The management of Hodgkin's disease in relapse after primary radiation therapy

BEACOPP and COPP/ABVD as salvage treatment after primary extended field radiation therapy of early stage Hodgkins disease – Results of the German Hodgkin Study Group

Patients with early stage favorable Hodgkin's disease who relapse after extended field radiotherapy have satisfactory results. We retrospectively analysed patients with relapsed HD after initial radiation therapy alone to determine treatment outcome and prognostic factors. Nine-hundred and forty five patients in localized stages without risk factors received either 40 Gy extended field RT or 30 Gy EF RT followed by an additional 10 Gy to involved lymph node regions. 107 patients relapsed and received salvage therapy. Characteristics of the 107 patients at relapse were as follows: median age was 34 years (range 18--75) with relapse occuring at a median of 19 months (range 4--98 months), 31% were female. The majority of patients (93%) were treated with conventional chemotherapy. Sixty-nine percent were treated with COPP/ABVD like regimens, 21% with BEACOPP, and 3% received various other regimens. Seven percent were treated with radiotherapy alone. Complete remission was achieved in 87% of all salvaged patients. The median follow-up after relapse was 45 months. FF2F (freedom from second treatment failure) and OS (overall survival) were 81% and 89%, respectively. In multivariate analysis age was the major prognostic factor for FF2F and OS (p<0.0001, for both). Further independent prognostic factors were B symptoms (p=0.05) and salvage chemotherapy (p=0.03) for FF2F, and B symptoms (p=0.03) and extranodal involvement (p=0.02) for OS. The long-term outcome of patients relapsing after EF RT is excellent. Age, B symptoms, extranodal involvement and salvage chemotherapy were identified as prognostic factors for second relapse and survival.

Comparison of MOPP versus ABVD as salvage therapy in patients who relapse after radiation therapy alone for Hodgkin’s disease

BACKGROUND

The aim of this study was to determine salvage outcome in patients with Hodgkin's disease who relapse after radiation therapy, and to compare the efficacy of mechlorethamine, Oncovin, procarbazine and prednisone (MOPP) versus Adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) as salvage treatment.

PATIENTS AND METHODS

One hundred patients with Hodgkin's disease (97 with stage I-II disease at presentation) who relapsed after radiation therapy alone were salvaged with either MOPP or ABVD. Freedom from second relapse (FFSR) and overall survival (OS) were determined, and prognostic factors for salvage outcome were evaluated.

RESULTS

The median follow-up time since salvage therapy was 12 years. The 10-year FFSR and OS rates were 70% and 89%, respectively. Forty-one patients were salvaged with MOPP and 59 received ABVD. The type of salvage chemotherapy did not significantly influence FFSR or OS. Age >50 years at initial diagnosis was the only significant predictor for an inferior FFSR and OS on both univariate and multivariate analyses.

CONCLUSIONS

The two salvage regimens of MOPP and ABVD had similar efficacy in this group of patients with predominantly early-stage disease at initial radiation therapy. The inferior salvage outcome in patients aged >50 years is a contributing factor to the overall poor prognosis of patients presenting with Hodgkin's disease at an older age.

A population-based study of the outcome for patients with first relapse of Hodgkin's lymphoma

BACKGROUND

Our aims were to evaluate the response to salvage treatment in relation to initial treatment and to evaluate prognostic factors at the time of relapse in an unselected population of relapsing patients with Hodgkin's lymphoma (HL).

PATIENTS AND METHODS

In total, 124 patients younger than 60 yr of age with initial diagnosis of HL in Sweden relapsed between 1985 and 1995.

RESULTS

Fifty-eight patients relapsed after initial treatment with radiotherapy (RT) only, 62 after combination chemotherapy (CT), of whom 30 had received additional involved-field RT, and four after a short course of CT followed by extended-field RT. For 37 patients among the 58 relapsers after initial RT treated according to the recommendations of the National guidelines, the 5-yr Hodgkin-specific survival (HLS) was 85%, overall survival (OS) 73% and event-free survival (EFS) 62%, which is not inferior to survival in patients with primarily advanced stages. It was poorer in the 21 patients who initially had received RT only, even though they had been recommended for more extensive treatment. For patients initially treated with a full course (6-8 cycles) of CT the 5-yr HLS was 60%, OS 58% and EFS 22%. Bulky disease and age at diagnosis strongly affected survival in a multivariate analysis.

CONCLUSIONS

Patients initially treated with RT who relapse have a favourable outcome, provided they have been treated according to the recommendations of the guidelines at the time of diagnosis. Initially bulky disease and, as a consequence, additional RT as part of the initial treatment negatively affect survival at relapse in patients initially treated with a full course of CT.

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.

Prognostic variables and results of salvage treatment in Hodgkin's disease

Treatment results and prognostic variables were studied in 549 adult patients with Hodgkin's disease after first-line and salvage treatment. After first-line treatment, 479 out of 549 patients (87%) achieved complete remission (CR). During a mean observation time of 74 months, 99 patients (21%) relapsed. Sixty-nine patients (70% of relapsed patients) achieved a second CR. Variables predicting poor response (< CR) and shortened survival after first-line treatment were advanced disease, B-symptoms and age >60 years. In relapsing patients, age >60 years, relapse within 12 months and non-CR after relapse treatment predicted a poor prognosis, and none of these patients were alive after 10 years. Localized disease at diagnosis and relapse, and relapse later than 24 months predicted a good prognosis with 10-year survival after relapse of 68% and 57%, respectively. Patients with a second relapse had 5-year survival of 28% and 10-year survival of 14%. Based on the prognostic variables at first-line treatment and at relapse, selection of patients to more intensive treatment is discussed.

Continuous split course irradiation for stage I and II Hodgkin's disease: 20 year experience at the Medical College of Wisconsin

Between January 1970 and December 1989, 153 consecutive patients with stage I or II Hodgkin's disease were treated at the Medical College of Wisconsin Affiliated Hospitals. Eighty-eight patients were clinically staged and 65 patients underwent staging laparotomy. Ninety-nine patients were treated using continuous split course irradiation (CSCI) technique. Overall survival (OS) at 5, 10, and 15 years was 89%, 79%, and 68%, respectively. Disease-free survival (DFS) at 5, 10, and 15 years was 75%, 72%, and 68%, respectively. No significant differences were found in OS or DFS when comparing pathologically and clinically staged patients or when comparing patients treated using CSCI with those treated with the standard technique. Patients treated using CSCI tended to complete therapy in a shorter time, without increased morbidity.