Radiation therapy in clinical stage I and II Hodgkin's disease. The Princess Margaret Hospital Lymphoma Group

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.

Serum levels of interleukins 6, 10, and 13 before and after treatment of classic Hodgkin lymphoma

CONTEXT

Interleukins (ILs) 6, 10, and 13 seem to be important in the pathogenesis of Hodgkin lymphoma (HL), but there is insufficient data on the serum levels of these cytokines in patients with HL.

OBJECTIVES

To evaluate serum levels of IL-6, IL-10, and IL-13 before and after HL treatment and to determine their potential association with clinical and laboratory parameters.

DESIGN

Serum IL-6, IL-10, and IL-13 levels were quantified in the serum of 27 patients with HL by enzyme-linked immunosorbent assay. Results were evaluated against clinical and laboratory parameters, response to treatment, and presence of infection by the Epstein-Barr virus. As a control group, serum samples from 26 healthy blood donors were evaluated the same way.

RESULTS

Pretreatment serum levels of IL-6 and IL-10 were significantly higher in patients with HL (P < .001), and a significant decrease was observed after treatment (P < .001). Serum IL-13 was undetectable in both patient and control groups. Serum IL-6 was higher in patients with abdominal involvement (P  =  .02), hepatomegaly (P  =  .03), B symptoms (P  =  .02), and anemia (P  =  .02). Serum IL-10 levels were higher in patients with hypoalbuminemia (P  =  .04). No association with EBV status was observed. Lymphocytopenia and B symptoms were accurate predictors of IL-6 serum levels before treatment, and higher pretreatment levels of IL-6 were observed in patients with treatment failure (P  =  .03).

CONCLUSIONS

Serum levels of IL-6 and IL-10 were frequently elevated in patients with HL and decreased substantially after conventional chemotherapy. The association of elevated IL-6 and IL-10 levels in serum with some clinical and laboratory features suggests those ILs may be useful biomarkers for monitoring the HL disease and its response to chemotherapy.

Plasma Cytokine and Soluble Receptor Signature Predicts Outcome of Patients With Classical Hodgkin's Lymphoma: A Study From the Groupe d'Etude des Lymphomes de l'Adulte

Purpose

Approximately 15% of patients with localized and 30% with disseminated classical Hodgkin's lymphoma fail to respond or relapse after first-line treatment. Usual prognosis scoring systems are actually unable to identify this small subset of patients with good confidence, pointing out the need for additional prognostic biomarkers.

Patients and Methods

We prospectively analyzed the prognosis value of plasma levels of tumor necrosis factor (TNF), its soluble receptors TNF-R1 and TNF-R2, IL-10, IL1-RA, IL-6, and soluble CD30 (sCD30) when taken before any treatment in 519 consecutive patients with a first diagnosis of classical Hodgkin's lymphoma.

Results

Levels of TNFα higher than 46 pg/mL, TNF-R1 higher than 3 ng/mL, TNF-R2 higher than 5 ng/mL, IL-10 higher than 30 pg/mL, IL1-RA higher than 668 pg/mL, IL-6 higher than 30 pg/mL, and sCD30 higher than 80 U/mL were associated with poor event-free and overall survival. In multivariate analysis, high levels of IL1-RA, IL-6, and sCD30 were independent poor prognosis factors, and the cytokine signature based on their combination allowed the stratification of patients in four prognosis classes, reaching a 5-year event-free survival probability of 92%, 85%, 76%, and 15%, respectively. This index was more potent than other scoring systems to predict patient event-free survival, and remained independent from the international prognostic score (P < .001), adding significant prognostic information to its predictive power.

Conclusion

Plasma cytokine signature is sufficient to predict disease-related outcome in classical Hodgkin's lymphoma, and allows the identification of patients with very high risk of treatment failure.

Radiotherapy alone for lymphocyte-predominant Hodgkin's disease

PURPOSE

The purpose of the study was to analyze the results with radiotherapy alone in a select group of asymptomatic adults with nonbulky, early-stage lymphocyte-predominant Hodgkin's disease.

PATIENTS AND METHODS

Between 1963 and 1995, 36 patients with nonbulky stage IA (N = 27) or IIA (N = 9) supradiaphragmatic (N = 27) or subdiaphragmatic (N = 9) lymphocyte-predominant Hodgkin's disease were treated with radiotherapy alone. Eleven of the patients underwent laparotomy. Limited-field radiotherapy involving only one side of the diaphragm and extended-field radiotherapy encompassing both sides of the diaphragm were used in 28 and 8 cases, respectively. Median dose to involved areas was 40.0 Gy given daily in 20 2.0-Gy fractions. Salvage treatmentconsisted of MOPP (mechlorethamine, vincristine, prednisone, procarbazine), CVPP/ABDIC (cyclophosphamide, vinblastine, procarbazine and prednisone/doxorubicin, bleomycin, dacarbazine, lomustine, and prednisone), or ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) chemotherapy and/or involved-field radiotherapy.

RESULTS

Median follow-up was 8.8 years (range, 3.0-34.4 years). None of the 15 patients with supradiaphragmatic disease who received limited-field radiotherapy to regions that did not include the mediastinal or hilar nodes subsequently experienced relapse there. Only one of 20 patients who received supradiaphragmatic limited-field radiotherapy alone experienced relapse in the paraaortic nodes or spleen. The 5-year relapse-free and overall survival rates for the 20 patients with stage IA lymphocyte-predominant Hodgkin's disease treated with involved-field or regional radiotherapy were 95% and 100%, respectively. There were no cases of severe or life-threatening cardiac toxicity. No solid tumors have been observed in-field in patients treated with limited-field radiotherapy, even though they have been followed up longer than those treated with extended-field radiotherapy (median follow-up, 11.6 vs 5.5 years); two solid tumors have developed in-field in patients who received extended-field radiotherapy.

DISCUSSION

Involved-field or regional radiotherapy alone may be adequate in stage IA lymphocyte-predominant Hodgkin's disease patients. Longer follow-up will help to more clearly define the risks of cardiac toxicity and solid tumors that result from involved-field or regional radiotherapy, which appear to be low based on follow-up to date.

Radiotherapy alone in the treatment of clinical stage I-IIA, nonbulky, Hodgkin's disease: single-institution experience on 73 patients staged with lymphangiography and laparoscopy

From 1985 to 1998, at the Regional Cancer Center of Padua, patients with Hodgkin's disease (HD) routinely underwent a clinical staging procedure including lymphangiography and laparoscopy with multiple liver and spleen biopsies. Patients with IA and IIA nonbulky HD were treated with radiotherapy alone. The aim of this study is to analyze the efficacy of radiotherapy as radical treatment in this group of patients, and the role of lymphangiography and laparoscopy in the selection of patients with abdominal disease located to the spleen, liver, or the pelvic lymphatic chains. From January 1985 to January 1998, 94 previously untreated patients with biopsy-proven HD underwent clinical staging procedures consisting of history, physical examination, routine laboratory tests, chest radiography, total-body computed tomography scan, and bone marrow biopsy and were considered in stage I-IIA nonbulky. In addition, all patients underwent bipedal lymphangiography, which was positive in 12 (12.8%). Of the 82 patients with negative lymphangiography, 9 (11%) showed disease below the diaphragm at laparoscopy with multiple random spleen and liver biopsies. Of the remaining 73 patients, 32 were male and 41 were female with a median age of 29 years (range: 14-72 years).

European Organization for Research and Treatment of Cancer and Groupe d'Etude des Lymphomes de l'Adulte very favorable and favorable, lymphocyte-predominant Hodgkin disease

BACKGROUND

Lymphocyte-predominant Hodgkin disease (LPHD) is rare and has a natural history different from that of classic Hodgkin disease. There is little information in the literature regarding the role of chemotherapy in patients with early-stage LPHD. The objective of this study was to examine recurrence free survival (RFS), overall survival (OS), and patterns of first recurrence in patients with LPHD who were treated with radiotherapy alone or with chemotherapy followed by radiotherapy.

METHODS

From 1963 to 1996, 48 consecutive patients ages 16-49 years (median, 28 years) with Ann Arbor Stage I (n = 30 patients) or Stage II (n = 18 patients), very favorable (VF; n = 5 patients) or favorable (F; n = 43 patients) LPHD, according to the European Organization for Research and Treatment of Cancer and Groupe d'Etude des Lymphomes de l'Adulte (EORTC-GELA) criteria, received radiotherapy alone (n = 37 patients) or received chemotherapy followed by radiotherapy (n = 11 patients). The percentages of patients with VF disease (11% vs. 9% in the radiotherapy group vs. the chemotherapy plus radiotherapy group, respectively) or F disease (89% vs. 91%, respectively) within the two treatment groups were similar (P = 1.00). A median of three cycles of chemotherapy with mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) or with mitoxantrone, vincristine, vinblastine, and prednisone (NOVP) was given initially to six patients and five patients, respectively. A median total radiotherapy dose of 40 grays (Gy) given in daily fractions of 2.0 Gy was delivered to both treatment groups.

RESULTS

The median follow-up was 9.3 years, and 98% of patients were observed for > or = 3.0 years. RFS was similar for patients who were treated with radiotherapy alone and patients who were treated with chemotherapy followed by radiotherapy (10-year survival rates: 77% and 68%, respectively; P = 0.89). The OS rate also was similar for the two groups (10-year survival rates: 90% and 100%, respectively; P = 0.43). MOPP or NOVP chemotherapy did not reduce the risk of recurrence outside of the radiotherapy fields.

CONCLUSIONS

MOPP or NOVP chemotherapy did not improve RFS or OS significantly in patients with VF or F LPHD, although the statistical power was limited. Ongoing clinical trials will help to clarify the role of a watch-and-wait strategy or systemic therapy, including anthracycline (epirubicin or doxorubicin), bleomycin, and vinblastine-based chemotherapy or antibody-based approaches, in the treatment of these patients.

British National Lymphoma Investigation: pilot studies of neoadjuvant chemotherapy in clinical stage Ia and IIa Hodgkin's disease

In order to improve treatment in early Stage IA and IIA Hodgkin's disease, the British National Lymphoma Investigation (BNLI) has evaluated two neoadjuvant chemotherapy regimens with involved field radiotherapy. This article reports the results of the methotrexate, vinblastine and prednisolone (MVP) study in 39 patients and updates the previous report on vinblastine, bleomycin and methotrexate (VBM) in 30 patients. Both studies recruited clinical Stage IA or IIA Hodgkin's disease patients with intermediate risk of relapse into a prospective multicentre Phase II study. They received two cycles of chemotherapy followed by involved field radiotherapy and then four further cycles of chemotherapy. For MVP the 5-year survival is 97% and for VBM it is 93%. The 5-year event-free survival rates are 71% and 87% respectively. The acute pulmonary and haematological toxicity occurring with VBM was not acceptable and therefore the MVP study was performed. There was less toxicity with this regimen although modest acute pulmonary toxicity was still observed. However, in view of the length of treatment with MVP (9 months) and the excellent results reported by the Manchester group, future efforts of the BNLI are to be directed towards a new short course chemotherapy regimen, VAPEC-B (vincristine, doxorubicin, prednisolone, etoposide, cyclophosphamide and bleomycin).

Risk-adapted therapy for clinical stage I-II Hodgkin's disease: 7-years results of radiotherapy alone for low-risk disease, and ABVD and radiotherapy for high-risk disease

Treatment outcomes were documented for 204 adult patients with clinical Stage I-II Hodgkin's disease who were treated with risk-adapted ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) and radiotherapy (RT) at the Toronto-Sunnybrook Regional Cancer Centre between 1984 and 1994. Forty-nine patients with clinical Stage I disease (excluding bulky mediastinal presentations) and 50 patients with a combination of clinical Stage IIA disease, age 50 years or less, and favourable pathology (lymphocyte predominant or nodular sclerosing histology) were identified as low risk and treated with RT alone to 35 Gy. One hundred and five high-risk patients were treated with chemotherapy (86 with ABVD) followed by RT to 25 Gy. The 7-year cause-specific, overall and disease-free survivals were 95%, 90% and 75% respectively for the low-risk cohort, and 91%, 90% and 88% respectively for the high-risk cohort. In-field relapses accounted for 50% of the failures in both groups. Sixteen of 24 (67%) patients with RT failure and 6/14 (43%) with combined modality therapy (CMT) failure were salvaged. Twenty-eight per cent of the patients treated with RT and 21% of those treated with CMT developed hypothyroidism by 7 years. Fatal complications were recorded in 6% of the low-risk patients managed with RT and 8% of high-risk patients managed with CMT. Septic death and second malignancy accounted for the majority of treatment-related fatalities. Risk-adapted therapy emphasizing RT alone for selected patients with favourable prognostic factors and CMT based on ABVD provides excellent long-term disease control. Further treatment refinements, including the wider application of CMT with lower doses of chemotherapy and RT, will be required to reduce the rate of fatal complications to more acceptable levels.

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.

Treatment of relapsed Hodgkin's disease: strategies and prognostic factors

The major points in salvage therapy of patients in relapse following combination chemotherapy for advanced disease are: (1) success of any second-line approach is determined by prognostic factors which include age, duration of the initial remission, and quantity of disease at relapse; (2) induction failures (progression without remission or incomplete remission and short initial remission) require innovative therapy which currently entails high-dose chemotherapy with peripheral or bone marrow autologous support; (3) late relapse still retains an order to sensitivity to chemotherapy and can be treated with conventional dose combination with complementary radiation therapy to previously unirradiated bulky sites. The choice of regimen is empiric and can include a repeat of the regimen used for the original remission or induction. The relative advantage of HDC in this favorable group is uncertain.

Mantle irradiation alone for clinical stage I-II Hodgkin's disease: long-term follow-up and analysis of prognostic factors in 261 patients

PURPOSE

To evaluate mantle radiotherapy (MRT) alone as the initial therapy of patients with clinical stage (CS) I-II Hodgkin's disease (HD).

PATIENTS AND METHODS

We performed a retrospective study of patients treated with MRT alone for CS I-II supradiaphragmatic HD between 1969 and 1994. Prognostic factor analysis was performed for progression-free survival (PFS) and overall survival (OS). Outcome was also assessed in favorable cohorts defined in the literature.

RESULTS

There were 261 eligible patients. The median follow-up period for surviving patients was 8.4 years (range, 1.8 to 27.4 years). The 10-year OS rate was 73%. Multifactor analysis for OS showed that age was the only important prognostic factor. The 10-year PFS rate was 58%. On multifactor analysis for PFS, the most important prognostic factors were clinical stage, B symptoms, histology, number of sites, and tumor bulk. The 10-year PFS rate for lymphocyte-predominant disease was 81% for stage I and 78% for stage II. In favorable patient cohorts defined in the literature, the 10-year PFS rate ranged from 70% to 73% for the whole group and from 71% to 90% in patients with favorable stage I disease, but only from 48% to 57% in patients with favorable stage II disease. On competing-risks analysis, the cumulative 10-year incidence of first site of failure in the para-aortic/splenic region alone was 10.5%. Sixty percent of relapsed patients remain progression-free at 10 years after chemotherapy salvage.

CONCLUSION

These results support the use of MRT alone in patients with favorable CS I HD and CS I-II HD with lymphocyte-predominant histology. The remainder of patients with CS I-II HD require more intensive treatment.

Late effects of treatment for early-stage Hodgkin's disease

A comprehensive survey of late effects (physical, social and reproductive) following treatment at a single institution for early stage Hodgkin's disease (HD) was performed. A total of 611 patients with stage I and II HD treated between 1973 and 1984 were reviewed; 460 were alive and were mailed a self-reported questionnaire. A total of 363 (79%) replies were received. Twenty patients died of second malignancy, 14 of heart disease and nine from respiratory disease. There were 37 cases of second malignancy [relative risk (RR) 2.2, absolute excess risk (AR) 35.8]. The 15-year incidence of heart disease was 11% and there were nine myocardial infarction deaths (RR 1.55, AR 5.4). Twenty-eight (8%) respondents stated that their career had been greatly interfered with, 53 (14.5%) perceived financial loss. Sexual activity was disrupted in 25.8%. In total, 56 men had fathered 112 pregnancies. Of 171 women, 40.3% became pregnant, resulting in 92 live births. A total of 43 men and 16 women had sought medical advice with regard to infertility.

Long-term outcome of treatment for Ann Arbor stage 1 Hodgkin's disease: patterns of failure, late toxicity and second malignancies

PURPOSE

Radiation therapy results in excellent short-term survival in patients with early-stage Hodgkin's disease. However, the optimal therapeutic scheme that achieves the highest disease-free survival with the minimum long-term toxicity is yet to be determined. An analysis of the patterns of failure and late complications after radiation therapy was conducted to address this question.

METHODS AND MATERIALS

A retrospective study was conducted of 145 patients with Stage I Hodgkin's disease treated at M. D. Anderson Cancer Center from 1967 through 1987. Follow-up extended from a minimum of 30 to 339 months, with a median period of observation of 16.5 years. All the patients were treated with radiation therapy and, and 16 received combination MOPP-based chemotherapy as part of their initial treatment. The radiotherapy technique, was involved/regional in 71 (49%), extended in 62 (43%), and subtotal nodal irradiation in 12 patients. The median total dose was 40 Gy.

RESULTS

The actuarial freedom from progression at 10 and 20 years was 76% and 69%, respectively. Forty of 145 patients relapsed (27.6%). The site of primary disease was cervical adenopathy in 30 (75%), axillary in 7 (17.5%), mediastinal in 2 patients and subdiaphragmatic in one patient. Twenty-two patients were treated with involved/regional technique (55%), 17 with extended (42.5%), and 1 with subtotal nodal irradiation technique. There were three in field and four marginal recurrences. Six relapses occurred in non-irradiated nodal regions at the same side of the diaphragm and 17 in non-irradiated transdiaphragmatic lymph nodes (57.5%). Nine patients (22.5%) relapsed with visceral disease. Nineteen patients (47.5%) relapsed within the first 2 years, 15 (37.5%) 3 to 10 years after diagnosis and the remaining 6 (15%) after 10 years. Eleven of 40 patients died of disease after the first or subsequent relapses (27.5%). Three of six patients with late relapses had progression in viscera but only two died with disease. Thirty-eight of 145 patients developed late toxicity from the treatment (26.2%). Twenty-three patients experienced ischemic heart disease (15.9%), only 13 of whom received mediastinal irradiation (9%). Fifteen patients developed secondary malignant solid tumors (10.3%). Nine of those (6.2%) occurred within the irradiation field (two were also treated with chemotherapy). Two additional patients, one of whom received chemotherapy as part of the initial treatment, died of acute myelogenous leukemia. Non-Hodgkin's lymphoma and lung cancer were the most common second malignancies.

CONCLUSIONS

Limited field radiotherapy results in a significant number of relapses in non-irradiated, especially transdiaphragmatic lymph nodes. Subtotal nodal irradiation can prevent some relapses and therefore improve freedom from progression. Careful design of the treatment fields may decrease the risk of morbidity and mortality from coronary artery disease and second malignancies in early-stage Hodgkin's disease. Careful long-term surveillance may permit early detection and management of late relapses and treatment complications.

Long-term outcome of treatment for Ann Arbor Stage I Hodgkin's disease: prognostic factors for survival and freedom from progression

PURPOSE

The earliest stages of Hodgkin's disease are associated with excellent short-term survival with radiation therapy. This has led to controversies regarding pretreatment evaluation, the extent of irradiation, the role of chemotherapy, and the relative importance of prognostic factors. Long-term results were sought to address these controversies.

METHODS AND MATERIALS

A retrospective study was conducted of patients with Stage I Hodgkin's disease treated at the M. D. Anderson Cancer Center from 1967 through 1987. The median age at presentation of 145 patients was 31 years, and the male-to-female ratio was 1.8. Pretreatment evaluation included lymphangiography and bone marrow aspiration and biopsy in all patients. Laparotomy was performed in 101 of the 145 patients (70%). There were 133 patients with supradiaphragmatic presentations; 12 patients had infradiaphragmatic adenopathy. Only five patients had B symptoms (3.5%). Histologic subtypes of the disease included lymphocyte predominance 17.9%, nodular sclerosis 40.7%, mixed cellularity 40.7%, and one unclassified Hodgkin's disease with primary splenic involvement. All patients were treated with radiotherapy, and 16 (11%) also received combination chemotherapy as part of their initial treatment. Radiotherapy techniques included involved/regional field in 49%, extended field in 42.7% (mantle or inverted Y), and subtotal nodal irradiation in 8.3%. Follow-up extended from a minimum of 30-339 months, with a median period of observation of 16.5 years.

RESULTS

The median survival was 13.7 years. The 10- and 20-year survival rates were 83% and 66%, respectively. The only factor important for decreased survival was age >40 years at diagnosis (p < 0.0001). Out of 43 deaths, 11 were the result of Hodgkin's disease and the remaining 32 resulted from intercurrent disease, including treatment-related causes. Median freedom from progression was 10.5 years, and the 10- and 20-year freedom from progression were 76% and 69%, respectively. Out of 39 relapses, 5 (13%) occurred beyond 10 years. Women had higher freedom from progression (p = 0.0534) than men. Age, histology, bulk of disease, site of involvement including the mediastinal presentations, and the addition of chemotherapy did not influence the freedom of progression. Although very few patients (12 of 145) received subtotal nodal irradiation, the freedom from progression at 10 years was 91.7% for this group versus 64.7% for the group of patients who were treated with more limited techniques.

CONCLUSION

Treatment with radiation therapy for patients with Stage I Hodgkin's disease leads to an excellent outcome, but patients require long-term surveillance as late relapses are not rare. Age is the only factor that affects survival, and gender marginally affects freedom from progression. Subtotal nodal irradiation may improve freedom from progression; further investigation of this treatment is justified.

Multicentre dosimetry study of mantle treatment in Australia and New Zealand

PURPOSE

To determine the difference between expected and measured dose for patients prescribed a mantle treatment for Hodgkin's disease and estimate the range of dose at critical sites and between different treatment centres.

METHODS AND MATERIALS

Twenty three radiotherapy centres were surveyed with regard to the accuracy of dose delivery to a custom-built upper-torso phantom. Thermoluminescent dosimeters were used to monitor the delivered dose at sites such as mid-plane, spinal cord, neck, axilla and lung.

RESULTS

The intended dose to the phantom at each centre was 1 Gy to central axis mid-plane. Of the centres surveyed, the median measured dose to this region was 0.96 Gy with a minimum of 0.92 and a maximum of 1.00 Gy. Median dose to the axilla region was low (0.90 Gy) whereas median dose to the blocked lung and neck region were higher than expected, 0.18 Gy and 1.25 Gy, respectively. The 95% confidence interval on the reported relative dose using the 4000 thermoluminescence dosimetry readings in this study was +/- 1.5%

CONCLUSION

In this controlled experiment, using conventional methods to calculate dose, there was a surprising variability in the dose delivered at the central axis mid-plane position. This was traced to lack of uniformity in the use of equivalent squares to calculate the output factor. The measured doses to axilla and lung are explained by photon and electron scattering effects. Centres, where dose compensation was included, had a superior dose homogeneity in the neck. The off-axis dose calculations depend on computer planning software but the magnitude of these differences is secondary to that of central axis mid-point dose differences. Improved consistency of dose calculation techniques between centres would enable more reliable dose response evaluation from multicentre clinical studies of Hodgkin's disease.

Management of early-stage Hodgkin's lymphoma. The radiation oncology experience at Northwestern University/Northwestern Memorial Hospital

Early-stage Hodgkin's lymphoma patients treated with radiotherapy alone or combined modality therapy were retrospectively analyzed for survival, patterns of failure, salvage, and toxicity. Of 75 evaluable patients, 47 were given radiotherapy alone and 28 were given combination radiotherapy and chemotherapy. Of the patients studied, 26 were clinical stage I and 49 were clinical stage II, with nine patients upstaged at laparotomy. Minimum follow-up was 2 years, with a median of 81 months. Complete response rate was 95%. Relapse-free survival and overall survival were 89% and 96%, respectively, at 2 years; 78% and 86% at 5 years; and 76% and 82% at 10 years. Of 16 patients who relapsed (21%), 13/47 patients were treated with radiotherapy and 3/28 were treated with combined modality therapy. Salvage rates were higher in those treated with radiotherapy alone. There were 13 deaths: six from disease, two from treatment-related complications, and five from second primary malignancies. There was a higher incidence of second malignancies and deaths due to complication in patients treated with combined modality therapy. Radiotherapy alone or with chemotherapy is an effective modality in the treatment of Hodgkin's lymphoma. Treatment should be selected properly to optimize results and decrease complications.

Clinical stage I and II Hodgkin's disease: long-term results of therapy without laparotomy. Experience at one institution

BACKGROUND

We concluded a program in which we administered radiotherapy only to clinical stages I and II Hodgkin's disease patients at standard risk, with the addition of 4 cycles of combination chemotherapy before radiotherapy for high-risk patients.

PATIENTS AND METHODS

From 1980 to 1991, 313 patients with clinical stages I or II Hodgkin's disease underwent treatment in our hospital. Fifty percent of the patients in groups previously identified as being at high risk for relapse received 4 cycles of combination chemotherapy before radiotherapy. The remaining half of the patients received radiotherapy only.

RESULTS

Low- and high-risk patients aged 15-59 years had, respectively, complete remission (CR) rates of 97% and 94%, 5-year survivals of 95% and 91%, and 5-year freedom from relapse (FFR) rates of 78% and 89%. Older low- and high-risk groups had CR rates of 97% and 93%, 5-year survivals of 60% and 56% and 5-year FFR of 77% and 93%, respectively.

CONCLUSION

Here we present our favorable results after treating standard-risk patients with clinical stages I and II Hodgkin's disease with radiotherapy only. With the addition of chemotherapy, the rate of relapse in the high-risk patients was reduced below that of the standard-risk patients. Overall survival was the same for the high- and standard-risk patients.

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.

Radiation therapy for early stage Hodgkin's disease: Australasian patterns of care. Australasian Radiation Oncology Lymphoma Group

PURPOSE

Analysis of treatment outcome for Stage I-IIA supradiaphragmatic Hodgkin's disease treated solely by irradiation in Australia and New Zealand.

METHODS AND MATERIALS

Patients with supradiaphragmatic Hodgkin's disease only who were treated by irradiation alone with curative intent between 1969 to 1988 were retrospectively reviewed. Ten radiation oncology departments in Australia and New Zealand contributed patient data to the study. Patient, tumor, and treatment variables were recorded. Disease-free interval, survival, and complications were analyzed.

RESULTS

Eight hundred and twenty patients were reviewed. The median age was 29 years. There were 437 men and 383 women. The distribution of 310 clinically staged patients was 170 stage IA, 5 IB, and 135 IIA. Five hundred and ten patients received laparotomies, and pathologic staging was as follows: IA 214, IB 13, IIA 283. The 10-year actuarial disease-free rate was 69% and overall survival rate was 79%. Increasing age, male sex, higher number of involved sites, the use of involved field irradiation, no staging laparotomy, and earlier year of treatment were significantly associated with an increased risk of relapse and lower survival. Actuarial 10-year survival following recurrence was 48%. Acute complications requiring interruption to treatment occurred in 46 patients (6%), but < 1% had their treatment permanently suspended. Actuarial complication rates at 10 years were: cardiac 2%, pulmonary 3% and thyroid 5%. There were 44 second malignancies including 10 non-Hodgkin's lymphomas, 3 leukemias, 7 lung, and 6 breast cancers. Mean delay to the development of a second cancer was 6 years. The 10-year actuarial rate of second malignancy was 5%.

CONCLUSIONS

The Australasian experience of early stage Hodgkin's disease is consistent with the results in the published literature and confirms that irradiation produces a high cure rate with minimal toxicity.

Salvage radiotherapy following chemotherapy failure in Hodgkin's disease--what is its role?

Radiotherapy is rarely used as salvage therapy following chemotherapy failure in Hodgkin's disease. Analysis of our experience identified only 11 cases from over 400 patients treated, and data from other centres are similarly sparse. Three (43%) of 7 patients with relapse confined to nodal sites were salvaged with radiotherapy alone. Actuarial relapse free survival at 5 years was 27% (+/- 12 SE) with survival 45% (+/- 15 SE). These data were then combined with four other detailed series in the literature to delineate the patient and disease characteristics of 60 patients, and better assess the role of salvage radiotherapy. This confirms that radiotherapy has an important role in salvaging a small proportion of cases, who can be spared the risk of more aggressive regimens, such as high dose chemotherapy. Patients with relapse confined to one or two nodal sites, and having a disease free interval greater than 12 months, have the best prospects for salvage. Initial stage IV disease seems to have little bearing, provided relapse is confined to nodal sites.

Early-stage Hodgkin's disease: long-term results with radiotherapy alone or combined radiotherapy and chemotherapy

BACKGROUND

Controversy still exists over the optimal management of early-stage Hodgkin's disease (HD); presentation features may have a different prognostic impact according to initial therapy, and long-term toxicity must be fully evaluated.

PATIENTS AND METHODS

This study included 164 patients with stage IA-IIA HD treated with radiotherapy (RT) alone or combined radio- and chemotherapy (CT) according to presenting features and their attendant prognostic significance. The RT group included 88 patients with favorable prognostic features; the combined modality group included 76 patients with one or more unfavorable features. In the RT group, 85% of patients received extended-mantle or STNI; in the combined modality group, RT consisted of mantle- (49%), extended mantle- (37%), and involved-field irradiation (14%); CT consisted of 6 cycles of MOPP before 1984; 3 cycles of ABVD were substituted for MOPP thereafter.

RESULTS

Complete remission was obtained in 94% and 99% of patients of the RT and combined modality groups, respectively. The 10-year actuarial relapse-free survival (RFS) in the RT group was 62% and was influenced by stage (p = 0.04) and histology (p = 0.01); in the combined modality group, RFS was 88% and was influenced by the presence of bulky disease. Overall survival and tumor mortality between the therapy groups were comparable. RT-related toxicity consisted of mediastinal fibrosis (8 cases), myelitis (3), hypothyroidism (2); other long-term events included 2 cases of acute leukemia in the combined MOPP and RT group. Altogether, 8 of 20 patients who died were in their first complete remission.

CONCLUSIONS

In stage IA-IIA HD, the combined modality therapy reduced the risk of relapse compared to radiation alone; long-term toxicity of RT was not negligible and relapses could occur late.