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

Prognostic factors in Hodgkin's lymphoma

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

Treatment of nonlaparotomized (clinical) stage I and II Hodgkin's disease patients by extended field and splenic irradiation

PURPOSE

At the New York Presbyterian Hospital-Cornell Medical Center, patients with unequivocal clinical stage I and IIA Hodgkin's disease (HD) have been treated with mantle, splenic, and extended field radiation therapy (EFRT) (without surgical staging). A 24-year retrospective review was conducted to determine the effectiveness of our patient selection on the outcome of patients treated with this modality.

METHODS AND MATERIALS

During the period 1971 to 1994, 94 patients with clinically staged HD, with favorable prognostic factors, were retrospectively reviewed. Patients with pathological or equivocal staging, "B" symptoms, bulk disease, history of previous chemotherapy, and/or Stage III or IV disease were excluded from our analysis. There were 27 Stage IA and 67 Stage IIA patients. All patients were treated to 3600 cGy with a 400 cGy boost to the involved field. The median follow-up was 52 months, mean of 62.1 months.

RESULTS

Ten of 94 patients (10.5%) relapsed. Seven of the relapses were in the pelvis, one submandibularily, one in the tonsil, and one in the axilla. Nine of the relapses had nodular sclerosis histology, one had lymphocyte predominance, and none had mixed cellularity. The median time to relapse was 38 months; mean time 42. 3 months. All patients are alive, well and free of disease, including nine who received subsequent chemotherapy and one who underwent autotransplantation.

CONCLUSIONS

Careful clinical staging of early, asymptomatic HD patients treated with mantle, splenic, and EFRT may obviate the need for exploratory laparotomy.

[The role of radiotherapy in the management of advanced Hodgkin's disease]

The use of radiotherapy in advanced stages of Hodgkin's disease remains controversial. The rationale for its use is based on efficacy at all stages of the disease as well as in patients with recurrent disease, but also on the topography of the recurrences after exclusive chemotherapy (which occur at non irradiated sites in 75% of cases), and on its ability to improve relapse rates as shown in many randomized trials. Unfortunately, this improvement does not translate into higher survival rates because of the increased late morbidity and an inadequate selection of patients who might benefit from irradiation. The benefits of radiotherapy are probably the highest in stage III rather than IV, in patients with scleronodular disease, and in those with mediastinal involvement experiencing a complete response to radiotherapy. A better survival should be observed with the shift towards a decrease of the doses delivered, an improvement of the quality of the irradiation, and a better definition of the volumes to be treated in association with the use of optimal chemotherapies.

Positioning and immobilization of patients undergoing radiation therapy for Hodgkin's disease

The prognosis for patients with Hodgkin's disease is largely determined by the initial management, therefore, special attention must be given to the precision of the often complex treatment in these relatively young and curable patients. Positioning and immobilization is extremely important and may have a role in the final outcome of the treatment. Alpha Cradles, along with laser alignment systems, have been routinely used for these patients in our institution for approximately 10 years. Despite these efforts, difficulties are encountered in precisely reproducing the setup. A modification was therefore made to an Alpha Cradle to include an arm support with handles that fix the position of the patient's elevated arms during the treatment. This modification provides improved repositioning and alignment of the patients, which may have an impact on the final outcome of the treatment. The positioning device also offers improved patient comfort, and, as a result, reduced patient motion as evidence by the reduced number of adjustments required when port films are examined. Additionally, the described technique reduces the risks of over- or underdosage at the junction between the mantle and the para-aortic fields.

Is pelvic irradiation necessary in stage III1A Hodgkin's disease?

Eighteen patients with pathologic Stage (PS) III1A Hodgkin's disease were treated with mantle and para-aortic field radiation therapy alone between 1973 and 1988. The median follow-up time is 84 months (range 20-174 months). The 5-year survival and relapse-free survival rates are 76 and 82%. Six patients had extensive splenic involvement or bulky mediastinal adenopathy, and three have relapsed and are dead of disease. Of the other 12 patients, only one has had recurrence of disease and died. Patients with PS III1A Hodgkin's disease are good candidates for mantle and para-aortic radiation therapy only, provided that they do not have extensive splenic involvement or large mediastinal adenopathy.

Influence of clinical trials on current treatment strategy for Hodgkin's disease

This paper critically reviews the prospective randomized trials conducted over the past three decades in Hodgkin's disease of adults. On the basis of current findings, it is difficult to conclude which randomized trials were influential in defining widely accepted treatment strategies or treatment sequencies, as many studies were poorly conceived and/or executed. However, other reasons may have come into play. The treatment decision making of Hodgkin's disease involves a complex mosaic of prognostic factors and therefore of potentially successful treatment options. Although irradiation and chemotherapy are both effective in different stages, their optimal integration in a multi-disciplinary approach remains to be assessed. Over the years, different research philosophies were translated into different study designs for each stage or patient subset, and in some instances multiple treatment approaches represented a confounding factor in the search for true and reliable prognostic variables. Also, by the time a given trial became mature enough to provide meaningful results, other single arm or randomized studies were undertaken, often yielding premature data. Thus, the instability of treatment results from preliminary analyses can influence subsequent trial design and engender perplexity among physicians. Prospective randomized trials remain today the most reliable tool to assess in Hodgkin's disease the cost benefit ratio of given treatments in clearly identifiable prognostic subsets.

Radiation therapy for pathologic stage III Hodgkin's disease with and without chemotherapy

Ninety-eight patients with pathological Stage (PS) III Hodgkin's disease treated between 1969 and 1984 were retrospectively analyzed. Treatment consisted of radiation therapy (RT) alone in 46 patients and combined radiation therapy and chemotherapy (CMT) in 52 patients. The median follow-up was 10 years (range 3-19 years). Fifteen-year year survival for patients with Stage III1-is better than for Stage III2 patients (82% vs 53%; p = .014). Patients with Stage III1A have a favorable prognosis regardless of treatment modality. The probability of freedom from relapse at 15 years for patients with pathological Stage III1A treated with radiation therapy is 70%, compared to 83% for pathological Stage III1A patients treated with combined modality therapy (p = .56). In patients with pathological Stage III2A, III1B, and III2B relapses were less frequent with the use of combined modality therapy compared to radiation therapy. We conclude that pathological Stage III1A patients may be treated with radiation therapy alone; the other subsets of patients benefit from combined radiation and chemotherapy.