratio of the maximum width of mediastinal disease to the chest diameter at T5-T6 greater than or equal to 0.33, or as an area of mediastinal disease greater than or equal to 100 cm2. Bulk disease outside the chest was defined as a mass of lymph nodes measuring 5 cm or more in any axis. The presence of mediastinal bulk disease was of adverse prognostic significance for remission duration and survival in patients with Stage IA-IIB Hodgkin's disease, but for patients with more advanced disease the effect of mediastinal bulk on remission duration and survival was not statistically significant. The mediastinal bulk variable which most significantly related to prognosis was the ratio of the maximum mediastinal disease to the chest diameter at T5-T6.

Prognostic significance of lymphography in stage IIIs Hodgkin's disease (HD)

Ninety-six patients with pathological stage IIIs Hodgkin's disease, uniformly treated with six cycles of MOPP and TNI, were retrospectively analysed in an effort to determine whether the lymphographic aspect of lymph nodes influence the prognosis. Case material was grouped according to the presence of lymph nodes less than 3 cm in diameter or larger at lymphography. Five-year survival and disease-free survival were 85 and 78% for patients with small lymph node involvement, compared to 48 and 30% for patients with larger lymph nodes. The comparative analysis between the lymphographic aspect and other prognostic factors shows that large lymphographic involvement is strongly correlated with the presence of large spleen involvement (P less than 0.0000029), followed by stage III2 (P less than 0.000612), followed by greater than or equal to 5 involved sites (P less than 0.012), followed by age greater than 40 yr (P less than 0.047). Conversely, no significant correlation was found with symptoms, histology and mediastinal involvement. Modifications of current treatment for both large and small lymph node involvement are discussed.

The Lampe lecture. Radical radiation therapy in the treatment of laparotomy staged Hodgkin's disease patients

In 1970, a policy for the treatment of Stage IIIA Hodgkin's disease patients at the University of Minnesota, which included complete staging procedures and extended field or total nodal irradiation (TNI), was introduced. Evaluation of the results 4 years later indicated that certain patients, especially those with large mediastinal masses and/or hilar disease, or who were spleen positive, were having higher recurrence rates than patients without these characteristics. In 1974, a new approach to treatment for patients with large mediastinal masses or spleen positive disease was instituted which involved treating the whole lung or hemi lung in patients with large mediastinal masses and/or hilar disease, and the liver in patients who had positive spleens. The results of this treatment modification are reported in this study. Long term follow-up reveals that this approach has led to a recurrence free survival and overall survival similar to that noted in patients treated with combined modality treatment without the obvious risk of subsequent leukemia related to combination chemotherapy and radiotherapy. In addition, the complications of the treatment are tolerable and do not demonstrate an increase over patients not treated in this manner. Radical radiation therapy is recommended as a treatment of choice for Stage IA, IIA, and IIIA patients with or without splenic involvement, and with or without hilar disease and/or large mediastinal masses with appropriate radiation field modification to adjust for disease extent.

New aspects of Hodgkin's disease: staging for conservative management

A variety of curative primary and salvage therapies exist for the management of Hodgkin's disease (HD). Consideration of the toxicity of initial therapy is becoming critical for long-term patient management. The recommendation for the routine use of combined modality therapy or whole lung irradiation has been made for the treatment of Stage IA and IIA bulky mediastinal HD based on the correlation between chest X-ray data and increased failure rates in patients managed initially with radiation alone. Thoracic CT scan data has yielded important information as to the possible cause of failure in those patients managed with radiation alone and recommendations are made to substage mediastinal HD for conservative management and to reevaluate the routine use of combined modality therapy. The management of Stage IIIA disease with radiation and/or chemotherapy, the role of splenic involvement for therapy, and the proposed value of substaging disease into IIIA1 and IIIA2 anatomic subsets is discussed. Finally, biochemical and immunological testing may play a future role for initial management.

Hodgkin disease clinical stages I, II, and III (A, B): results of radiotherapy with or without chemotherapy

Between 1961 and 1976, 387 patients with Hodgkin disease were examined, evaluated, and treated at the Instituto Portugues de Oncologia de Francisco Gentil. After reviewing histological and clinical staging presentation, the authors retrospectively analyzed the results obtained with 303 patients classified in clinical stages I, II, and III (A, B) who were treated with or without chemotherapy in two time periods (before and after 1970) according to individual therapeutic modalities. The improvement of the 5-year survival rates in the last period was associated with the introduction of extended-field irradiation and multidrug chemotherapy (MOPP). However, the incidence of serious complications was higher in the group of patients subjected to combined field irradiation and MOPP. The authors suggest a stricter protocol based on the current recommendations for the treatment of Hodgkin disease in order to achieve better results with minimum possible hazards.

Diagnosis and management of Hodgkin's disease in the adult

Appropriate management of Hodgkin's disease is based on both the stage of disease and the specific anatomic sites of involvement within each stage. As a result of the combination of sequential staging and effective treatment, histopathologic subclassification has become less important. Although not generally appreciated, this is also true for constitutional symptoms. During the past 15 years, differences in survival between early and advanced stages have diminished progressively with refinements both in management of newly diagnosed patients, and in management of relapsing disease. Currently, our five-year survival figure for laparotomy-Staged I and II patients is 95%. The corresponding result for Stages IIIA and IIIB patients is 85%; and 67% of our Stage IV patients, who were treated with mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) are projected to be surviving at five years. With the anticipation of a high probability for cure, quality of life including the possibility for parenthood has become increasingly important. In the past, the trend has been to increase treatment for patients with poor prognostic factors. However, very little attention has been paid to the possibility of administering less treatment for very precisely staged patients with good prognostic factors. In this review, management is discussed by stage. Emphasis is placed on the indications for less treatment as well as for more intensive therapy in adult patients with Hodgkin's disease.