Further follow-up of results of treatment in 90 laparotomy-negative stage I and II Hodgkin's disease patients: significance of mediastinal and non-mediastinal presentations

Stage I and II Hodgkin's Disease Presenting in Infradiaphragmatic Nodes

Twenty patients with Hodgkin's disease limited to infradiaphragmatic (ID) nodes have been treated at the University and Hospital Radiotherapy Departments in Florence between 1960 and 1978. Clinicopathologic features and treatment modalities of these patients were reviewed and results compared with those of 2 similar series previously published by other authors. With respect to the patients with disease above the diaphragm, the ID presentation occurred more often in males in all the 3 reviewed series; a relative prevalence of the lymphocytic predominance histotype and of an older age was observed in 2 only of the 3 series; laparatomy seems unnecessary in lymphographic-negative patients. The analysis of therapeutic results suggests that inverted Y irradiation is a sufficient treatment when inguinal or lower iliac nodes only are affected; paraortic region and spleen involvement warrant a more radical program including the supradiaphragmatic irradiation or systemic chemotherapy.

Follow-Up of Pathological Stage I and IIA Supradiaphragmatic Hodgkin's Disease Primarily Treated with Radiotherapy

One hundred and fifty-five consecutive previously untreated adult patients with supradiaphragmatic pathologic stage IA (71) and IIA (84) Hodgkin's disease treated only with radiotherapy (RT) at the Istituto Nazionale Tumori of Milano from 1970 to 1978 were reviewed. Staging procedures included lymphangiography and laparotomy in all cases. Most patients were irradiated with a conventional cobalt machine. Mantle fields were adopted for 36.8% of cases, mainly at stage I, whereas 63.2% received mantle plus paraaortal irradiation. Doses were above 40 Gy for involved sites and 35–40 Gy for prophylactically irradiated nodes. Minimum and median follow-up were 30 months and 6 years, respectively. All patients achieved complete remission at the end of RT. As of June 1981, 89 of 155 patients (57.5%) were alive and free from progression, 60.6% at stage I, and 54.8% at stage II. Relapses occurred in 54 of 155 cases (35%) after a median free interval of 21 months. Marginal recurrences accounted for 5.8%, true recurrences for 9%, nodal extensions for 8.4%, and extranodal extensions for 11.6%. Males older than 40 years and mediastinal involvement were correlated with higher relapse rates. Salvage treatment consisted of RT alone in 8 patients and chemotherapy plus or minus RT in 44, whereas 2 patients died before a new treatment could start. As of June 1981, 38 of 54 relapsed patients (70.4%) were alive and disease free, whereas 2 were alive with evidence of disease. Actuarial overall survival at 6 years was 90.3% for all cases, 97.1% for stage I, and 84.8% for stage II. Treatment toxicity was analyzed, and problems concerning surgical staging procedures, optimal RT and role of chemotherapy as primary or salvage treatment were discussed.

Bulky mediastinal Hodgkin's disease management and prognosis

Of a total of 235 Stage I and II Hodgkin's disease patients treated between 1970 and 1979, 103 (43.8 per cent) had mediastinal involvement in 45 of whom the disease was bulky and in 58 non-bulky. This report concentrates on bulky disease patients of whom 45 per cent did not relapse after therapy and 71 per cent are alive. Patients with mediastinal disease were treated with radiotherapy (63), sequential chemo-radiotherapy (37) or chemotherapy alone (3). In the radiotherapy group the relapse rate for bulky disease was significantly higher (65 per cent) than for non-bulky disease (44 per cent) (P less than 0.05) although there was no significant difference in survival. Neither relapse rate nor survival differed significantly in bulky disease patients treated with radiotherapy compared with combined chemo-radiotherapy although there was a 20 per cent difference in relapse-free survival rate in favour of the combined treatment group at five years. Treatments were not allocated randomly and the chemo-radiotherapy group contained a disproportionate number of patients with adverse features (greater than 3 node areas involved, limited lung extension) compared with the irradiated group; 11/25 and 2/17 respectively. The number of lymph node areas involved appeared to influence the relapse rate in the radiotherapy group. There was no correlation between mediastinal mass size and number of node areas involved suggesting that these two features may be independent prognostic factors.

Current concepts and controversies in the management of early stage Hodgkin lymphoma

Over the past three decades, due to the recognition of late effects related to high-dose extended field radiotherapy and heavy alkylator chemotherapy, combined modality therapy with abbreviated chemotherapy and limited field radiotherapy has emerged as the standard of care for early stage Hodgkin lymphoma, with cure rates in excess of 80%. Currently, however, controversy remains over identifying the most appropriate criteria to risk-stratify patients with early stage disease, so that those with a favorable prognosis receive limited treatment without compromising cure rates and those with unfavorable risk receive more intensified therapy. The optimal risk stratification system remains unclear, with variable definitions of favorable and unfavorable disease used by research groups in North America and Europe. Thus, comparison of clinical trial results has been challenging, and additional controversies persist regarding optimal chemotherapy regimens, duration of therapy, and the role of radiotherapy. Investigations are ongoing to assess the potential of functional imaging and biomarkers as tools for risk stratification. The collective goal is to further refine current stratification strategies to allow for an individualized, risk-adapted treatment approach that minimizes long-term late effects without compromising high cure rates.

The management of stage I-II supradiaphragmatic Hodgkin's disease with chemotherapy alone

The treatment of choice for patients with early stage Hodgkin's disease (HD) has been extended field or subtotal nodal irradiation. Remission rates of over 95% have been obtained, however, about 5% of stage I and II patients will suffer from progressive disease while on therapy and an additional 15-20% will relapse. Chemotherapy (Ch) alone has not been adequately tested in early-stage HD. In this study, all HD stage I and II patients treated with Ch alone in the University Hospital "Clínica Puerta de Hierro" between 1980 and 1997 were reviewed. Thirty-five patients were treated between 04/80 and 12/97. All patients achieved complete remission. The median follow-up was 119 months (range 21-240 months), no patients were lost at follow-up. Overall survival (OS) was 97% (IC 95%, 92-100) at 5 years and 88% (IC 95%, 75-100) at 10 years. Failure free survival (FFS) was 93% (IC 95%, 83-100) at 5 years and 66% (IC 95%, 47-86) at 10 years. Three (8.5%) patients died: two due to a second tumour (non-Hodgkin's lymphoma and myeloid acute leukaemia) and the other due to sepsis post-Ch. Univariate and multivariate analysis only associated histology subtype relative risk (RR) 4.0 nodular sclerosis (95% IC, 1.0-5.5; p:0.02) with higher relapse. Other prognostic factors did not reveal significant differences with respect to failure free or OS. In conclusion, we believe that death from HD in early-stage patients is unusual and mortality from causes other than HD occurs many years later. Outside clinical trials due to the lack of clear prognostic factors, with the exception of specific situations, patients should be informed of all the possible alternatives as well as the consequences of the treatments employed. In our experience, it appears that using Ch alone in the initial stages does not jeopardize overall patient survival, with similar results being achieved.

Current treatment of Hodgkin's disease

In spite of the fact that Hodgkin's disease (HD) remains still an enigma its management and treatment yield a cure rate of about 80% of all patients. However, this management has two limits: on one side favourable cases which should not be overtreated because of unacceptable side-effects, and on the other side very unfavourable cases which should be treated differently because of a very high rate of failure and/or relapse. Then it becomes necessary to precise as thoroughly as possible these two limits in order to choose the adequate treatment for the patient. Prognostic factors based on patient and disease characteristics allow a relatively exact classification of favourable and unfavourable cases. This distinction in two prognostic groups has therapeutic implications in terms of chemotherapy (regimen, duration) and radiotherapy (extension, doses). Other specific situations have to be considered, e.g. pediatric cases, pregnancy, old age and HIV-infected patients who need an adapted management according to very different situations.

Assessment and significance of mediastinal bulk in Hodgkin's disease: comparison between computed tomography and chest radiography

PURPOSE

In Hodgkin's disease (HD), mediastinal bulk is currently defined from chest radiograph (CXR) measurements as a ratio of the maximum transverse mass diameter to the internal thoracic diameter at T5/6 level > or = 0.33. We evaluated how computed tomographic (CT) measurements of bulk correspond to those obtained from the CXR and correlated nodal mass long axis diameter with freedom from progression.

METHODS

Ninety-five adult patients who had a CXR thoracic ratio of greater than 0.3 and a CT scan within 28 days of the CXR were included in the study, provided that both investigations were performed before the start of treatment. Measurements of the widest mediastinal diameter and internal thoracic diameter were made on both CXR and CT scan. The thoracic ratio (TR) was calculated for each modality and compared using paired t tests. The longest diameter of the largest individual nodal mass (LIM(CT)) was also measured from the CT and correlated with freedom from progression using Cox regression.

RESULTS

There was excellent correlation between CT and CXR for measurement of TR, with TR(CT) greater than TR(CXR) (mean difference of 2%). A TR(CT) of 0. 35 was found to be equivalent to a TR(CXR) of 0.33. No single measurement of nodal size correlated with the current definition of bulk. However LIM(CT) greater than 10 cm did correlate with increased risk of progressive HD (P =.03), even after adjustment for other prognostic variables (chemotherapy regimen and Hasenclever Prognostic Index).

CONCLUSION

Excellent correlation was observed between assessment of TR by CXR and CT scan. The longest diameter of the LIM(CT) greater than 10 cm was found to be associated with an increased risk of disease progression.

Stage IA-IIB Hodgkin's disease: management and outcome of extensive thoracic involvement

PURPOSE

To examine the presentation, management, and outcome of patients with extensive intrathoracic involvement in early-stage Hodgkin's disease.

PATIENTS AND METHODS

One hundred seventy-two patients with clinical Stage IA-IIB Hodgkin's disease and extensive intrathoracic involvement were studied. Extensive intrathoracic disease was defined as either large mediastinal adenopathy (LMA, defined as the width of the mass greater than one-third the maximum thoracic diameter, n = 154) or as extensive (> 10 cm) cephalocaudad intrathoracic disease that did not fulfill formal chest radiograph criteria for LMA (n = 18). Patients were divided into three groups based on staging and extent of treatment. Forty-seven patients were treated with radiation alone after a laparotomy (RT-lap), 47 patients received combined modality therapy after laparotomy (CMT-lap), and 78 patients were treated with combined modality therapy without staging laparotomy (CMT-no lap). MOPP was used in 82% of the CMT patients. Low-dose whole-cardiac RT was used in nearly 50% of patients treated either with RT or CMT.

RESULTS

The 10-year actuarial freedom from relapse rates were 54% with RT alone and 88% with CMT (p = 0.001); overall survival rates were 84 and 89%, respectively (p = NS). The median time to relapse was only 17 months. Over 80% of relapses occurred within the first 3 years. The most common site of relapse in all patients was the mediastinum. Relapses below the diaphragm were rare, even in CMT patients who did not receive abdominal radiation treatment. The principal acute morbidity was symptomatic pneumonitis, which occurred in 29% of patients receiving any part of their chemotherapy after RT, compared to 13% if all the chemotherapy was given before RT and 11% if RT alone was administered. There was a low late risk of myocardial infarction (3%) in the two groups with the longest follow up (RT-lap, CMT-lap), but a higher risk of second malignancy in the CMT-lap group (21%) compared with the RT-lap group (2%).

CONCLUSION

Extensive intrathoracic involvement is a distinctive presentation of early-stage HD that has a high relapse risk if treated with RT alone. The introduction of CMT has been associated with improvements in freedom from relapse. The low rate of peripheral relapse with CMT suggests that reductions in field size may be achievable. The use of low-dose whole-heart RT with modern techniques is not associated with a high risk of late cardiac complications and should be used in patients who present with extensive pericardial disease or cardiophrenic lymphadenopathy. The high rate of second malignancy in the CMT group with the longest follow-up suggests that careful long-term surveillance for such patients is warranted.

Management of early stage Hodgkin's disease: the role of radiation therapy and/or chemotherapy

The treatment of early stage HD has become more complicated over the past 10 years. The development of standards for both radiation therapy and chemotherapy have made it more feasible to treat HD in community practice settings. Yet initial treatment decisions may have profound long-term effects on patients who are young and likely to have a long survival. Whenever possible, routine cases should be treated along guidelines of standard accepted practice, and physicians should refer patients to major centres for the management of more complicated cases. There is hope that less toxic chemotherapy will be effective in curing occult microscopic disease, perhaps eventually obviating the need for staging laparotomy and splenectomy. Yet for now, there are little long-term data defining specifics of treatment, or the long-term efficacy or toxicity of modified regimens. Thus at present, the management of patients with HD in ways that do not adhere to standard practice, such as modifying standard RT or chemotherapy, should be strongly discouraged outside controlled clinical trials. In parts of the USA there is still a general acceptance of staging laparotomy and splenectomy as a means to aggressively stage patients in order to minimize treatment. By utilizing diagnostic laparotomy and splenectomy, the majority of patients with PS IA-IIA HD will be cured with RT alone thus sparing them the toxicity of combined chemotherapy and RT, and preserving the effectiveness of chemotherapy in case of relapse. Using this approach, patients who are likely to need chemotherapy due to a high risk of relapse (LMA, or extensive B symptoms), or high risk for having abdominal involvement (more than one positive abdominal radiographical test) should not undergo a staging laparotomy. In addition, chemotherapy and limited field irradiation may be preferred under special circumstances (i.e. for paediatric patients). Diagnostic staging laparotomy and splenectomy is not routinely performed outside the continental USA. Academic centres in Canada, Europe and South America have identified prognostic factors to aid in determining treatment for clinically staged patients. Patients with the most favourable characteristics receive RT alone with CMT used for the remainder of patients. On average, without the information obtained at staging laparotomy, patients require more treatment, either with larger radiation fields, or with the more frequent use of chemotherapy.

Management of early stage Hodgkin's disease: the role of radiation therapy and/or chemotherapy

Clinical trials in early stage Hodgkin's disease comparing radiation therapy (RT) alone versus chemotherapy (CMT) have indicated fewer relapses in the CMT groups. However, none of the trials have demonstrated an overall survival difference. Risk factors for relapse in early stages include large mediastinal adenopathy, fevers, and weight loss. Ongoing clinical trials might prove less toxic CMT effective in curing occult microscopic disease, perhaps eventually obviating the need for staging laparotomy and splenectomy.

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.

Hodgkin's disease with bulky mediastinal involvement: effective management with combined modality therapy

PURPOSE

To assess results, complications, treatment techniques, and patterns of failure in patients with bulky mediastinal Hodgkin's disease treated with combined modality therapy.

METHODS AND MATERIALS

Between 1980 and 1988, 48 patients with Hodgkin's disease who had large mediastinal masses were treated at Stanford University. All patients were staged with clinical studies which included computed tomographic scans of the chest and bipedal lymphograms. Initially, 10 patients underwent staging laparotomy and splenectomy, subsequently all patients were staged by clinical criteria alone. Mediastinal mass ratios ranged from .35 to .85 (mean .46). The majority of patients had at least one site of extralymphatic extension (E-lesion) within the chest. Combined modality therapy included MOPP (prednisone deleted after mediastinal irradiation) in 15, ABVD in 14, and PAVe in 19 patients. All patients received mantle irradiation (mean dose 44 Gy) but only patients with abdominal disease received subdiaphragmatic irradiation.

RESULTS

The actuarial survival and freedom from relapse were 84% and 88% at 9 years. There was an intrathoracic component of failure in all seven patients who either failed to achieve an initial complete response or who experienced a relapse after a complete response. Both patients who experienced a relapse after a complete response achieved durable second responses with subsequent chemotherapy. Two of five patients who failed to achieve an initial complete response were treated successfully with alternative chemotherapy.

CONCLUSIONS

Routine combined modality therapy is the treatment of choice for patients with Hodgkin's disease who have large mediastinal masses.

The reliability and value of determining mediastinal involvement and width on chest radiographs in patients with Hodgkin's disease

Over the years several methods for evaluating mediastinal involvement in Hodgkin's disease have been applied to chest radiographs and conflicting results have been reported. In a retrospective study of 104 patients we evaluated interobserver variability in assessing mediastinal involvement and investigated various cut-off points for mediastinal size as to their ability to identify patients with high- and low-risk for recurrence. For mediastinal involvement the concordance rate for two reviewing radiologists was 94% (98/104) and compared with prior assessment by outside radiologists the concordance rates were 90% (94/104) and 88% (92/104), respectively. A good correlation between the reviewing radiologists was found for the quantitative evaluation of mediastinal diameter and thoracic ratios. ROC curves and relative risk figures were used to investigate the various cut-off points for mediastinal width and for the ratios of the maximal mediastinal diameter to the chest diameter at Th 5-6 (M1) and to the chest diameter at the widest thoracic level (M2). Neither the ROC curve analysis nor the use of relative risk figures revealed a cut-off point clearly more accurate in predicting recurrence. In conclusion, our results do not suggest that interobserver variability in mediastinal assessment, differences in the method of mediastinal measurement, or the cut-off points applied to mediastinal width can explain the discrepancies in the reported data on the prognostic value of mediastinal width in Hodgkin's disease, but rather factors such as patient selection and differences in treatment given may be responsible.

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.

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.

Treatment of lower torso stages I and II Hodgkin's disease with radiation with or without adjuvant mechlorethamine, vincristine, procarbazine, and prednisone

From 1956 to 1987, 60 patients with either lymphangiogram-staged or laparotomy-staged I-II lower torso presentations of Hodgkin's disease were treated with radiation with or without Mustargen (mechlorethamine), vincristine, procarbazine, and prednisone (MOPP). In 22 with inguinal/femoral or pelvic disease and 24 with abdominal disease, treatment consisted of radiation only. Fourteen other patients with abdominal disease received MOPP chemotherapy before radiotherapy. In 11, the chemotherapy was limited to two cycles. At 10 years, the determinate survival and freedom from progression rates for all patients were 82% and 72%, respectively. For patients with inguinal/femoral or pelvic disease who were treated with radiation only, the corresponding rates were 90% and 86%. For patients with abdominal disease who received radiation only, the determinate survival and the freedom from progression rates were only 66% and 50%, respectively. However, corresponding results for 14 patients with abdominal disease who were treated with MOPP and radiation were 100% and 92% (P = 0.033 and P = 0.009, respectively.

Radiation therapy in the management of bulky mediastinal Hodgkin's disease

From July 1981 to July 1985, 20 patients with bulky mediastinal Hodgkin's Disease (maximum mediastinal width divided by the maximum intrathoracic diameter for a mediastinal mass ratio (MMR) greater than 0.33 were treated at Stanford University with definitive radiation therapy alone. The majority of these patients were selected to receive radiation therapy because they had the more favorable characteristics of minimal extralymphatic involvement, mediastinal masses that were superior and central in location, and a MMR less than or equal to 0.50. All 20 patients were laparotomy staged, and 17 received some radiation to the mantle before laparotomy. Seventeen patients had pathologic stage (PS) II disease (13 PS IIA, 4 PS IIB), two had PS IIISA, and one had PS IB. Eleven patients (55%) had extralymphatic involvement. All patients were irradiated to the mantle field using a shrinking field technique (mediastinal dose, 4400 to 5500 cGy, mean 4990 cGy). After completion of the mantle, all patients with good clinical responses received infradiaphragmatic radiation. Treatment complications included two cases of mild radiation pneumonitis, five of hypothyroidism, five of localized Herpes zoster, one of amenorrhea, one of non-Hodgkin's lymphoma, and one of sepsis. Four patients relapsed. All had an intrathoracic component to their failure. All four patients were salvaged with MOP(P) chemotherapy and are currently alive and free of disease. For the entire group, the actuarial freedom from relapse is 80% at 7 years and the survival is 100%. Median follow-up time is 67 months. The authors conclude that radiation therapy alone is effective in the management of selected patients with Hodgkin's disease who have extensive mediastinal involvement, even when the MMR exceeds 1/3.

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).

Thoracic irradiation in Hodgkin's disease: disease control and long-term complications

A total of 590 patients with Stage IA-IIIB Hodgkin's disease received mantle irradiation at the Joint Center for Radiation Therapy between April 1969 and December 1984 as part of their initial treatment. Recurrence patterns as well as pulmonary, cardiac and thyroid complications were analyzed. Pulmonary recurrence was more frequently seen in patients with large mediastinal adenopathy (LMA); 11% of patients with LMA recurred in the lung in contrast to 3.1% with small or no mediastinal disease, p = 0.003. Hilar involvement, when corrected for size of mediastinal involvement, was not predictive of lung relapse. Patients with LMA also had a high rate of nodal relapse above the diaphragm (40%) following radiation therapy (RT) alone as compared to similarly treated patients with small or no mediastinal adenopathy (6.5%), p less than 0.0001. This risk of nodal recurrence was greatly reduced (4.7%) for LMA patients receiving combined radiation therapy and chemotherapy (CMT), p less than 0.0001. Sixty-seven patients (11%) with hilar or large mediastinal involvement received prophylactic, low dose, whole lung irradiation. No decrease in the frequency of lung recurrence was seen with the use of whole lung irradiation. Radiation pneumonitis was seen in 3% of patients receiving radiation therapy alone. In contrast, the use of whole lung irradiation was associated with a 15% risk of pneumonitis, p = 0.006. The risk of pneumonitis was also significantly increased with the use of chemotherapy (11%), p = 0.0001. Cardiac complications were uncommon with pericarditis being the most common complication (2.2%). Thyroid dysfunction was seen in 25% of patients and appeared to be age-related. These data suggest that the long-term complications of mantle irradiation are uncommon with the use of modern radiotherapeutic techniques. The use of prophylactic whole lung irradiation is no longer recommended since its use did not reduce pulmonary relapse but did increase the risk of pneumonitis. Chemotherapy is also associated with an increased risk of pneumonitis, however, its use in patients with large mediastinal adenopathy appears justified.

The prognostic influence of mediastinal bulk in pathological stage IIA Hodgkin's disease treated initially with radiotherapy

The response to treatment and survival has been assessed in 61 patients with pathological Stage IIA Hodgkin's disease with mediastinal involvement who were treated initially by supradiaphragmatic radiotherapy alone. Although 57 (93%) obtained complete remission, 29 have relapsed giving a total of 33 (54%) treatment failures. The percentage of patients actuarially disease free at 5 years is 44% although overall survival is 90%. The "bulk" of the mediastinal disease was assessed on a plain chest X-ray by measurement of the widest diameter of the mass compared to thoracic diameters at various levels as well as by determination of the area of the mass. The ratio of the widest diameter of the mass to the widest internal thoracic diameter provided the greatest prognostic information. Patients with a ratio greater than 0.33 (30% of total) had an actuarial disease-free survival of 24% at 5 years compared to 54% in patients with smaller mediastinal masses (P less than 0.05). Mediastinal bulk was not correlated with histological grade. Patients with the largest mediastinal masses (ratio greater than 0.37) (10% of total) have a lesser survival, but in the remainder, measurement of the mediastinal mass did not predict survival, indicative of the excellent salvage rate with subsequent chemotherapy. The implication of these findings for the treatment of stage IIA Hodgkin's disease with mediastinal involvement is discussed.

A risk factor for relapse in Hodgkin's disease: female gender?

A retrospective study of 163 patients with Hodgkin's disease treated between 1969 and 1987 was performed to identify adverse prognostic factors. One hundred and thirty-five patients (83 per cent) attained a complete remission and 42 (31 per cent) of these have relapsed (median follow-up--43 months). Using multivariate analysis, no independent factors predicted for the event of relapse. However, analysis of disease-free survival revealed that females fared significantly worse than males (p less than 0.05) and this was independent of other prognostic variables. Female sex has not been recognized as an independent prognostic factor predictive of inferior survival and inferior disease-free survival.

Tumor burden as the most important prognostic factor in early stage Hodgkin's disease. Relations to other prognostic factors and implications for choice of treatment

Two hundred ninety patients with Hodgkin's disease pathologic stage (PS) I or II were treated in the prospective randomized trial of the Danish National Hodgkin Study (see Appendix) with radiotherapy +/- adjuvant combination chemotherapy. The initial tumor burden of each patient was assessed, combining tumor size of each involved region and number of regions involved. Multivariate analyses of prognostic factors including treatment, tumor burden, histologic subtype, pathologic stage, number of involved regions, mediastinal size, systemic symptoms, erythrocyte sedimentation rate (ESR), sex, and age were carried out. With regard to disease-free survival tumor burden was by far the most important prognostic factor for patients treated with adjuvant chemotherapy as well as for patients treated with radiotherapy alone. With regard to survival from Hodgkin's disease only tumor burden and age were independently significant. A combination of tumor burden, histologic subtype, and sex singled out patients with a high relapse rate both after radiotherapy only, and after radiotherapy plus chemotherapy. This combination also singled out patients destined to die from Hodgkin's disease more accurately than other prognostic factors.

Hodgkin's disease: a reassessment of prognostic factors following modification of radiotherapy

Between 1970 and 1982, 175 patients with Stage IA, B, IIA, B, or IIIA Hodgkin's disease were treated with curative radiotherapy following surgical staging. The patients treated prior to 1975 received either regular extended or total nodal field treatments (Treatment Group 1, N = 65). Unsatisfactory results from this treatment program led to treatment modification in 1975. The modified protocols consisted of low-dose lung irradiation in patients having large mediastinal masses and/or hilar disease, and low-dose liver irradiation for Stage IIIAS+ patients (Treatment Group 2, N = 110). Recurrence-free survival rates improved significantly for various risk groups. Univariate analysis indicated that age, stage, symptoms, mediastinal mass size, number of sites involved, hilar disease, stage, and symptoms were significant risk factors in Treatment Group 1. In Treatment Group 2, only sex was a statistically significant risk factor. Stepwise Cox regression analysis for risk factors selected mediastinal mass size and stage as the most significant prognostic factors in Treatment Group 1. In Treatment Group 2, number of initial disease sites and sex were the most significant risk factors. The results of the study show significant improvement in recurrence-free survival rates in Treatment Group 2. It is concluded that these improvements are due to the modification in treatment.

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.

Therapeutic implications of mediastinal involvement in advanced Hodgkin's disease

47 patients with advanced Hodgkin's disease (stage IIIB or IV) and mediastinal involvement, treated during the period 1969-78 and followed till death or from 36 to 126 months after initiation of therapy, were analysed. All 47 patients had received combination chemotherapy (MOPP or equivalent regimens). 20 had also received additional radiotherapy to mediastinum (and in some cases to other involved areas as well). The 2 treatment groups did not differ significantly with regard to the more important prognostic factors. Both in the case of stages IV and IIIB patients in the group treated with combination chemotherapy alone, remissions were significantly more often only partial, the frequency of relapse and of treatment failure was significantly higher, and relapse-free survival was significantly poorer than in the group treated with additional radiotherapy. Furthermore, survival from Hodgkin's disease and crude survival including all causes of death were significantly better for patients treated with combination chemotherapy plus mediastinal irradiation. Consequently, for patients with advanced Hodgkin's disease and mediastinal involvement a combined approach including radiotherapy as well as combination chemotherapy would seem advisable.

The management of stage II Hodgkin's disease with a large mediastinal mass: a prospective program emphasizing irradiation

Between October 1980 and July 1983, 13 patients with clinical Stage II Hodgkin's disease who had a large mediastinal mass (mediastinal mass ratio, MMR greater than 1/3) were entered into a prospective treatment program emphasizing irradiation. Careful clinical staging, including CT scanning, was completed in order to define precisely the extent of disease in the chest. All patients had a negative lymphogram. The range of MMR was .34 to .56 (median .39). By the time mantle irradiation was completed the MMR ranged from .21 to .35. One patient had such extensive pulmonary parenchymal extension that treatment with combined modality therapy was necessary. Twelve patients underwent laparotomy after adequate reduction of the mediastinal mass size, but only two had subdiaphragmatic disease detected. One patient had disease extension into the lung during mantle irradiation and one patient failed in a rib six months after completion of irradiation. Both have been treated successfully with salvage chemotherapy. All the remaining patients received prophylactic irradiation below the diaphragm and all are doing well with a median follow up of 21 months. The 2 year actuarial freedom from relapse of the entire group of 13 patients is 83%. These early results are very encouraging for this unfavorable group of patients with large mediastinal masses. This may be due to the routine use of CT scans to determine tumor volume and aggressive mantle irradiation, which often includes prophylactic treatment to the lungs. Careful monitoring of tumor response and use of a shrinking field technique has helped to keep complications to a minimum.

The management of stage II supradiaphragmatic Hodgkin's disease at St. Bartholomew's Hospital. A retrospective review of 114 previously untreated patients over 14 years

Between January, 1968 and July, 1981, 114 consecutive patients with newly diagnosed supradiaphragmatic stage II Hodgkin's disease were treated at St. Bartholomew's Hospital on the basis of pathologic staging (PS) in 56 (47 IIA, 9 IIB) and clinical staging (CS) in 58 (23 IIA, 35 IIB). Complete remission (CR) was achieved in 104 (91%) patients, of whom 27 have relapsed. Ninety-three patients remain alive, the cumulative predicted survival at 10 years being 81%, with a minimum follow-up of 2 years and a maximum of 15 years. Mantle radiotherapy (RT) was prescribed for 76 patients, of whom 67 (88%) entered CR. The duration of CR correlated inversely with the presence of intrathoracic lymphadenopathy. No patient with PS IIA and a normal chest radiograph has yet relapsed, whereas in contrast, a rising probability of relapse is related to increasing volume of intrathoracic lymphadenopathy. Combination chemotherapy (CT) with mustine, vinblastine, procarbazine, and prednisone (MVPP) was prescribed to 38 patients, 27 with "B" symptoms and 11 stage IIA patients with "unfavorable" features. CR was attained in 32 (84%) patients, of whom 24 subsequently proceeded to mantle irradiation. Only one of these has relapsed, compared to two of eight patients who did not receive adjuvant RT (P = NS). The duration of remission of patients receiving combined modality therapy (CT + RT) or CT alone was significantly longer (P less than 0.05) than that of patients receiving RT alone, in spite of the fact that the CT + RT group comprised predominantly patients with unfavorable features.

Combined modality therapy for mediastinal Hodgkin's disease. Prognostic significance of constitutional symptoms and size of disease

Combined modality therapy was used in an attempt to increase the complete remission rate and survival of previously untreated patients with Hodgkin's disease. MOPP (nitrogen mustard, vincristine, procabazine, prednisone) chemotherapy was followed by radiotherapy. The median duration of follow-up exceeded 5 years. Complete remissions were achieved in 63 of 71 patients (89%) with mediastinal masses. The actuarial survival of 10 years was 72% for patients with small mediastinal masses (mediastinal mass ratio less than 0.35) and 46% for patients with large mediastinal masses (P less than 0.05). The corresponding disease-free survival figures were 69% and 46%, respectively (P less than 0.05). A small mediastinal mass did not affect prognosis. Systemic symptoms especially affected the prognosis in patients with a large mediastinal mass, since in symptomatic patients the actuarial survival and freedom from relapse were 19%, whereas all asymptomatic patients survived without relapse. In patients with a small mediastinal mass, systemic symptoms had no significant effect on the actuarial survival or disease free survival. Age and stage did not affect the prognosis in patients with large mediastinal masses. It was concluded that MOPP chemotherapy followed by radiotherapy was an adequate treatment for asymptomatic patients with large mediastinal disease. However, in symptomatic patients with large mediastinal masses, this treatment was clearly inadequate.

A multivariate analysis of prognostic factors in early stage Hodgkin's disease

A multivariate analysis of the prognostic factors was carried out with a Cox model on 1,139 patients with clinical Stage I + II Hodgkin's disease included in three controlled clinical trials. The following indicators had been prospectively registered: age, sex, systemic symptoms, erythrocyte sedimentation rate (ESR), number and sites of involved lymph node areas, histologic type, clinical stage, pattern of presentation, results of staging laparotomy when performed, as well as the date and type of treatment. A linear logistic analysis showed that most of the indicators are interrelated. This emphasizes the necessity of a multivariate analysis in order to assess the independent influence of each of them. The two main prognostic indicators for relapse-free survival are systemic symptoms and/or ESR and number of involved areas. The only significant factor for survival after relapse is age. Sex has a small but significant influence on relapse-free survival. The relative influence of each indicator varies with the type of treatment and these variations may help in understanding the biologic significance of the indicators.

The management of localized, infradiaphragmatic Hodgkin's disease: experience of a rare clinical presentation at St Bartholomew's Hospital

Between 1969 and 1982, 23 previously untreated patients with Hodgkin's disease (HD) confined to infradiaphragmatic sites were treated at St Bartholomew's Hospital. The distinguishing clinical characteristics of the patient population were a male: female ratio of 20:3. The mean age was 39 years, which was significantly older (P less than 0.05) than the mean age of patients with supradiaphragmatic HD (32 years) referred during the same period. Sixteen patients underwent formal pathological staging while one additional patient underwent a diagnostic laparotomy without splenectomy. The final pre-treatment stages were PS IA: 5; PS IIA: 11; CS IIA: 1; PS IIB: 1; CS IIB 5. Splenic involvement correlated closely with the number of nodal sites involved, being detected in 1/7 patients with one site only compared with 8/9 with more (P less than 0.001). Complete remission (CR) was achieved in 21 (91 per cent) patients: 12/12 following 'inverted Y' radiotherapy (RT) and 9/11 following combination chemotherapy. Twenty patients remain alive and 18 continue without recurrence of HD between 15 months and 12 years. All patients who failed to enter CR or who relapsed had presented with three or more sites of involvement or with constitutional ('B') symptoms. These results confirm the generally good prognosis of this uncommon presentation of HD and also suggest that prognosis is determined by the bulk of disease rather than its precise anatomical localization, provided that appropriate therapy is administered.

Prognostic significance of the number of involved areas in the early stages of Hodgkin's disease

An analysis of 1059 patients with clinical stage (CS) I and II Hodgkin's disease was undertaken to determine the prognostic significance of the number of involved sites. In this group of patients the number of involved lymph node areas was highly correlated with the probability of dissemination of occult disease. In the subgroup of patients with involvement of two lymph node sites (CS II2) approximately 50% demonstrated occult dissemination on the other side of the diaphragm as evidenced by subsequent relapse in the untreated subdiaphragmatic region. However, only 15% to 20% of this group had unsuspected disease in regions other than the spleen or the paraaortic lymph nodes. In CS I and II2 supradiaphragmatic patients, who underwent a staging laparotomy, splenic involvement was a powerful prognostic indicator. When the spleen was not involved, less than 10% of patients had disease elsewhere below the diaphragm, whereas, when the spleen was involved as many as 40% of patients had additional subdiaphragmatic sites involved. In the subgroup with three or more lymph node areas involved (CS II3), the proportion of patients with extension of disease on the other side of the diaphragm, as evidenced by later relapse was also about 50%. But in these patients, unlike the CS II2 patients, analysis of relapse patterns showed that occult disease had already disseminated to the pelvic nodes or to extra nodal sites. Furthermore, splenic involvement was of much less prognostic significance because CS II3 patients who did not demonstrate splenic involvement at staging laparotomy had similar relapse incidence and similar relapse patterns as those with positive spleens.

The EORTC treatment of early stages of Hodgkin's disease: the role of radiotherapy

Since 1964, the European Organisation for Research and Treatment of Cancer has conducted three subsequent clinical trials on clinical Stages (CS) I + II Hodgkin's disease (HD) in which 1059 patients have been entered. The first trial compared regional radiotherapy (RT) with mantle field or inverted Y, versus the same RT followed by a weekly injection of vinblastine for 2 years. The relapse free survival (RFS) and overall survival (S) were higher in patients treated by RT and chemotherapy (CT). This benefit, however, was significant only in patients with a mixed cellularity histologic type. The second trial compared the therapeutic efficacy of splenic irradiation versus splenectomy and found that in both arms, RFS and S were identical. Moreover, it was found that splenic involvement was correlated with an increased incidence of relapse in extranodal sites and in non irradiated lymphatic areas. In this trial, CT was given only to patients with poor histologic types, mixed cellularity or lymphocytic depletion. In the third trial, staging laparotomy was performed only to further delineate a good prognostic group which could be treated by RT alone. In this limited treatment group, there was no difference in RFS and S between mantle field and mantle field + para-aortic RT. In the extensive treatment group, total nodal irradiation (TNI) was compared with RT + MOPP. The RFS was slightly lower in the TNI arm, but there was no significant difference in S. The data of the 3 trials underline the importance of prognostic factors in the choice of optimal treatment and show that their significance depends upon the type of treatment. Multivariate statistical analyses showed that the main prognostic factors, which can help to identify the subsets of patients who can be treated by RT alone, are (1) systemic symptoms and elevated erythrocyte sedimentation rate (ESR), (2) the number of involved lymphatic areas, and (3) staging laparotomy. Extended RT (mantle + para-aortic + spleen treatment) gives satisfactory results in patients without systemic symptoms and/or elevated ESR and one or two involved sites, whereas TNI or combined modality treatment becomes mandatory for patients with 3 or more involved sites or splenic involvement and/or systemic symptoms. With proper adjustment of the irradiated volume, a very large proportion of CS I + II patients can be best treated by RT alone.

Prognostic significance of mediastinal mass in adult Hodgkin's disease

The authors analyzed the prognostic significance of mediastinal involvement with Hodgkin's disease in 169 pathologically stage adults (greater than or equal to 17 years) treated at the Mayo Clinic between 1974 and 1978. Sixty percent of the patients presented with mediastinal disease, evenly divided between those with a mediastinal to thoracic ratio (MTR) less than 0.33 and greater than or equal to 0.33. They were of younger average age and were more likely to have nodular sclerosis histologic subtype than those patients without a mediastinal mass. The median follow-up from diagnosis was 4.1 years with 90% of the patients being followed for 2 or more years. The 5-year disease-free survival (DFS) for the radiation only group was 70% in patients without mediastinal disease, 53% in the less than 0.33 MTR group and 44% in the greater than or equal 0.33 MTR group (P = 0.25). The 5-year survival was 92% in the patients without mediastinal disease, 88% in the less than 0.33 MTR group and 90% in the greater than or equal to 0.33 MTR group (P = 0.70). This lack of significant difference both in the 5-year DFS and survival between the three groups was also seen in the patients taken in toto (169) and in those receiving combined modality treatment (36). However, in early stage (I and II) patients, treated with radiation only, those with a large mediastinal mass had a 5-year DFS (33%) that was significantly worse than both the small mass patients (71%) and those with no mediastinal mass (87%) P less than 0.005). The pattern of relapse in the 40 patients who failed following treatment by radiation only was not affected by an increasing size of mediastinal involvement. At the time of this analysis 27 of the 40 patients who had relapsed following treatment by radiation only (all stages) had remained free from second relapse. The authors do not believe that the current data either support or negate the use of a combined modality approach in the initial treatment of Hodgkin's disease patients presenting with a large mediastinal mass. Only further follow-up will establish whether the treatment of patients, who have relapsed following radiation only, is durable and results in an overall survival comparable to that obtained by using combined modality initially.

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.

Mediastinal fibrosis simulating residual Hodgkin's disease

A 28-year-old male with nodular sclerosing Hodgkin's disease and massive mediastinal adenopathy was treated with combination chemotherapy and radiotherapy. Following 1,300 rads and six cycles of chemotherapy the patient was felt, on the basis of chest x-ray and CT scan, to have extensive residual mediastinal and intrapericardial involvement with tumor. At thoracotomy he was found to have markedly enlarged mediastinal lymph nodes with the normal tissue being replaced by dense sclerotic material without tumor. In Hodgkin's disease, CT scanning has proved to be an extremely valuable tool in assisting in staging and treatment planning. This case emphasizes, however, that one must be cautious in the interpretation of persistent abnormalities following curative therapy. Carefully selected patient information obtained from exploratory thoracotomy continues to be helpful in defining disease status.

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.

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.

Mantel irradiation for stage I and stage II Hodgkin's disease--results of a 10 year experience

One hundred and thirty patients with Stage I and II supradiaphragmatic Hodgkin's disease treated with mantle irradiation alone at the Peter MacCallum Hospital, Melbourne between 1968-1977 were analysed retrospectively. The median followup was 7.4 years with a minimum of three years. There were 64 clinically staged (CS) and 66 pathologically staged (PS) patients. The major difference between the two groups was the transdiaphragmatic relapse which occurred in 33% of CS patients, and 7.5% in PS patients. The actuarial five year relapse free survival (RFS) was 48% for CS patients and 67% for PS patients, but the five year overall survival was 90% for both groups, reflecting the impact of salvage treatment. Avid attention must be given to radiotherapy techniques to minimise local treatment failures. High grade nodular sclerosis Hodgkin's disease is associated with poor RFS even after adjustment has been made for stage and constitutional symptoms (p less than 0.003). Further studies will be made on this group of patients who may benefit from combined modality treatment. For PS I and II patients mantle irradiation gives a five year RFS of 67%, thus offering potential for cure in these patients.

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

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

CT scan modification in the treatment of mediastinal Hodgkin's disease

Seventy-one patients with Hodgkin's disease who were initially treated at Johns Hopkins with radiation or radiation-chemotherapy from 1975--1980 had a five-year cumulative disease-free survival of I-A--100% (12 patients); II-A--85% (33 patients); II-B--83% (seven patients); III-A--75% (ten patients); and III-B--66% (nine patients). Fifty patients with mediastinal masses at the time of treatment demonstrated no marginal misses, two mediastinal recurrences (96% local control), and three lung disseminations. CT scan data yielded stage and treatment modification in 60% (9/15) of recent patients with mediastinal Hodgkin's disease. This demonstrates the need for routine thoracic scans and individual treatment planning in all mediastinal cases. Recommendations for combination treatment in early stage disease are made only for pericardial or extrathoracic chest wall extension based on CT scan findings, our low failure rates, radiation organ tolerances, and available relapse data in the literature, not arbitrary size designations from upright chest radiographs. It can be concluded that patients with mediastinal Hodgkin's disease require CT scan analysis to identify unusual patterns of presentations, sites at risk, and to allow for proper application of radiation portals and/or chemotherapeutic management.

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

Prognostic factors have been re-evaluated for 88 patients with Stage III Hodgkin's disease to see if they have remained significant on a long-term basis. Treatment had consisted of two cycles of MOPP followed by radiotherapy to the mantle, abdomen, and pelvis; all patients had achieved complete remission. Case material was grouped according to the presence of absence of mediastinal disease. Five-year survivals for Stage IIIA and IIIB patients were 85 and 80%; corresponding disease-free survivals were 76 and 73%. Significant prognostic factors include age, histopathology, and extent of abdominal disease, but the relative importance of these factors differs for the mediastinal and nonmediastinal patients. Modifications of current treatment policy for both mediastinal and nonmediastinal patients are discussed in relation to the prognostic factors.