Management of subdiaphragmatic early-stage Hodgkin's disease

Hodgkin's Disease Stage I and II with Exclusive Subdiaphragmatic Presentation. The Experience of the Departments of Radiation Oncology and Hematology, University “La Sapienza” of Rome

During the period 1978 to 1994, 1054 patients with Hodgkin's disease were evaluated and treated at the Departments of Radiation Oncology and Hematology, University “La Sapienza”, Rome. A total of 549 patients presented with clinical or pathological stage I and II; 37 of these had Hodgkin's disease below the diaphragm (BDHD), and 512 above the diaphragm (ADHD). A comparison of patients with BDHD versus those with ADHD showed that the first group had a higher male to female ratio. A comparison of cases with stage II BDHD versus those with stage II ADHD showed that patients with BDHD were older (48 years vs 28 years), had different histologic features and a higher incidence of systemic symptoms (67% vs 33%). Stage II BDHD patients had a worse prognosis; in fact, there were significant differences in the overall survival and relapse-free-survival rates for cases with stage II BDHD versus those with stage II ADHD (overall survival, 46% vs 80%, P<0.001; relapse-free survival, 44% vs 69%, P<0.005). Stage was found to be the most important prognostic factor for BDHD cases without systemic symptoms treated with radiation therapy alone. The type of infradiaphragmatic presentation (intra-abdominal vs peripheral disease) did not influence outcome, probably due to the more aggressive therapy received by the intra-adbominal group. Treatment recommendations for BDHD cases should be tailored to the stage and the presence or absence of intra-abdominal localization. For patients with stage IA extended fields, irradiation (inverted Y) is sufficent. However, combined modality therapy should be the treatment of choice for stage II cases, particularly in the presence of intra-abdominal disease. Patients with systemic symptoms also require combined modalities.

Infradiaphragmatic Hodgkin lymphoma: a large series of patients staged with PET-CT

Introduction

Infradiaphragmatic Hodgkin Lymphoma (IDHL) accounts for 3-11% of adult cases of stage I-II Hodgkin Lymphoma and the treatment strategy in IDHL is still heterogeneous. All previous published studies were conducted before the PET-CT era. PET may provide a more accurate evaluation of IDHL stage. The aim of this study was to analyze the clinical and biological characteristics of IDHL patients staged by CT scan or PET-CT in eight French hematology departments and their impact on outcomes in these patients.

Methods

Baseline clinical and biological data and outcomes in patients with a first diagnosis of stage I-II IDHL treated with ABVD +/- radiotherapy were retrospectively collected.

Results

Among the 99 patients included, 65 (66%) were staged with PET-CT. These patients were older (53 years vs 46 years, p=0.043), had lower ESR (27 vs 58mm, p=0.022), higher hemoglobin level (13.6 vs 12.8g/dL, p=0.015), less frequent Ann Arbor stage II (74% vs 91%) and less central adenopathy involvement (60% vs 82%, p=0.024). Treatment was chemotherapy alone in 55% of patients and the remaining patients received chemo-radiotherapy (CRT). Five-year PFS and OS rates in PET-CT-staged patients were 78% (95% CI 64-87) and 88% (95% CI 73-95), respectively, compared with 65% (p=0.225) and 82% (p=0.352) in CT-staged patients. The CRT strategy was associated with fewer relapses (p=0.027).

Conclusion

This study showed that the characteristics of CT-staged IDHL patients were less favorable than those of PET-CT-staged patients and indicated that CRT provided better PFS than did chemotherapy alone.

Subdiaphragmatic Hodgkin's disease: the University of Florida experience

PURPOSE

To assess the long-term outcomes and late effects of patients with subdiaphragmatic Hodgkin's disease.

METHODS AND MATERIALS

Twenty-one patients with Stage I and II subdiaphragmatic Hodgkin's disease were treated with curative intent between February 1966 and February 1998 at the University of Florida. Patient characteristics were as follows: mean age, 38.7 years (range, 3-75 years); 20 males and 1 female; 33% lymphocyte predominant, 43% nodular sclerosing, 14% mixed cellularity, 5% lymphocyte depletion, and 5% unclassified Hodgkin's disease. Treatment included inverted Y irradiation (InY) (8 patients), total nodal irradiation (TNI) (7 patients), and combined modality irradiation and chemotherapy (CMT) (6 patients). Median follow-up was 12.3 years (range, 3.1-33.6 years).

RESULTS

Progression-free survival and overall survival were 80% and 70%, respectively, at 10 years. There were no deaths from Hodgkin's disease. Treatment failures occurred in 1 of 8 patients after InY, 1 of 7 after TNI, and 1 of 6 after CMT. Two of 3 recurrences were in patients with 3 or more sites of involvement and/or splenic involvement; 1 was in-field. There were 5 second malignant neoplasms and 3 cardiac events, including 4 second malignant neoplasms and 2 cardiac events in the 9 patients > or =40 years old at diagnosis and 1 second malignant neoplasm and 1 cardiac event in the 12 patients <40 years old. All 3 second solid malignancies in this study occurred 7-14 years after treatment in areas receiving 10-20 Gy.

CONCLUSIONS

Subdiaphragmatic Hodgkin's disease is an uncommon manifestation with excellent disease control achieved with InY, TNI, and CMT. This subgroup of patients with Hodgkin's disease is predominantly male and older than subgroups with other presentations, which may predispose the group to a higher risk for serious adverse events after treatment. We recommend InY with spleen for clinical Stages IA and nodular sclerosis or lymphocyte-predominant clinical Stage IIA, InY alone for pathologic Stages IA and IIA, and CMT for all Stage I/II patients with greater than three involved sites, B symptoms, bulky disease (>6 cm), central (para-aortic) presentation, or splenic involvement.

Subdiaphragmatic stage I & II Hodgkin's disease: long-term follow-up and prognostic factors

PURPOSE

To report long-term follow-up results and to analyze prognostic factors for overall and disease-free survival in patients with subdiaphragmatic Stage I & II Hodgkin's disease.

METHODS AND MATERIALS

From September 1962 to April 1995, 109 patients presented at the M. D. Anderson Cancer Center with subdiaphragmatic Hodgkin's disease. The medical records of these patients were retrospectively reviewed; 22 patients who received no treatment at the M. D. Anderson Cancer Center or who had radiation therapy at other institutions were excluded. The remaining 87 patients formed the basis of this study. The median age of our group was 33 years with a male: female ratio of 3.3:1. The histological subtypes were nodular sclerosis in 21 (24.1%) patients, mixed cellularity in 31 (35.6%), lymphocyte predominance in 33 (37.9%), lymphocyte depletion in 1 (1.1%) and unclassified histology in 1 (1.1%). Of the patients, 32 (36.8%) underwent laparotomy for diagnosis or staging purpose, 74 (85.1%) had lymphangiography, and 35 (40.2%) had computerized tomography of the abdomen and pelvis. Among the patients, 22 (25%) had more than three sites of nodal involvement at presentation, 56 (64.4%) had pelvic or abdominal disease, and 14 (18.4%) had bulky disease that was defined as disease with the largest dimension > or = 7 cm. Stage distribution was IA in 33.3%, IIA in 39.1%, and IIB in 27.6%. Treatment was radiotherapy alone in 60 (69%) patients, chemotherapy and radiation in 23 (26.4%), and chemotherapy alone in 4 (4.6%).

RESULTS

The 10- and 20-year actuarial overall survival rates for all patients were 74.6% and 55.3%, and the corresponding disease-free survival rates were 72.4% and 67.5%, respectively. On univariate analysis, age > 40 years, B symptoms, nodular sclerosis or mixed cellularity histology, and decreased albumin or hemoglobin levels were statistically significant adverse pretreatment factors for overall survival. B symptoms, decreased albumin level, more than 3 sites of disease at presentation, and Stage II were statistically significant negative pretreatment prognostic factors for disease-free survival. Only B symptoms and decreased albumin level predicted worse outcome in both overall and disease-free survivals. On multivariate analysis, age > 40 years, nodular sclerosis and mixed cellularity histology, and decreased hemoglobin levels were three independent risk factors for overall survival. An analysis of the pattern of failure revealed that the majority of the patients with central Stage II disease who did not receive mantle radiation failed in the supradiaphragmatic area. Late complications of radiation were infrequent.

CONCLUSIONS

Long-term follow-up of this group of patients revealed similar overall and disease-free long-term survival, as would be expected from supradiaphragmatic Hodgkin's disease. For patients with central Stage II disease, it is anticipated that supradiaphragmatic radiation therapy would improve the disease-free survival.

Infradiaphragmatic Hodgkin's disease: the Swedish National Care Programme experience. The Swedish Lymphoma Study Group

A Swedish national care programme has provided guidelines for staging, treatment and follow-up of all patients with Hodgkin's disease (HD) since 1985. Between January 1985 and December 1992, 920 patients were reported and followed prospectively. Of a total of 533 patients with stage I and II disease, 484 presented with supradiaphragmatic HD and 49 (9%) with infradiaphragmatic HD. The median follow-up time was 4.3 yr (3.3-10 yr). Significant differences in average age (45 +/- 21 yr and 55 +/- 19 yr), male:female ratio (1.1:1 and 2.8:1) and B-symptoms (25% and 47%) were observed in patients with supra- and infradiaphragmatic HD, respectively. Forty-six patients with infradiaphragmatic HD were treated with a curative intention and 40 (87%) achieved a complete response. Eleven (28%) of the 40 patients have recurred and 8 patients have died of HD. Complete response rates and recurrence frequencies did not differ from those observed in patients with supradiaphragmatic HD. Mortality was, however, significantly higher (p = 0.001) in the infradiaphragmatic group; this was due mainly to poorer effects of salvage treatment in a elderly population. In this population-based study, patients with peripheral disease in stage IA respond well to inverted Y irradiation alone, whereas it appears to be important to give stage II patients chemotherapy or a combined modality treatment in order to avoid unacceptably high recurrence rates.

Radiotherapy for early infradiaphragmatic Hodgkin's disease: the Australasian experience

PURPOSE

To review the Australasian results of Stage I and IIA Infradiaphragmatic Hodgkin's Disease (IHD) treated solely by irradiation.

METHODS AND MATERIALS

Eligible patients had IHD only and were treated by irradiation with curative intent over the period of 1969 to 1988. Ten radiation oncology centres from within Australia and New Zealand were surveyed for patient, tumour and treatment variables. Disease free rates, survival and complications were analysed.

RESULTS

106 patients with IHD were studied. The average potential follow up was 9.4 years. The male to female ratio was 3.3:1. The median age was 37.5 years. Histological subgroups were as follows; lymphocyte predominant 43%, mixed cellularity 21%, lymphocyte depleted 5%, nodular sclerosing 27% and unclassifiable 4%. Fifty nine patients had laparotomy of which 22 (37%) were positive for tumour. Nine laparotomies were performed for diagnosis and the remainder for staging. One patient was up-staged by laparotomy and three were down-staged. Sixty-eight patients presented with inguinal disease alone, five with abdominal disease alone, 19 with two sites of involvement and 12 with inguinal, pelvic and abdominal disease. In two patients the site was unknown. There was no correlation between site of involvement, age, sex or histological subtype. Forty seven cases were clinically staged (CS) as follows: CS IA-23, CS IIA-24. The other 59 were pathologically staged (PS) as follows: PS IA-37, PS IB-1, PS IIA-21. Treatment consisted of involved field alone (16), inverted Y (68), inverted Y and spleen (13), para-aortic irradiation only (3), or total nodal irradiation (6). Mean dose was 37 Gy. There were 30 recurrences to give an acturial 10-year disease-free rate of 70%. In multivariate analysis lower number of tumour sites, lymphocyte predominant histology and higher dose were all significantly correlated with higher disease free rates. Eight patients died of Hodgkin's disease and 19 of other causes. The 10-year overall survival rate was 71%. Older age and higher number of disease sites were significantly correlated with shorter survival. Fourteen of 30 relapses may have been avoidable by the use of total nodal irradiation. In particular ten of 21 patients with abdominal disease relapsed in nodal sites which would have been covered by total nodal irradiation.

CONCLUSIONS

The rate of control in IHD could perhaps be improved by avoiding involved field irradiation or by aggressive therapy with total nodal irradiation or combined modality chemo-irradiation in Stage II disease. Staging laparotomy does not appear to be indicated.

Infradiaphragmatic Hodgkin's disease: long term results of combined modality therapy

Hodgkin's disease (HD) confined below the diaphragm accounts for less than 5% of all patients with HD. Although the major characteristics of this presentation appear established, optimal modalities of treatment still remain difficult to define. From April 1972 to October 1988, 28 patients with newly diagnosed infra-diaphragmatic HD, clinical stages I or II have been treated with 3 successive prospective protocols combining initial chemotherapy and radiotherapy (40 gy). This series of patients accounted for 4,3% of patients with HD limited to clinical stages (CS) I and II. Overall survival and freedom from relapse at 15 years were 74,4% and 73% respectively, without significant differences between clinical stages I and II, presence or absence of B symptoms or histologic subtype. There is only a trend (p < 0,10) in favour of patients younger than 40 years. In all 7 clinically staged IA patients no relapses were seen and combined treatment does not appear to be better than inverted Y irradiation alone. On the other hand initial chemotherapy seems necessary in patients with CS II A and B since 15 of our 21 patients are alive in first CR whereas the crude rate of transdiaphragmatic nodal relapses may reach up to 53% following radiotherapy alone.

Hodgkin's disease

This synthesis of the literature on radiotherapy for Hodgkin's Disease is based on 104 scientific articles, including 2 meta-analyses, 22 randomized studies, 5 prospective studies, and 58 retrospective studies. These studies involve 38,362 patients. The literature review clearly shows that radiotherapy is a cornerstone of treatment for localized Hodgkin's disease. At early stages, long-term survival is 80% to 90% when treatment is tailored to known prognostic factors. There is a tendency toward increased use of chemotherapy as additional treatment, however no evidence shows that it increases survival. To further improve survival following radiotherapy an attempt is being made to reduce long-term toxicity by better defining the patient groups who require lower radiation volumes, and delivering a dose that is as low as possible to avoid secondary solid tumors or delayed cardiopulmonary or gastrointestinal effects, while not jeopardizing therapeutic results. In advanced disease, radiotherapy may be needed as a complement to chemotherapy to effectively control bulky disease. For recurrent disease, radiotherapy may be considered as relapse treatment or additional therapy in conjunction with high-dose chemotherapy.

Treatment of subdiaphragmatic Hodgkin's disease: is radiotherapy alone appropriate only for inguino-femoral presentations?

PURPOSE

Evaluate the role of staging laparotomy, and the impact of disease subsites on treatment outcome, for sub-diaphragmatic Hodgkin's Disease.

METHODS AND MATERIALS

Between 1966 and 1989, 23 patients with Hodgkin's disease limited to sites below the diaphragm were treated at the Royal Adelaide Hospital. The high male:female ratio (2:8), low proportion of nodular sclerosis subtype (26%), and older age (mean = 40) relative to supra-diaphragmatic Hodgkin's disease is consistent with most other series. Thirteen patients underwent staging laparotomy. Initial treatment consisted of radiation therapy alone in 11, chemotherapy alone in 7, and combined modality therapy in 4 patients. This data was then combined with other published series over the last decade, to analyse relapse patterns and treatment results in relation to initial site(s) of disease.

RESULTS

The overall, disease specific, and progression free 5 (and 10) year survival rates were 69%, 81%, and 58% respectively. There was no statistically significant effect of staging laparotomy on any of these parameters. Combining these results with those in the literature revealed an unacceptable relapse rate for patients with disease outside of the inguino-femoral region treated with inverted-Y radiation therapy alone.

CONCLUSIONS

For the majority of patients with sub-diaphragmatic Hodgkin's disease, staging laparotomy can be avoided. Inverted-Y radiation therapy should only be used for inguino-femoral presentations.