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

Hodgkin's disease with a mediastinal mass greater than 10 cm: results of four different treatment approaches

BACKGROUND

Management of Hodgkin's disease (HD) and large mediastinal adenopathy (LMA) usually includes intensive chemotherapy (CT) with or without radiation therapy (XT) regardless of stage.

PATIENTS AND METHODS

One hundred and eighteen evaluable patients received one of four treatment regimens: (1) 6 cycles of MOPP or similar CT and XT; (2) 2 of MOPP followed by XT; (3) 6 of CVPP/ABDIC (cyclophosphamide, vincristine, procarbazine, prednisone/doxorubicin, bleomycin, decarbazine, prednisone, lomustine) followed by XT; or (4) 3 of NOVP (mitoxantrone, vincristine, vinblastine, procarbazine) and XT. XT doses included 30-40 Gy to areas of nodal involvement noted prior to therapy.

RESULTS

Complete remission (CR) rates for groups 1, 2, 3, and 4 were 100%, 85%, 87%, and 96%. Respective 3-year freedom from progression (FFP) results were 88%, 66%, 82%, and 88%, and 3-year freedom from tumor mortality (FTM) results were 100%, 84%, 84%, and 100%. The presence of B symptoms and stage IV disease was correlated with lower CR and 3-year FFP rates but similar 3-year survival.

CONCLUSIONS

Results of this study suggest that patients with stage I-III Hodgkin's disease and LMA greater than 10 cm treated with 3 NOVP and XT have results similar to those obtained for a similar group of patients treated with 2 to 6 MOPP or 6 CVPP/ABDIC and XT. NOVP has also been reported to produce limited toxicity in this trial and should be considered as an alternative to MOPP or doxorubicin-containing regimens in treatment of patients with early-staged disease and LMA greater than 10 cm.

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.

Radiotherapy for stage I Hodgkin's disease: 20 years experience at St Bartholomew's Hospital

One hundred and one consecutive patients with newly diagnosed stage I Hodgkin's disease (HD) received treatment at St Bartholomew's Hospital, between 1968 and 1987, with a median follow-up of 12 years. Eleven patients have been excluded from detailed analysis because they either received involved field radiotherapy (RT) or radiotherapy with chemotherapy or were lost to follow-up. Actuarial analysis predicts 78% to be alive and without relapse of Hodgkin's disease at 15 years. Ninety evaluable patients (clinical stage (CS) 24; pathological stage (PS) 66) received either mantle or inverted 'Y' RT and form the basis of this analysis. The median age was 33 years (63 men, 27 women). Histology at presentation was nodular sclerosing (39), lymphocytic predominant (27) or mixed cellularity (24). The presenting site was neck (78), axilla (6) groin (4) and mediastinum (2). Complete remission was achieved in all evaluable patients, the actuarial proportion in remission being 75% at 15 years. Factors predictive of a prolonged remission were pathological staging versus clinical staging (P = 0.02) and lymph node size less than 3 cm (P = 0.04). Actuarial overall survival in these 90 patients was 75% at 15 years and none of the above factors correlated with survival. Relapse of HD has occurred in 18 patients (5 within RT field, 10 without and 3 in both). Second remission was achieved in 15/18. The actuarial rate of second remission and survival was 40% at 10 years. Sixteen patients have died, 7 of Hodgkin's disease, 7 of unrelated causes and 2 of second malignancy. A further 3 patients who developed second malignancy are still alive. At 15 years the actuarial mortality related to HD was 12%. These results confirm the importance of long follow up to assess the efficacy of primary therapy.

Refractory and relapsing Hodgkin's disease: role of high-dose chemotherapy with bone marrow transplantation

Thirty percent of adult patients with Hodgkin's disease fail primary treatment or relapse after treatment. Whereas overall mortality for Hodgkin's disease is about 20%, half the patients who relapse will die. Among patients with refractory or relapsing disease, about a third can be rescued by conventional salvage treatment. Unfortunately, except for patients with late relapse, remission after conventional salvage treatment is generally not of long duration. However, durable complete remissions can now be achieved in nearly a third of patients with refractory or relapsing disease by means of very aggressive (myeloablative) chemotherapy with consecutive autologous bone marrow transplantation (aBMT). The rate of durable complete remissions seems to be even higher if previous exposure to chemotherapeutic agents is not in excess of two different treatment protocols (optimal timing of aBMT) and if responsiveness to cytotoxic drugs is preserved (low degree of drug resistance). Bone marrow transplantation should be restricted to patients whose resulting long-term prognosis justifies such radical treatment. Reflecting ongoing clinical therapy-studies, in particular in Germany, the role of bone marrow transplantation in a general concept of salvage treatment should be pointed out. Patients should be considered candidates if they fail alternating primary chemotherapy or develop an early relapse after this treatment, but still show responsiveness to chemotherapeutic agents.

A meta-analysis of stages I and II Hodgkin's disease

To compare radiotherapy alone to chemotherapy plus radiotherapy in the treatment of early stage Hodgkin's disease, the English language medical literature was searched for reports on randomized clinical trials in Stages I and II Hodgkin's disease from 1975 through 1986. Twenty-three reports with 2999 patients were entered into matched study analysis. Data on extended-field radiotherapy (EF), involved-field (IF), chemotherapy alone, combination chemotherapy and radiotherapy (CM), disease stage, laparotomy staging, and complications were gathered. A proportional hazard rate was used to estimate and compare relapse-free (RFS) and overall survival rates (S). Iteratively reweighted least square analysis was used to estimate survival curves. Twelve-year RFS for CM (889 patients) was significantly superior to EF (1350 patients) (P less than 0.01). Twenty-year RFS in EF was better than IF (760 patients) (P less than 0.01). Twelve-year S for CM was not significantly different than for EF but was better than for IF (P less than 0.05).

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.

Laparotomy-staged IA versus IIA Hodgkin's disease. A comparative study with evaluation of prognostic factors for stage IIA disease

Ninety-one laparotomy-staged (LAP) IA and IIA Hodgkin's disease (HD) patients were analyzed to evaluate the prognostic significance of stage, mediastinal status, extranodal disease and histology. Forty IA patients were treated with radiotherapy (XRT) only; of 51 IIA patients, 44 received XRT only and 7 had additional chemotherapy. Disease-free survival (DFS) at 5 and 10 years was 81% and 70%, respectively, with overall survival (S) of 93% and 86%, respectively. Disease-free survival for IA patients (93% at 5 and 10 years) was significantly superior to IIA (73% at 5 years, 52% at 10 years). Survival differences were not statistically significant. For IIA patients receiving XRT only, large mediastinal disease was an adverse factor for DFS. Small mediastinal disease in IIA was significantly better than no mediastinal disease. For the whole group of LAP IA and IIA treated by XRT only, three prognostic groups were identified: (1) Stage IA and Stage IIA with mediastinal disease, but less than 7.5 cm in width was highly favorable with less than 10% relapse; (2) Stage IIA nonmediastinal had an intermediate prognosis with relapse in about 33%; (3) Stage IIA large mediastinal (greater than or equal to 7.5 cm) had an unfavorable DFS with relapse in about 55%. The third group contained a highly unfavorable subset with mediastinal masses greater than 10 cm, all of whom relapsed. Salvage therapy was successful in 60% of relapsing patients. In the context of relatively effective salvage therapy, the role of adjuvant chemotherapy in adverse prognostic groups is discussed and it is concluded that the only clearly justifiable use for adjuvant chemotherapy is in patients with massive (greater than 10 cm) mediastinal adenopathy.

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.