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

Radiation Therapy Can Be Safely Incorporated into Pretransplantation Treatment Regimens for Patients with Multiple Myeloma

Primary treatment of multiple myeloma (MM) often involves systemic induction therapy (SIT) followed by autologous stem cell transplantation (ASCT). Radiation therapy (RT) is sometimes used for palliation; however, many practitioners avoid RT out of concern that future peripheral blood progenitor cell (PBPC) collection required for ASCT may be compromised. In this study, we retrospectively examined the possible effect of RT on PBPC collection. We reviewed the charts of 732 patients with MM treated with RT at our institution from 1999 to 2017, including patients who received RT prior to PBPC collection for planned ASCT. RT plans (both MM and non-MM RT) were reviewed to estimate the percentage of bone marrow (BM) treated using published estimates of skeletal BM distribution. Statistics were performed using Pearson correlation and the t-test. The 732 MM patients included 485 planned for ASCT; of these, 223 received RT prior to PBPC collection and were included in the final cohort. The median age at PBPC collection was 59 years (range, 33 to 80 years). For SIT, patients received combination regimens including the following agents: bortezomib (142 patients; 64%), lenalidomide (111 patients; 50%), and alkylators (46 patients; 21%). Nine patients (4%) received dexamethasone alone. The median cumulative %BM treated per patient was 6.7 (range .0 to 47.4). The median RT dose was 24 Gy (range, 10.0 to 75.6 Gy). Mobilization was performed using granulocyte-colony stimulating factor (G-CSF) alone (189 patients; 85%), G-CSF with plerixafor (15 patients; 7%), or chemotherapy (19 patients; 9%). A median of 7.8 × 106 CD34+/kg PBPCs (range, .5 to 54.8× 106 CD34+/kg) were collected in a median of 3 (range, 1 to 9) apheresis procedures. One hundred ninety-six patients (99%) collected ≥2.0 × 106 CD34+/kg PBPCs, and 166 (83%) collected >5.0 × 106 CD34+/kg PBPCs. The number of PBPCs collected was not associated with %BM treated (P = .15) or RT dose (P = .56). The number of apheresis procedures performed was not associated with %BM treated (P = .54) or RT dose (P = .85). The amount of PBPCs collected did not differ significantly between patients receiving RT to the pelvis/sacrum (P = .20) and those receiving RT to the spine (P = .13). The time to platelet engraftment was longer for patients with higher %BM treated (P = .02). Eleven patients did not undergo a confirmed ASCT, owing to patient preference (3 patients), trial therapy (1 patient), comorbidities (1 patient), election for hospice (1 patient), inadequate collection (4 patients), or inadequate follow-up (1 patient). In our study cohort, RT prior to ASCT did not impair successful ASCT. RT must be carefully planned and delivered to ensure safe incorporation into pre-ASCT treatment regimens.

Persistent localized bone marrow aplasia after radiotherapy with preserved peripheral counts: a study of 8 cases

Localized, radiation (XRT)-induced sternal bone marrow (BM) aplasia was described in early studies in the radiation oncology literature; however, no pathologic studies have examined in detail this phenomenon in random iliac crest biopsies and its relationship to overall hematopoiesis. We retrospectively reviewed aplastic iliac crest BMs with discrepant peripheral blood (PB) counts after localized pelvic XRT. BM aplasia was defined as 5% or less cellularity in an adequate biopsy and/or hypocellular particles on aspirate smears. Discrepant PB counts were defined as either within or higher than normal limits or mild cytopenias. Eight patients with BM aplasia and discrepant PB counts were identified; each had received localized XRT to the sacrum, lumbar spine, or pelvis. Aplastic BMs showed replacement by mature fat and/or virtually acellular spicules. One case showed focal reticulin fibrosis. Mild cytopenias were seen in 6 cases and normal or increased counts in one case each. Aplastic BMs were observed 5 to 43 months after XRT. A myeloproliferative neoplasm was diagnosed in one case based on PB findings and JAK-2 mutation, despite BM aplasia. In one case, a right-sided aplastic BM, diagnosed 8 months after XRT, was followed 14 months later by a normocellular right aspirate and aplastic left BM biopsy. Prolonged, localized BM sterilization may be seen as a result of XRT to the iliac crest for several years. In the setting of preserved PB counts, this is not likely representative of overall hematopoiesis and serves as a potential diagnostic pitfall. Regeneration of hematopoietic activity at exposed sites may be possible.

Effects of cancer treatment on reproduction and fertility

OBJECTIVE

(1) To review the effects of cancer treatment on reproduction and fertility in both women and men and (2) to review current and new techniques that could be used to preserve fertility and hormone production in women who have undergone cancer treatment.

DATA SOURCES

Entries to MEDLINE and CANCERLIT through to October 2001 were searched for evidence relevant to this article.

METHODS OF STUDY SELECTION

This document is primarily based on large retrospective cohort series and case reports, as no randomized trials were available.

TABULATION, INTEGRATION, AND RESULTS

The first part of this review article focuses on the effects of radiation and chemotherapy on reproductive function and innovative medical and surgical techniques employed to minimize these effects. The second part of this article describes conservative methods of managing cervical, endometrial, and ovarian cancer for women who wish to preserve their fertility.

CONCLUSIONS

Over the last decade, there has been a trend toward trying to preserve reproductive function in young patients with malignancy. Information acquired over the last century on the reproductive effects of radiation and chemo-therapy has enabled us to tailor our treatment of various malignancies affecting young patients. As we learn more about the biology and clinical behaviour of gynaecologic malignancies, we are able to modify surgical management to preserve fertility in select cases. All of these trends are in keeping with our goal to optimize quality of life in cancer care without compromising safety or survival.

The effects of cryopreservation on semen from men with sarcoma or carcinoma

PURPOSE

This study evaluated prefreeze and postthaw semen quality before treatment in patients with different types of sarcomas and carcinomas to determine whether cryopreservation would be of value for these patients.

METHODS

Semen specimens were obtained from 50 normal donors and from 21 patients with carcinoma and from 14 patients with sarcoma. The specimens were cryopreserved by a standard freezing procedure using TEST-Yolk buffer. Prefreeze and postthaw sperm motion characteristics were measured.

RESULTS

Prefreeze total motile sperm count was significantly higher in donors (median: 129.6 x 10(6)/ml) than in men with carcinoma (46.9 x 10(6)/ml, P < .001) or sarcoma (66.3 10(6)/ml, P = .04). The percent motility and percent linearity were significantly lower in patients with carcinoma. In postthaw specimens, total motile sperm count, curvilinear velocity, and linearity were significantly lower in patients with carcinoma.

CONCLUSIONS

The two patient groups in this study had poor semen quality when compared with healthy donors both before and after cryopreservation. Sarcoma patients had better semen quality than carcinoma patients. As cancer therapy in these men could significantly impair their reproductive potential, these men should be advised to preserve their semen before starting treatment.

[Second malignancies after the therapy of Hodgkin's disease: the Freiburg collective 1940 to 1991]

AIM

To quantify the risk of second malignancies in patients with Hodgkin's disease treated at the Department of Radiotherapy, University Clinic Freiburg, with the object of comparing this risk with the international experience and as a contribution to the discussion about future treatment.

PATIENTS AND METHODS

Second malignancies were reviewed in 1,588 patients treated for Hodgkin's disease between 1940 and 1991. Treatment consisted of involved or extended field radiotherapy as a single modality or in combination with chemotherapy. Before the early 1970's, chemotherapy used (sequential) monodrug regimens. The mean follow-up was 8.3 years. The cumulative risk was calculated using the Kaplan-Meier method and related to the risk of a normal population taken from epidemiological data of the National Cancer Institute. An estimate of radiation dose at the site of origin of the second malignancy was obtained from representative measurements employing an Alderson phantom.

RESULTS

After 5, 10, 15 and 20 years the cumulative risk for all malignancies was 1.5%, 4.2%, 9.4% and 21%, respectively; for solid tumors it came to 1.2%, 3.1%, 7.9% and 19%; for non-Hodgkin lymphoma (NHL) the risk amounted to 0.1%, 0.9%, 1.4% and 1.9%; and for leukemia it was 0.1%, 0.3%, 0.6% and 0.6%. For the same time points the relative risk for all malignancies was calculated to be 1.1, 1.4, 1.8 and 2.5; for solid tumors it came to 1.0, 1.1, 1.6 and 2.5; for NHL it amounted to 3.3, 11.8, 9.3 and 8.0; and for leukemia it was 3.3, 3.1, 3.4 and 2.1. For combinations of radiotherapy and chemotherapy the risk for second malignancies was highest in patients receiving ABVD any time during their treatment. 51% of the second malignancies were located infield, 22% at the field border and 27% outfield. In those cases for which the cause of death was known, Hodgkin's disease accounted for 79% followed by second malignancies accounting for 8%. The results obtained in Freiburg fell within the range reported in international publications.

CONCLUSION

The increased incidence of second malignancies in cured Hodgkin's patients is along-term risk making regular follow-up mandatory. Although part of the second malignancies are unrelated to therapy, there is a need to carefully collect the data from patients treated according to new protocols in order to detect any changes in the number or kind of second malignancies in due time. This may well lead to a reassessment of therapeutic concepts.

[Radiation reactions in the gonads: importance in patient counseling]

PURPOSE

The intention of this article is to summarize the effects of radiation therapy on the female and male gonadal function.

RESULTS

In woman a decreasing tolerance to radiation is observed with increasing age, due to the decreasing number of follicles. The mean tolerance dose for sterilization is between 5 and 10 Gy. If both ovaries receive only scattered doses-radiation effects on the ovaries are dependent on the age of the women at the time of treatment. However, if both ovaries are included in the treatment volume of a tumor radiation therapy, sterilisation is unavoidable. In man even scattered doses are able to decrease the sperm cell counts in the range of 2 to 3 Gy in conventional fractionation regimes. Complete restoration of spermatogenesis is possible during the first 2 years after treatment, but is unlikely after 3 years. In contrast to the situation in female, impairment of male endocrine gonadal functions are observed only after testicular doses higher than 20 to 30 Gy. In female children the tolerance dose of the ovaries is higher than in the adult woman, while the gonadal endocrine function in boys is more sensitive than in adult men. In contrast, spermatogenesis is not initiated in young boys, and hence less radiation effects are induced.

CONCLUSIONS

In all treatment situations-in adults as well as in children-an additive effect of the combination of chemotherapy with radiation on gonadal function has been shown. However, the severity of damage by radio-chemotherapy is highly dependent on the drugs used.

Long-term survivors of childhood cancer. The medical consequences of cure

The late effects of cancer therapy are a significant problem and the risk can be predicted based on each individual's prior therapy. Although the use of effective therapy has led to the development of sequelae involving various organ systems, recognition of these complications has led to the design of new therapy targeted at minimizing these effects, especially in patients with good risk. Unfortunately, the risks of the late effects must be accepted in patients with cancers that are aggressive or in advanced stages to maximize the chance for cure. Continued education of cancer survivors regarding their risks of late effects is essential and gives them the ability to maintain healthy lifestyles, avoiding cancer-promoting behaviors such as smoking. It also gives survivors the opportunity to participate in screening programs to help in early recognition of the late consequences of therapy and to learn self-examination to detect second malignancies early. It is hoped that the use of early intervention will lead to an improved long-term outcome. Finally, continued surveillance of this population is essential to monitor the impact of the therapeutic modifications on late complications and potentially to detect the sequelae produced by newer treatment strategies. Because the number of childhood cancer survivors will continue to increase, it is imperative that the pediatricians and internists in the community who care for these survivors are aware of their risks for late effects so that they have access to and can benefit from early intervention.

A prospective analysis of subacute thyroid dysfunction after neck irradiation

PURPOSE

Exposure of the thyroid to therapeutic doses of external irradiation has been demonstrated to induce thyroid dysfunction. This study was designed to assess the relationship between irradiation and early thyroid dysfunction, prospectively.

METHODS AND MATERIALS

Twenty patients in whom the thyroid was incidentally exposed to therapeutic doses of irradiation were studied. The dose given to the thyroid was 40-54 Gy over 4-7 weeks. Thyroid function tests, including serum thyroid stimulating hormone (TSH), free thyroxine (free T4), free triiodothyronine (free T3), antithyroglobulin antibody, and antimicrosomal antibody, were performed prior to irradiation and at 3, 6, and 12 months after radiotherapy.

RESULTS

Serum TSH levels did not change significantly at 3 months after irradiation (mean TSH level: 1.33 microU/ml before irradiation, 1.74 microU/ml at 3 months, p = 0.11). However, a significant elevation was noted at 6 months (mean TSH: 3.50 microU/ml at 6 months, p = 0.0001, vs. preirradiation), when TSH levels were higher than preirradiation levels in 19 of 20 patients. After irradiation, 13 patients remained in a euthyroid state (euthyroid group), while in the other 7 patients hypothyroidism occurred (hypothyroid group) and thyroid hormone-replacement therapy was performed. After 6 months, elevation of TSH was less significant in the euthyroid group, whereas elevation of TSH persisted continuously and exponentially in the hypothyroid group. Thyroid autoantibodies did not turn positive in any patient during follow-up.

CONCLUSIONS

Damage of the thyroid develops in most patients when the organ is exposed to radiation. This radiation-induced damage is initially manifested within 6 months after irradiation.

Serial pulmonary function studies in children treated for newly diagnosed Hodgkin's disease with mantle radiotherapy plus cycles of cyclophosphamide, vincristine, and procarbazine alternating with cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine

BACKGROUND

The pulmonary toxicity of bleomycin-containing chemotherapy combined with mantle radiotherapy in children treated for Hodgkin's disease was longitudinally assessed.

METHODS

The results of serial pulmonary function studies in 37 children, newly diagnosed and treated at St. Jude Children's Research Hospital between September 23, 1983, and June 30, 1988, with cyclophosphamide, vincristine, and procarbazine (COP) alternating with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) plus low dose mantle radiotherapy are analyzed. All patients had pulmonary function studies at least before the first bleomycin dose, after completion of radiotherapy, and serially upon discontinuation of therapy. Bleomycin therapy was withheld whenever measured carbon monoxide diffusing capacity was less than 50% of the predicted value.

RESULTS

Vital capacity, diffusing capacity, and diffusing capacity per unit of alveolar volume declined during the first 6 months of therapy but improved there after. At 2 years postdiagnosis, diffusing capacity per unit of alveolar volume remained significantly reduced. Only one patient was symptomatic at the 2-year point. The survival rate of these patients was 95% at a median follow up of 93 months.

CONCLUSION

If bleomycin is with held when diffusing capacity is diminished to 50% predicted, clinical compromise of pulmonary function appears to be minimal in pediatric patients receiving alternating cycles of COP/ ABVD in combination with low-dose mantle radiotherapy. Survival was excellent, even with reduction of the total bleomycin dose.

Hematopoietic stem cell compartment: acute and late effects of radiation therapy and chemotherapy

The bone marrow is an important dose-limiting cell renewal tissue for chemotherapy, wide-field irradiation, and autologous bone marrow transplantation. Over the past 5-10 years a great deal has been discovered about the hematopoietic stem cell compartment. Although the toxicity associated with prolonged myelosuppression continues to limit the wider use of chemotherapy and irradiation, ways are being discovered to circumvent this toxicity such as with the increasing use of cytokines. This review describes what is known of how chemotherapy and irradiation damage stem cells and the microenvironment, how cytokines protect hematopoietic cells from radiation damage and speed marrow recovery after chemotherapy or marrow transplantation, and how various types of blood marrow cells contribute to engraftment and long-term hematopoiesis after high doses of cytotoxic agents and/or total body irradiation.

Male reproductive potential after MOPP therapy for Hodgkin's disease: a long-term survey

The testicular function of 47 men who had been treated by MOPP chemotherapy for a Hodgkin's disease was studied in a long-term survey. Azoospermia was constant during at least 14 months after completion of the treatment. After a follow-up period of 89.4 +/- 54.7 months, 26 men were still azoospermic. No correlation could be found between the therapeutic regimen and the results of semen analysis. For the same treatment, some men recovered spermatogenesis within 5 years, others after more than 10 years while some were still azoospermic after 20 years. However, the association of infra-diaphragmatic irradiation to high dose MOPP therapy had a profound detrimental effect on spermatogenesis: only 3/13 men recovered. Sperm recovery was often incomplete: 17/21 men had a sperm count below 20 million ml-1. Yet, spontaneous pregnancies were obtained with severe oligozoospermia: only 1/11 sperm counts performed close to fertilization exceeded 20 million ml-1, and 8 were below 5 millions ml-1. FSH failed to be either a sensitive or a specific marker of sperm recovery, a discrepancy between FSH level and spermiogram being noticed in 18.2% of cases.

Simultaneous supra- and infradiaphragmatic irradiation in Hodgkin's disease

From 1982 to 1989, 68 patients with Stages IA to IIIB Hodgkin's disease were treated by simultaneous supra- and infradiaphragmatic irradiation (SSI-RT). 46 patients received exclusive radiotherapy for Stages IA and IIA (extended mantle field irradiation (EMF) 31, and total lymphatic irradiation (TLI) 15). Combined modality treatment including pre-irradiation chemotherapy, was given to 22 patients (CH-EMF 12 and CH-TLI 10). The median follow-up was 64 months. 5-year overall survival was 94% in combined Stages IA and IIA, and 100% in Stage IIIA. 5-year freedom from relapse was 87% in combined Stages IA and IIA, and 80% in Stage IIIA. Toxicity was evaluated in 64 patients. Acute and long term toxicity was similar to previously reported data on sequential supra- and infradiaphragmatic irradiation. In SSI-RT prior chemotherapy affected pre-irradiation blood counts and was associated with delayed post-irradiation haematological recovery. The relative mean white blood cell (WBC) decrease ranged from 47% (EMF) to 61% (TLI). The mean platelet decrease ranged from 43% (EMF) to 80% (CH-TLI). Both prior chemotherapy and total lymphoid irradiation increased haematotoxicity. The mean duration of breaks ranged from 3.9 days in EMF to 14.9 days in CH-TLI. The mean treatment time, ranging from 43 days in EMF to 54 days in TLI, was significantly shorter than in sequential schedules (up to 112 days). Our results indicate that SSI-RT is an effective and safe treatment. Its use seems to be limited mainly by prior chemotherapy. As compared to sequential schedules, the risk of match line overlap is avoided, overall treatment time is decreased, and treatment costs are minimized.

Hypothalamic-pituitary dysfunction after radiation for brain tumors

BACKGROUND

Patients with brain tumors who are treated with radiation frequently have growth hormone deficiency, but other neuroendocrine abnormalities are presumed to be uncommon.

METHODS

We studied endocrine function in 32 patients (age, 6 to 65 years) 2 to 13 years after they had received cranial radiotherapy for brain tumors. The doses of radiation to the hypothalamic-pituitary region ranged from 3960 to 7020 rad (39.6 to 70.2 Gy). Nine patients also received 1800 to 3960 rad (18.0 to 39.6 Gy) to the craniospinal axis. Serum concentrations of thyroid, gonadal, and pituitary hormones were measured at base line and after stimulation.

RESULTS

Nine patients (28 percent) had symptoms of thyroid deficiency, and 20 patients (62 percent) had low serum total or free thyroxine or total triiodothyronine concentrations. Of the 23 patients treated only with cranial radiation, 15 (65 percent) had hypothalamic or pituitary hypothyroidism. Of the nine patients who also received spinal (and thus direct thyroid) radiation, three (33 percent) had evidence of primary thyroid injury. Seven of the 10 postpubertal, premenopausal women (70 percent) had oligomenorrhea, and 5 (50 percent) had low serum estradiol concentrations. Three of the 10 men (30 percent) had low serum testosterone concentrations. Overall, 14 of the 23 postpubertal patients (61 percent) had evidence of hypogonadism. Mild hyperprolactinemia was present in 50 percent of the patients. Responses to stimulation with corticotropin-releasing hormone and corticotropin were normal in all patients except one, who had panhypothalamic dysfunction. However, serum 11-deoxycortisol responses to the administration of metyrapone were low in 11 of the 31 patients (35 percent) tested. Three of the 32 patients, (9 percent) had no endocrine abnormalities, 9 (28 percent) had an abnormal result on tests of thyroid, gonadal, prolactin, or adrenal function, 8 (25 percent) had abnormalities in two axes, 8 (25 percent) in three axes, and 4 (12 percent) in all four axes.

CONCLUSIONS

Cranial radiotherapy in children and adults with brain tumors frequently causes abnormal hypothalamic-pituitary function. The most frequent changes are hypothyroidism and gonadal dysfunction, although subtle abnormalities in adrenal function may also be present.

Long-term effects on pulmonary function of mantle radiotherapy in patients with Hodgkin's disease

Twenty-five patients (21-45 years old) treated for Hodgkin's disease with mantle radiotherapy but no chemotherapy underwent chest radiography and pulmonary testing with spirometry, pulmonary mechanics and exercise test combined with arterial blood gas analysis, lung scintigraphy, assessment of pulmonary artery pressure with Doppler cardiography and vector ECG 10-20 years after treatment. The doses to mediastinum ranged from 35-43 (mean 40) Gy given in 26 fractions with the split-course technique. Radiographic signs of slight to moderate pulmonary fibrosis were seen in 18 patients. Minor restrictive ventilatory defects were found with decreased VC, TLC and lung compliance and increased maximal elastic recoil. Little evidence of airflow obstruction was found. Exercise capacity was decreased in three individuals but the mean value for the study group as a whole was normal. Arterial PO2 at maximum exercise was reduced but no patient had diminished hemoglobin saturation. Lung scintigraphy showed defects in 21 patients, mostly consisting of slight abnormalities at the lung periphery and apices. The perfusion seemed to be more affected than the ventilation, suggesting primary vascular lesions. Twelve patients showed signs of right ventricular hypertrophy in vector ECG and four of these had systolic pulmonary artery pressure greater than or equal to 30 mm Hg. The observed abnormalities were mostly of a minor degree and few clinically significant long-term effects of mantle radiotherapy on pulmonary function were observed.

An updated dose-response analysis in Hodgkin's disease

Although radiotherapy cures a very high percentage of early stage patients with Hodgkin's disease (HD), there is a controversial dichotomy in the dose recommendations believed necessary to achieve greater than 95% local control: Whereas one school of thought is to administer 40-44 Gy, other reports claim equal results with about 36 Gy. It is also not clear what doses are required for various tumor cell burdens. The original recommendation of 40-44 Gy was derived from a retrospective analysis of in-field control of disease from mostly kilovoltage data three decades ago. However, there have been many advances in the evaluation of the extent of the disease and in the practice of radiotherapy since the 1960s. Many more dose-control studies have been published in recent years, necessitating a revisit to the dose-response question in HD. Here we have compiled the dose-control data from the 60s to the 90s and analyzed the original and the updated data with the same statistical method to see any differences. We also have performed similar analysis of dose-control information for subclinical disease, less than 6 cm and greater than 6 cm disease. Whereas original analysis (1040 sites at risk) suggested 98% in-field control with 44 Gy, our re-analysis including modern megavoltage data (4117 sites at risk) shows that similar in-field control rates could be achieved with 37.5 Gy. With megavoltage radiotherapy, the doses required for 98% in-field control for subclinical disease and disease of less than 6 cm and greater than 6 cm are, 32.4 Gy (1426 sites at risk), 36.9 Gy (1005 sites at risk) and 37.4 Gy (98 sites at risk), respectively. The results of current updated analysis will provide in-field disease control probabilities for different disease burdens and can serve as a guide in deciding dose prescriptions for practicing radiation oncologists.

Estimation of doses to heart, coronary arteries, and spinal cord in mediastinal irradiation for Hodgkin's disease

Early-stage Hodgkin's disease is highly curable with radiotherapy. However, radiotherapy for Hodgkin's disease is not without complications, particularly those related to irradiation of the mediastinum. In attempts to decrease complications, it is important not to compromise the results. To plan such a strategy, one needs to know the doses delivered to various volumes of normal tissues with present techniques. However, such dose-volume data do not exist. Here we demonstrate, with computerized tomography-based dosimetric techniques, such a dose-volume relationship for the heart, coronary arteries, and spinal cord. The doses were determined retrospectively in eight patients. With a prescribed dose of 44 Gy, the volumes of the heart receiving at least 22, 26, 31, 35, 40, or 44 Gy were: 77%, 75%, 70%, 57%, 33%, and 2%, respectively. The average modal doses to the coronary arteries were: anterior interventricular artery, 18.48 Gy; circumflex arterial branch, 37.84 Gy; left coronary artery, 34.76 Gy; and right coronary artery, 36.96 Gy. The average maximum spinal cord dose was 37.25 Gy. A similar prospective documentation of dose-volume relationships and correlation with (functional) long-term complications may be helpful in the development of new strategies for decreasing complications.

Fertility following cancer therapy

This article reviews the literature relating to fertility following cancer therapy. Normal fertility clearly relies on normal gonadal and normal sexual function. Consideration is given here to the possible effects of surgery, radiotherapy and chemotherapy on fertility. Surgical techniques have now been described which in selected patients may allow normal erectile and ejaculatory function in the male, where previously impotence was inevitable. Maintaining radiation doses to the testes and ovaries to a minimum will reduce the incidence of radiation-induced sterility and may allow recovery of gonadal function. It is clear that cytotoxic chemotherapy does not inevitably result in permanent sterility. Some regimens are more toxic in this respect than others, and reducing the number of courses may improve the chances of retaining fertility. Hormonal manipulations designed to protect the gonad against cytotoxic damage have thus far been unsuccessful in the clinical situation.

Physiologic consequences of local heart irradiation in rats

Noninvasive methods have been used to study the long-term cardiovascular and pulmonary functional changes at rest and after exercise in adult rats following local heart irradiation with single x-ray doses of 15, 17.5 or 20 Gy, and in non-irradiated control animals. Rats that had undergone a chronic exercise program were compared with untrained cohorts. The earliest dysfunction detected was an increased respiratory rate (f) at 10 weeks after irradiation in the highest dose group. In contrast, both telemetric heart-rate (HR) and rhythm and indirect systolic blood pressure measurements performed at rest only revealed changes starting at 43 weeks after irradiation with 20 Gy, up to which point the rats showed no clinical signs of heart failure. However, the number of minutes required for the recovery of the HR to pre-exercise levels following the implementation of a standardized exercise challenge was elevated in untrained rats compared with their trained cohorts at 18 weeks after irradiation with 20 Gy. Increases in recovery times were required in the two lowest dose groups, starting at 26 weeks after irradiation. It was concluded that the reserve capacity of the cardiopulmonary system masks functional decrements at rest for many months following local heart irradiation, necessitating the use of techniques which reveal reductions in reserve capacities. Further, the influence of local irradiation to the heart and lungs deserves closer scrutiny due to mutual interactions.

The effects of different cumulative doses of chemotherapy on testicular function. Results in 75 patients treated for Hodgkin's disease during childhood or adolescence

Testicular function was evaluated in 75 boys after treatment for Hodgkin's disease with involved-field or extended-field irradiation and stage-dependent chemotherapy (vincristine, prednisone, procarbazine, Adriamycin [doxorubicin], and cyclophosphamide [OPPA/COPP]). Although pubertal development and testosterone levels were normal in all patients, 18 of 75 (24.0%) had elevated basal and 65/74 (87.8%) elevated stimulated luteinizing hormone (LH) levels, demonstrating chemotherapy-induced Leydig cell damage. In addition, there was a 40.5% and 53.4% incidence of elevated basal and stimulated FSH values, respectively, indicating severe impairment of spermatogenesis as confirmed by azoospermia in four patients. Testicular dysfunction was observed in patients treated before as well as during puberty. The incidence of elevated basal follicle stimulating hormone (FSH) and LH values was significantly higher in patients who had received higher cumulative doses of chemotherapy, i.e., 28.9% and 13.2% with two OPPA, 45.5% and 36.4% with two OPPA/two COPP, and 62.5% and 43.8% with two OPPA/four to six COPP, respectively. Chemotherapy for Hodgkin's disease causes a high and apparently dose-related incidence of testicular dysfunction in prepubertal as well as in pubertal boys affecting Leydig cell function as well as spermatogenesis. Circumstantial evidence indicates that procarbazine is the major gonadotoxic agent involved.

Thyroid iodine content and serum thyroglobulin level following external irradiation to the neck for Hodgkin's disease

Fifty-four clinically euthyroid patients were evaluated 1 up to 17 yr after external irradiation to the neck for Hodgkin's disease. T4 level was decreased in 6%, while basal TSH level was increased in 44%, and TSH response to TRH was increased in 66% of the patients with normal basal TSH level. Thyroid iodine content (TIC), measured in 50 patients, was below 5 mg in 18. The 29 patients with normal basal TSH level had a mean TIC (6.8 +/- 2.7 mg) significantly lower (p less than 0.01) than the control population (14.6 +/- 5 mg). A significant positive correlation was found between log T4 and log TIC (r = 0.55, p less than 0.01). Thyroglobulin (Tg) level was increased in 53% of the patients with no palpable thyroid abnormality. It was not related to TSH level but was related to younger age at irradiation. T4 treatment decreased Tg level to the normal range in 5 of 8 patients. These facts suggest subclinical thyroid abnormalities and patients with elevated Tg levels should be considered at risk for developing a thyroid tumor.

Thyroid function in survivors of cancer

Thyroid function was assessed in three selected groups of children who had survived cancer. Children in group 1 had received radiotherapy to the thyroid area, group 2 had radiotherapy to the thyroid area and adjuvant chemotherapy, and group 3 had chemotherapy with or without radiotherapy away from the thyroid area. There were 75 survivors and 63 (40 boys, 23 girls) were available for study. Eighteen (29%) were found to have thyroid dysfunction, and these included all those who had had lymphangiograms or received a radiation dose greater than 40 Gy to the thyroid area. Only nine of the 18 children were already known to have thyroid dysfunction, and only 15 of 44 children who had had irradiation to the thyroid area had had their thyroid function examined. This study shows that children who have received radiotherapy to the thyroid area should have their thyroid function assessed regularly. Chemotherapy does not appear to be a risk factor but longer follow up of these children is necessary.

Complications from large field intermediate dose infradiaphragmatic radiation: an analysis of the patterns of care outcome studies for Hodgkin's disease and seminoma

There are only infrequent complications from intermediate dose infradiaphragmatic radiation to the para-aortics or para-aortic and iliac nodal regions as given in Hodgkin's disease or seminoma. Nonetheless, such complications can cause significant debility and may be lifelong. Treatment related factors associated with such complications should be identified and where possible, avoided. We have analyzed the records of 1,026 patients treated nationwide in the Patterns of Care Outcome. Studies including the Hodgkin's national practice survey (387 patients), Hodgkin's large facility survey (253 patients), and Seminoma national practice survey (386 patients). There were 883 patients who received infradiaphragmatic radiation to the para-aortics or para-aortic and iliac regions. Complications which occurred in these patients included gastrointestinal injury, hepatitis, nephritis, gonadal injury, hematopoietic injury, second malignancy, and miscellaneous others. There were 139 complications of any severity and 35 major complications requiring hospitalization for management. The 3-year actuarial complication rates were 14% and 4% for any and major complications, respectively. There was a statistically significant increase in both any complications and major complications with dose (p less than .01). The most frequent complications were those related to gastrointestinal injury such as peptic ulceration, hemorrhage, chronic diarrhea, and intestinal obstruction. Major bowel complications comprised 60% (21/35) of major complications and increased with dose from 1% for doses less than 3,500 cGy to 3% for doses greater than or equal to 3,500 cGy (p = .03). This study indicates that total dose is an important factor in determining complications, particularly gastrointestinal injury, in patients receiving infradiaphragmatic radiation in Hodgkin's disease and seminoma and that prior G.I. disease is associated with an increased risk of radiation related bowel complication. The radiotherapist should seek to optimize the therapeutic ratio in these diseases where gross disease can be controlled with 3500 cGy or less with few exceptions.

Cardiopulmonary function in long-term survivors of childhood Hodgkin's lymphoma: a pilot study

Twelve patients who had received mantle radiotherapy for Hodgkin's lymphoma during childhood underwent cardiopulmonary testing 7 years or more after the initial diagnosis and treatment. All but one patient had been asymptomatic. Results of echocardiography, pulmonary function tests, or exercise studies were abnormal in 9 of the 12 patients. Long-term follow-up of cardiopulmonary function will be important to determine the ultimate significance of these abnormalities. These potential complications must be considered in planning prospective therapeutic studies in children with Hodgkin's disease.

Treatment of patients with "minimal" stage IIIA Hodgkin's disease

Treatment recommendations for patients with upper abdominal Stage IIIA Hodgkin's (III1A) disease have varied widely. The current study reports on a combined institutional retrospective review of 85 patients with surgically staged III1A Hodgkin's disease. Twenty-two patients received combined modality therapy (CMT), 36 patients were treated initially with total nodal irradiation (TNI), and 27 with mantle and para-aortic radiotherapy (MPA). Patients treated with CMT had an actuarial 8-year freedom from relapse (FFR) of 96% as compared to a FFR of 51% in TNI treated patients (p = 0.002), and a FFR of 54% in MPA treated patients (p = 0.004). Of the 11 relapses in MPA treated patients, 7 had a component of their failure in the untreated pelvic or inguinal nodes. The patients treated with CMT had an 8-year actuarial survival of 100% as compared to 79% in TNI treated patients (p = 0.055) and 78% in patients treated with MPA (p = 0.025). Histology and the number of splenic nodules were the most important prognostic variables. Patients with MC/LD histology and greater than or equal to 5 splenic nodules have a high risk of relapse (10/13) when treated with radiation alone (TNI or MPA). We recommend CMT for this group of patients. Patients with NS/LP histology and 1-4 splenic nodules represent a favorable subset of Stage III1A patients. Only 4/21 patients have relapsed and all 21 patients are currently alive without disease regardless of treatment. We currently feel that patients with Stage III1A Hodgkin's disease with NS/LP histology and splenic disease limited to 1-4 nodules are good candidates for MPA as an alternative to TNI or CMT.

Recovery of spermatogenesis following pelvic irradiation for Hodgkin's disease

Spermatogenesis of 18 male patients who underwent pelvic irradiation for Hodgkin's disease was assessed. All patients had supplemental testicular shielding to limit the testicular dose. The total calculated gonadal dose ranged from 28 to 135 rad, delivered in 22 to 29 fractions, whereas the adjacent lymph nodes were treated to 3750-4500 rad. Sperm concentration of 20 million per ml or greater was considered fertile. Oligospermic and azoospermic determinations were considered subfertile. Whereas only one of six patients (17%) was fertile when tested less than 18 months following pelvic radiotherapy, four of six (66%) were fertile when tested between 18 and 26 months following therapy. Seven of eight patients (88%) were fertile when tested more than 26 mo following completion of treatment. The results are compared to other reports in the literature. Our data support the concept of a time-dependent recovery of spermatogenesis following irradiation. The observed relatively short duration of temporary sterilization should encourage the use of meticulous pelvic shielding, including supplemental testicular shielding to minimize the absorbed gonadal dose.

Thyroid cancer following radiotherapy for Hodgkin's disease: a case report and review of the literature

Improved survival resulting from advances in therapy in patients with Hodgkin's disease is associated with long-term morbidity, including the potential for the development of a second solid malignancy. We report a 44-year-old man with an unusually aggressive course of thyroid carcinoma 15 years after treatment for Hodgkin's disease. In a review of the English-language literature, we found 21 cases of thyroid cancer following radiotherapy for Hodgkin's disease, with latency periods ranging from 6 to 48 years. The development of secondary thyroid cancer after high-dose neck irradiation may be related to hypothyroidism, itself a complication of radiotherapy. Thyroid function should be measured at least once a year in all patients given neck irradiation, with initiation of thyroid hormone replacement if there is evidence of sustained hypothyroidism.

Erythropoietic recovery in human after extended field radiotherapy. Ferrokinetic studies of patients treated by radiotherapy followed by autologous bone marrow transplantation and of patients treated by moderate doses (20 Gy) of radiotherapy

The ability of human irradiated bone marrow to provide suitable environment for migrating stem cells has been studied in four patients. These had received chemotherapy plus doses of 40 Gy to thoracic vertebrae and sternum, followed by autologous bone marrow transplantation. The erythropoietic activity in the non-irradiated areas was increased but it was low in irradiated areas at 3.5 weeks and undetectable at 6 months after autotransplantation. This shows that no nidation of migrating stem cells actively contributed to bone marrow regeneration after 40 Gy and suggests the existence of environmental lesions. No extramedullary erythropoiesis and no bone marrow extension were found in these patients. Four patients who had received doses of 20 Gy to extended bone marrow volume were submitted to ferrokinetic studies from one to 18 years after radiotherapy. In non-irradiated areas the erythropoietic activity was within the normal range. In irradiated areas, it was significantly lower than in the non-irradiated areas and was intermediate between the erythropoietic activity in the sacrum of six healthy control subjects and in the irradiated areas of the four autografted patients. Bone marrow extension was found in these patients. This study suggests that bone marrow recovery after irradiation might not be an all-or-none phenomenon. It would be of interest to better document the dose-effect relationship.

The paradoxes in patterns and mechanism of bone marrow regeneration after irradiation. 1. Different volumes and doses

Bone marrow regeneration (BMR) following irradiation has been largely studied as a dose-effect phenomenon, however, a large literature has simultaneously developed utilizing a wide variety of volumes, both in clinical studies and in experimental studies. In human situations radiation treatment fields and the amount of bone marrow organ exposed have ranged from total body irradiation (small daily and total doses) to large field (half-body) single high doses encompassing 50% of the bone marrow, to segmental or localized field (50-25%). Volume factors, more than dose, determine patterns of suppression and regeneration which have been documented by a variety of assay systems. Experimental evidence is presented which indicates that high dose irradiation (500-1000 cGy) to large volumes of bone marrow (50%) does not completely suppress bone marrow regeneration but results in a rapid compensatory response. The nadir response of bone marrow CFUc-GM stem cell compartment was directly proportional to increasing doses of irradiation (200-2000 cGy) delivered to a single limb. Immediate depression of CFUc-GM was followed by an increase proliferative phase with the most notable difference observed in doses less than or greater than 1000 rad. Following doses of 500 and 1000 rad to large field (half-body), an immediate depression was again observed followed by an immediate and greater compensatory response particularly after the 1000 rad dose. Comparisons ae made between the small and larger volumes at similar doses and indicate a greater overall compensatory response after the larger field irradiation, being more rapid in onset particularly after the 1000 rad dose. Although in-field regeneration of bone marrow occurs after single dose radiation to different volumes of bone marrow, experimental and clinical evidence from protracted conventional doses of irradiation to different volumes of bone marrow (greater or less than 50%) indicate significantly different response mechanisms. From our laboratory and clinical investigations it can be determined that bone marrow is extremely sensitive to radiation insult and has different compensatory mechanisms to "fine tune" its response in proportion to the volume insulted.

Testicular function in young men in long-term remission after treatment for the early stages of Hodgkin's disease

16 young men in long-term remission after standard treatment for the early stages of Hodgkin's disease were examined for testicular function 48 to 125 months after termination of therapy. The patients had received mantle field irradiation, plus either irradiation of infradiaphragmatic lymph nodes (7 patients) or 6 cycles of MOPP (9 patients). 5 patients had almost normal semen quality judged by seminal fluid analysis. 11 patients had reduced semen quality (8 severely reduced) and often elevated FSH values. Semen samples of poor quality were significantly more common in patients treated with MOPP (7/9) than in those treated with infradiaphragmatic irradiation (1/7). One patient showed signs of regeneration of spermatogenesis. None had experienced reduction in libido and sexual performance after therapy; correspondingly, none had below normal testosterone values or elevated LH values. Patients should be informed about the risk of infertility before treatment. If in a given case several treatment options with equal prospective antineoplastic effect are weighed against one another, the patient's possible desire to retain fertility should favour the use of radiotherapy as opposed to chemotherapy, especially including alkylating agents.

Serial thyroid function measurements in children with Hodgkin disease

Thyroid function was measured serially in 28 children with Hodgkin disease diagnosed from 1971 to 1978. The patients' ages ranged from 4 to 16 years at diagnosis, and treatment consisted of chemotherapy only (four patients), radiation alone (15), or radiation plus chemotherapy (nine). None of the four children given chemotherapy only developed thyroid hypofunction, in contrast to 21 (88%) of the 24 children given high doses of radiation (P less than 0.001). Thyroid function in three patients with compensated hypothyroidism and in one child with primary hypothyroidism reverted to normal without thyroid replacement. One child given chemotherapy only and one child given radiation only became transiently hyperthyroid. These results indicate that patients given combined modality therapy for Hodgkin disease are at high risk for thyroid abnormalities. The results of long-term follow-up of thyroid function demonstrate, however, that all such thyroid abnormalities may not necessarily be permanent.

Thyroid dysfunction after radiotherapy in children with Hodgkin's disease

Thyroid function was measured in 119 children, 16 years of age or less, after radiotherapy (XRT) for Hodgkin's disease. Thyroid abnormalities developed in 4 of 24 children (17%) who received 2600 rad or less, and in 74 of 95 children (78%) who received greater than 2600 rad to the cervical area, including the thyroid. The abnormality in all but three (one with hyperthyroidism and two with thyroid nodules) included the development of elevated levels of thyroid stimulating hormone (TSH). Age, sex, and administration of chemotherapy were not significant factors in the development of thyroid dysfunction. All children had lymphangiograms (LAG) and no time relationship was noted between thyroid dysfunction and LAG-XRT interval. The mean interval from radiotherapy to documented thyroid dysfunction was 18 months in the low-dose group and 31 months in the high-dose group, with most patients becoming abnormal within 3 to 5 years. Of interest was a spontaneous return of TSH to within normal limits in 20 children and substantial improvement in another 7. This study confirms the occurrence of dose-related occult hypothyroidism in children following external irradiation of the neck.

Respiratory function tests after mantle irradiation in patients with Hodgkin's disease

Pulmonary function tests were performed in 43 patients with Hodgkin's disease before mantle irradiation and at 3, 6, 9, 12 and 15 or more months thereafter. Treatment was given with a telecobalt unit to a total dose of 36 to 42 Gy, the higher dose being reserved for cases with considerable mediastinal involvement. The functional parameters explored included static and dynamic lung volumes, gas exchanges, ventilatory efficiency, and airway resistance. Measured parameters were expressed as a percentage of the pre-treatment value (PTV) in the individual patient. In the whole group, only small variations in the functional indices were observed at 3 to 6 months after mantle irradiation. In patients with normal PTVs a greater variation in static and dynamic volumes was observed at 3 to 6 months after mantle irradiation, with complete recovery thereafter. The gas exchange parameters also showed a similar variation at 3 to 6 months but no recovery was demonstrated in the subsequent examinations. No changes in ventilatory efficiency and airway resistance were observed. In patients with abnormal PTVs, usually presenting large mediastinal adenopathy, all parameters improved after mantle irradiation, and the favourable effect of tumour regression was probably more important than the radiation damage on the pulmonary parenchyma.

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.

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.

Late effects on human bone marrow after extended field radiotherapy

Thirty-two patients with lymphoma were treated with extended radiotherapy (RT) at a dose of Gy and were studied by ferrokinetic studies and surface counting at various times following irradiation. Loss of hematopoietic activity in the irradiated areas is compensated by increased activity in the non-irradiated areas. Despite the return of peripheral blood counts to normal, the hyperactivity of the non-irradiated bone marrow persists over up to 13 years after RT, while the hematopoietic activity of the irradiated areas remains depressed and is only slightly higher than immediately after RT. The hypoactivity persisted even when the hemopoietic tissues had been subjected to the intense stimulation provoked by an aplasia caused by chemotherapy. However, a recovery was observed for dose of 20 Gy or lower. The hemopoietic activity of the irradiated bone marrow appears to be related to the volume of the marrow irradiated and is higher after a mantle + inverted Y field than after a mantle field. Both marrow scintigraphies with 59Fe in 7 out of 9 patients studied revealed an extension of hematopoiesis into a normally dormant area of the marrow, such as the femora. In 2 patients an erythropoietic activity was observed in spleens which had received a dose of 40 Gy, and extra medullary erythropoiesis was found in approximately two-thirds of the patients.

The effects of conventionally fractionated, extended portal radiotherapy on the human peripheral blood count

Conventionally fractionated, extended portal radiotherapy (CFEPRT) has been used to treat two diseases in which there was no marrow infiltration (viz. Hodgkin's disease and medulloblastoma). Blood count indices have been monitored during therapy and in the recovery phase. The lymphocytes were the most sensitive and the monocytes the most refractory leucocytes to change; the monocyte count tended to recover during CFEPRT. The platelet count fell gradually and soon after the neutrophil count. The nadir counts for white cells and platelets occurred early or toward the middle of CFEPRT, after which levels were maintained. The hemoglobin slightly and progressively declined. The patterns of change were similar for the two portals analyzed. Absolute eosinophilia occurred in 9 of the 53 CFEPRT patients, often in the recovery period. All patients who maintained their early nadir levels throughout the rest of the CFEPRT demonstrated fast recovery of all indices following completion of radiotherapy; the lymphocyte count recovered fastest. Recent prior CFEPRT or standard MVPP (nitrogen mustard, vinblastine, procarbazine, prednisolone) chemotherapy rendered the blood count more liable to radiation induced cytopenia. A lapse of more than 3 months between MVPP and CFEPRT allowed greater tolerance to the radiotherapy. Recent MVPP may be less myelosuppressive than recent mantle radiotherapy with respect to subsequent tolerance to CFEPRT.