Mortality from Hodgkin's disease in the United States. Evidence for the multiple-aetiology hypothesis

Changing patterns in the Epstein-Barr virus (EBV)and Hodgkin lymphoma association in Tunisia

We compared the features of the Epstein-Barr virus (EBV) and Hodgkin lymphoma (HL) association in Tunisia in two periods of time, 1991-2001 (111 cases) and 2002-2012 (122 cases). The investigation of the EBV status by EBER in situ hybridization showed a significant decrease in the prevalence of EBV-positive HL from 69.3 % for the period 1991-2001 to 40.1 % for the 2002-2012 period (p = 0.00001). EBV positivity has decreased in all age groups but was more pronounced among young patients, in the 15-24-year age group (46.1 vs 10.3 %, p = 0.003), in the 25-34-year age group (56.2 vs 25 %, p = 0.04), and among children (88.4 vs 59.2 %, p = 0.01). This decrease in EBV-positive HL over time contrasted with a remarkable increase in EBV-negative HL in young adults aged 15-34 years (51.2 vs 83 %; p = 0.001), especially among women (59.1 vs 91.2 %; p = 0.01). The decrease in EBV-positive HL over time concerns particularly the nodular sclerosis histological subtype (69.2 vs 31.6 %, p = 0.000001). These results indicate that the epidemiology of HL and its association with EBV are changing over time, with a trend toward a Western profile, and point toward the emergence of other environmental causative factors, especially among young women, which remain to be identified.

Childhood determination of Hodgkin lymphoma among U.S. servicemen

BACKGROUND

Hodgkin lymphoma in young adults is inexplicably linked to economic development.

METHODS

We conducted a nested case-control study of the 656 servicemen with Hodgkin lymphoma diagnosed between ages 17 to 32 while on active duty in the U.S. military during 1950-68. Controls, chosen randomly from the servicemen on duty at the time, were matched on service, birth year, and induction date. Information came from preinduction records and military records for the period ending at onset or the equivalent date.

RESULTS

Risk was independently increased with small sib-ship size [OR, 2.3; confidence interval (CI), 1.6-3.5], low birth order (OR, 1.9; CI, 1.4-2.6), and an interval of at least 5 years between birth and that of a previous or subsequent sibling (OR, 2.1; CI, 1.5-3.1). Other factors independently and significantly associated with elevated risk of Hodgkin lymphoma were: tallness, high body mass index, more education (but not higher income) in the county of birth, BB or AB blood type, and past infectious mononucleosis (but a deficit of other childhood viral infections). Early fatherhood conveyed high risk (OR, 2.6; CI, 1.4-4.8), especially if with a high-risk sibling configuration. Factors unrelated to risk included personal education, preinduction or military occupation, induction test score, and rank. Findings were similar for nodular sclerosis and mixed cell histologic subtypes.

CONCLUSIONS

Protection from the environment in childhood, but not in adulthood, increases the likelihood of young adult Hodgkin lymphoma, which may result from nonspecific isolation from early infections and/or exposure to late infection by a specific but unidentified ubiquitous childhood virus.

IMPACT

Events in childhood protect against later Hodgkin lymphoma.

Comparison of age distribution patterns for different histopathologic types of breast carcinoma

BACKGROUND

Historically, female breast carcinoma has been viewed as an etiologically homogeneous disease associated with rapidly increasing incidence rates until age 50 years, followed by a slower rate of increase among older women. More recent studies, however, have shown distinct age incidence patterns for female breast cancer when stratified by estrogen receptor (ER) expression and/or histopathologic subtypes, suggesting etiologic heterogeneity.

MATERIALS AND METHODS

To determine if different age incidence patterns reflect etiologic heterogeneity (more than one breast cancer type within the general breast carcinoma), we applied "smoothed" age histograms at diagnosis (density plots) and a two-component statistical mixture model to all breast carcinoma cases (n = 270,124) in the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. These overall patterns were then reevaluated according to histopathologic type, race, and ER expression.

RESULTS

A bimodal age distribution at diagnosis provided a better fit to the data than a single density for all breast carcinoma populations, except for medullary carcinoma. Medullary carcinomas showed a single age distribution at diagnosis irrespective of race and/or ER expression.

CONCLUSIONS

Distinct age-specific incidence patterns reflected bimodal breast cancer populations for breast carcinoma overall as well as for histopathologic subtypes, race, and ER expression. The one exception was medullary carcinoma. Of note, medullary carcinomas are rare tumors, which are associated with germ-line mutations in the BRCA1 gene. These descriptive and model-based results support emerging molecular data, suggesting two main types of breast carcinoma in the overall breast cancer population.

Prognostic factors for hematologic cancers

This article reviews the molecular biology of hematologic cancers and the current understanding of prognostic factors for these cancers. Specific molecular biomarkers that have potential as prognostic factors for various hematologic cancers are discussed. Quantitative and statistical methods of evaluating the usefulness of prognostic factors are presented.

Epstein-Barr virus in pediatric Hodgkin disease: age and histiotype are more predictive than geographic region

Epidemiologic studies have implicated Epstein-Barr virus (EBV) in the great majority (80%-100%) of Hodgkin disease (HD) cases in South American countries, versus only 30%-40% in the United States and other industrialized countries. Other EBV-related malignancies are known to be geographically localized, including nasopharyngeal carcinoma in south China and Burkitt lymphoma in equatorial Africa. Some studies, however, have suggested that age and histiotype, rather than geographic region, are the major determinants of the association between EBV and HD. To further characterize this relationship in children, we matched 26 cases of pediatric Hodgkin disease from south Brazil and 26 cases from the U.S.-forhistiotype and age. The Brazilian children (22 males, 4 females) had a median age of 9 years, while the median age of the U.S. group (11 males, 15 females) was 7.5 years. Formalin-fixed, paraffin-embedded biopsy material was examined for EBV early RNA1 (EBER1) expression by in situ hybridization. This antigen was detected solely in Reed-Sternberg cells or their variants in positive samples. The same proportion of cases was positive (15/26 or 58%) in both groups of children. After adjustment for histiotype and age, the association between EBV and HD remained independent of geographic location, but was more frequent in children aged < or = 10 years at diagnosis. These findings support the multiple-etiology hypothesis for Hodgkin disease.

Evaluation of Epstein-Barr virus antibody patterns and detection of viral markers in the biopsies of patients with Hodgkin's disease

We assessed the relationship of Epstein-Barr virus (EBV) serology to the presence or absence of EBV genome in 39 cases of Hodgkin's disease (HD). Biopsies from patients included in 2 previous published studies, 1 involving patients from the United States (eastern Massachusetts) and 1 from Denmark, were evaluated for EBV (EBER-1) and latent membrane protein (LMP-1). The presence of EBV in Reed-Sternberg cells in the biopsies correlated with the histologic subtype of HD (mixed cellularity and lymphocyte depletion) but not with IgG antibody titers against the viral capsid antigen (VCA). These data suggest that, unlike Burkitt's lymphoma, the IgG antibody against VCA is not predictive of the presence or absence of EBV in Reed-Sternberg cells in HD. The predictive value of other antibodies should be evaluated.

Patterns of presentation of Hodgkin disease. Implications for etiology and pathogenesis

BACKGROUND

The etiology of Hodgkin disease remains uncertain. Patterns of presentation of Hodgkin disease are analyzed by histologic subtype with implications for etiology and pathogenesis.

METHODS

The authors performed a detailed analysis of anatomic sites of involvement, histopathologic findings, and clinical features in 719 patients with Hodgkin disease who underwent staging laparotomy with splenectomy between April 1969 and December 1986. The presence of disease in each of 17 sites of potential nodal involvement was determined for each patient from a combination of clinical and surgical staging. Association among nodal sites was assessed in 2 x 2 tables by estimating the odds ratio and testing the significance with the chi-square test. A strict significance level (P = 0.01) was used. Log-linear models were used for assessing association in 2 x 2 tables while adjusting for other factors.

RESULTS

The mediastinum, left side of neck, and right side of neck were the most common sites involved for patients with nodular sclerosing (NS) or mixed cellularity (MC) histologic subtypes. Each of these sites was involved 60% of the time. These sites were four or more times as common as other nodal sites above or below the diaphragm. In contrast, the mediastinum was involved in only 8% of patients with lymphocyte predominance (LP) histologic subtype. Significant associations were found between mediastinal disease and low cervical/supraclavicular lymph node disease, mediastinal disease and NS histologic subtypes, peripheral nodal disease and LP histologic subtypes, and between splenic disease and mixed cellularity/lymphocyte depletion (MC/LD) Hodgkin disease. The age at onset and sex of patients with Hodgkin disease and the patterns of nodal distribution were somewhat different for NS and MC/LD histologic subtypes. Even greater differences were seen between LP and other histologic subtypes.

CONCLUSIONS

This study supports the conclusion that NS and MC Hodgkin disease spread by continguity, most often originating in the neck or mediastinum, and is consistent with evidence suggesting an infectious agent in the pathogenesis of these subtypes of Hodgkin disease. In contrast, LP Hodgkin disease is characterized by different sites of presentation and patterns of spread. This suggests that two or perhaps three clinicopathologic subtypes of Hodgkin disease exist. Implications for etiology and pathogenesis are discussed.

Viral involvement in Hodgkin's disease

The etiology of Hodgkin's disease (HD) is unknown, but a growing body of evidence suggests that the Epstein-Barr virus (EBV) plays a role in a proportion of cases. Clonal EBV genomes have been detected in affected tissues, and EBV has been localized to Reed-Sternberg (RS) cells, the putative malignant cells in HD. EBV latent genes, including the EBER RNAs and the latent membrane protein, LMP-1, are expressed by RS cells. These data suggest that EBV is playing a role in the pathogenesis of HD; however, it is clearly not involved in all cases. Using in situ hybridization, we can detect EBV within the RS cells in approximately 40% of cases. Epidemiological data suggest that HD is a heterogeneous condition and the distribution of EBV-associated cases is not random. Studies from several groups indicate that mixed cellularity cases are more likely to be EBV-associated than nodular sclerosis cases. Our data further suggest that the majority of pediatric and older cases of HD are EBV-associated, whereas the RS cells in young adult cases only rarely harbor EBV. We therefore speculate that another virus is responsible for the young adult peak in incidence which is seen in developed countries.

Hodgkin disease mortality in the United States: 1979-1988

Mortality trends for Hodgkin disease in the United States were examined from 1979 to 1988 with the use of mortality data for multiple causes of death, which were obtained from the National Center for Health Statistics. A progressive decrease in the death rate from Hodgkin disease was observed over this period. The decrease in death rate was greatest among white patients. Patients who were 55 years or older had the highest death rate. Analysis by geographic region showed decreases in each of the regions, with no significant difference among groups of states with high and low incidences of acquired immune deficiency syndrome. However, the decrease in the South was approximately 35% greater than that in the North-east. In 1988 the most significant difference in death rates between male and female patients was in the 35-54-year age group, whereas a significant difference in death rates between white and black patients was seen only in patients who were 55 years of age or older. In summary, although there has been a significant reduction in deaths resulting from Hodgkin disease between 1979 and 1988, the decreases observed have varied between sexes and among age groups, racial groups, and geographic regions.

Genetics of Hodgkin's and non-Hodgkin's lymphoma: a review

Host susceptibility factors have been documented in both HD and NHL wherein a subset of pedigrees provide evidence for an autosomal dominantly inherited factor. Families with both HD and NHL occurring in genetically informative patients provide evidence in support of a possible common pathogenetic pathway for these diseases, as does recent cytogenetic and molecular genetic evidence. AIDS as an unmasking factor for familial predisposition to lymphoma and other cancers may be a powerful tool for identifying lymphoma- and cancer-prone families, but to date has not been employed. In concert with ecogenetic research, it will be important that lymphoma-prone families be subjected to multidisciplined research involving experimental designs developed by geneticists and epidemiologists in concert with pathologists, immunologists, and molecular geneticists.

Hodgkin's disease

The epidemiological features of Hodgkin's disease (HD) suggest that it is a heterogeneous condition which may have different aetiologies in different age groups. The risk factors for the development of HD in young adults suggest that delayed exposure to a common infectious agent may be involved in this age group. Seroepidemiological studies have shown that HD patients have elevated antibody titres to Epstein-Barr virus (EBV) and the elevated titres have been shown to precede the diagnosis of HD. Recent molecular studies provide support for the idea that EBV is involved in the pathogenesis of HD. EBV genomes are consistently found in a proportion of tumour biopsies, the EBV-infected cells are clonal and the EBV genomes have been localized to Reed-Sternberg cells. Furthermore, EBV latent gene products are expressed by the Reed-Sternberg cells. The majority of HD samples from patients aged greater than 50 years and less than 15 years are EBV positive, whereas the minority (less than 15%) of samples from young adults contain detectable EBV DNA. The results suggest that EBV plays a role in HD in children and older adults but that other agents, possibly other viruses, are involved in young adults.

Time trends in Hodgkin's disease incidence. The role of diagnostic accuracy

A prior study of Hodgkin's disease (HD) incidence using national cancer survey data (1969-1980) identified unprecedented rate declines among white persons older than 40 years, and rate increases among young adults aged 15 through 39. These trends could be due to improved diagnostic accuracy. To investigate this hypothesis, the authors updated incidence rates in whites by age, sex, and histologic subtype through 1984; quantified diagnostic accuracy in corresponding detail using Repository Center for Lymphoma Clinical Studies data, which include original and expert review diagnoses on lymphoma patients; and recalculated HD incidence rates (1969-1984) corrected for diagnostic error. Updated HD incidence rates through 1984 continued to decline in older adults and showed persistent increases for young adults with the nodular sclerosis (NS) histologic subtype. The percentage of original HD diagnoses confirmed on review (confirmation rate) decreased with age and increased over time; in older adults, these patterns opposed observed incidence trends. However, for young adults, confirmation rates of NS, the most common subtype at these ages, were high and changed little over time. After adjustment for diagnostic error, incidence rates for older adults were lower than previously observed and showed no secular changes. However, young adults with NS had slightly larger rate increases than in uncorrected data. Thus, contemporary changes in HD incidence for whites primarily involve growing risk to persons at the start of adult life. These patterns are compatible with trends in suspected sociodemographic risk factors that suggest an infectious etiology for HD.

Regional variation in Hodgkin's disease incidence by histologic subtype in the US

Geographic distribution in Hodgkin's disease (HD) incidence was examined for whites by age, sex and Rye histologic subtype in several regions of the US for 1969 to 1971 and 1973 to 1980, using data from national cancer surveys. Average annual age-adjusted rates (1973-1980) ranged between 2.0 and 3.6 per 100,000 persons. Significant regional variation in HD was confined to elevated rates in Connecticut and San Francisco-Oakland, and low rates in Hawaii, Atlanta, and New Orleans. In young adults (ages 20-34 years) HD was positively associated across regions with rates for children (ages 5-14 years), and with community-wide socioeconomic status (SES), but did not vary with older adult rates. Patterns of geographic variation differed among the histologic subtypes, with no significant variation for the lymphocyte predominance form. Incidence of nodular sclerosis increased with regional SES, and was inversely correlated with rates of lymphocyte predominance. Among women, HD incidence became less heterogeneous across regions with time.

Recent incidence and secular trends in Hodgkin's disease and its histologic subtypes

Incidence data from national cancer surveys (1947, 1969-71, 1973-80) in selected regions of the United States were used to describe the epidemiology of Hodgkin's disease (HD) in whites over all regions by age, sex and Rye histologic subtype in the 1970s, and time trends for HD overall. Before 1971, rates increased in young adults, notably men, and in older persons. During the 1970s, rates in children were stable, but young adult rates were high and rose slightly, particularly among women; both trends reflected elevated incidence of Nodular Sclerosis, the only subtype with increasing rates. For adults over 40, rates of all subtypes declined after 1969-71. Thus HD incidence in this country is not static, even over the last decade. Rate stability in younger children may indicate disappearance of environmentally caused HD. Incidence declines for older persons suggest a cohort effect, depletion of young adult susceptibles, or improvements in diagnostic accuracy.

Interpersonal linkage among Hodgkin's disease patients and controls in Western Australia

Interpersonal linkages were studied in 178 Hodgkin's disease patients, aged 60 years or younger, who lived in Western Australia between 1964 and 1975, and in their matched controls. Eighty-nine living subjects were interviewed about places and periods of residence, school attendance and employment, and possible linkages were computed based on concurrence of these events. Subjects were also shown the names of all patients and controls and asked to mark the names they recognized, giving details of acquaintanceships. The acquaintanceship method yielded more and the concurrence method fewer case-case links than expected. Little overlap occurred in linkages identified by the two methods. The acquaintanceship method is thought to be the more reliable. Risk factors suggested in the literature were also investigated. Increased risk of Hodgkin's disease in living patients was associated with being unmarried, being born outside Western Australia, smoking cigarettes, and having lived and worked on a farm and worked with animals. These effects did not explain the excess of case-case linkages found by the acquaintanceship method.

Epidemiologic comparison of cancer of the testis and Hodgkin's disease among young males

In 1970 the epidemiologic similarities between Hodgkin's disease and multiple sclerosis were first described, suggesting that a common agent or agents might be involved in their etiology. The hypothesis proposed at that time was that the agents followed the paralytic polio model: widespread infection with an agent of low pathogenicity at an early age, resulting in acquired immunity in later life. Lack of early infection results in the disease appearing in adulthood, with severe repercussions. This article extends the paralytic polio model to include testicular carcinoma, since the epidemiologic similarities between it and Hodgkin's disease are striking. Specifically, the authors compare age at clinical onset, histologic type, time trends, race, socioeconomic status, geographic variation, occupation, and familial aggregation. It is suggested that the possibility of common etiologies involved in the pathogenesis of these two cancers be tested further by epidemiologic, clinical, or laboratory studies.

Climate, socioeconomic status and Hodgkin's disease mortality in the United States

This study examines the relative effects of climate and socioeconomic status (SES) on standard mortality ratios (SMR) from both young adult and older adult Hodgkin's disease (HD) in the United States. Climate variables explain a greater percentage of the variation in the SMR for HD than do SES variables. After adjusting for SES, indicators of climate exhibit a strong correlation with the young adult SMR, but not with the older adult SMR. These findings suggest that environmental factors play an important role in the etiology of young adult HD and support the hypothesis that young adult HD is a different disease from the older adult form.

Incidence of familial Hodgkin's disease

The family histories of 131 patients with histologically defined Hodgkin's disease (HD) were studied and 2,517 first and second degree relatives and spouses were identified and followed-up. The causes of death in deceased relatives were ascertained from death certificates. The numbers of deaths from selected causes were compared with the numbers that would be expected if the relatives had suffered the same mortality rates as the Scottish national population. A 4-fold increase in deaths due to HD was found among first and second degree relatives of patients with the disease (6 cases observed compared with 1.4 expected). Five of the 6 familial cases were related to index patients with the mixed cellularity form of the disease, the remaining case was the brother of a patient with the lymphocyte-depleted form of the disease. The increased risk was seen among relatives of both young and older patients and there was no consistent intrafamilial similarity in age of onset or time of onset of disease.

Simultaneous Hodgkin's disease in three siblings with identical HLA-genotype

We report 3 cases of Hodgkin's disease (HD) within a family of seven children. All three children had mixed cellularity type in different stages of the disease (IV-B, III-A, and II-A). The diagnosis was made within a one-month interval. HLA typing shows an identical genotype in the 3 HD patients, which was different from the rest of the family. One of the patients developed an idiopathic thrombocytopenic purpura (ITP) with temporary response to prednisone and MOPP-C chemotherapy that subsided after splenectomy. The HLA identity, in addition to the simultaneous onset of the HD, suggests a combination of both genetic and environmental factors in the pathogenesis of this disease.

Descriptive Epidemiology of Hodgkin's Disease in the Province of Torino, 1965-1971

Age-standardized incidence rates of Hodgkin's disease in the province of Torino in 1965-1971 were 2.81/100,000/year in males and 1.64 in females, i.e., somewhat lower than in urban areas of other industrialized countries. In the whole province, age-distribution for males was similar to previous findings elsewhere, with a young-adult peak at ages 25-34. However, in the city of Torino, males showed a first peak in the age-class 35-44, while in the rest of the province an infantile peak (0-14 years) was found. By dividing the latter area in suburbs and nonmetropolitan area, the infantile peak was confirmed only in the nonmetropolitan area. Females showed a different behavior: in the city of Torino there was a unimodal curve (peak in age-class 55-64), and in the rest of the province there was a bimodal curve with a first peak in age-class 15-24. These patterns have been analyzed in relation to the suggestion of a distribution by age of Hodgkin's disease following 3 types (nonindustrialized countries, urban areas of industrialized countries and rural areas of industrialized countries). No significant differences in the distribution of cases were found among the smallest geographical units considered (ULSs), in contrast with previous findings on cancer of the larynx and bladder, which showed marked geographical differences within the province of Torino.

Epidemiology of hemopoietic system neoplasms in Argentina

The mortality caused by blood neoplasms in Argentina shows great irregularity. This was found to be caused in certain ways by (a) differences in the sexes and ages of the populations studied; (b) differences in available health services; and (c) environmental factors. Thus high rates and clusters of lymphomas and multiple mylomas were observed in zones with arsenical water, for example.In rural districts, the rates are lower, especially among old-aged people.Lower rates of leukemias were also observed among Spaniards compared to Italians (p=0.001) residing in Argentina. Turkish, Syrian, and Lebanese showed higher rates than Argentinians, Spaniards, or Italians.The results of a case-control study are given in which the following were observed: (a) Among the ancestors of cases HSN there are fewer Spaniards (not significant) and Latin-Americans (p=0.03) and more people who were born in Central or Eastern Europe (p=0.01). (b) In case group, there was more frequent contact with animals, especially dogs; and a greater exposure to petroleum and its products, and to insecticides.

Familial Hodgkin's disease

A family with Hodgkin's disease is described. Each affected member of the family had mediastinal involvement and in each case the histology was that of nodular sclerosing Hodgkin's disease. The significance of these findings with reference to the aetiology of the disease is discussed.

Hodgkin's disease in Medellin, Colombia

Four hundred and fifty two cases of Hodgkin's disease (H.D.) were studied in Medellin, Colombia, following the Rye histological classification: The relative frequency of H.D. was 2.3% for all malignancies and 34% for the solid lymphoreticular tumors. The percentage of H.D. in children as compared with adults was 27%, which is higher than usually reported. The age curve of incidence was bimodal with a first high peak at age 5--9 years and a lower second peak between 15--25 years. Males predominated mainly in children, 4.5--1. The epidemiological pattern for H.D. in our area generally corresponded with the Type I recently described for developing countries; but a high frequency for Nodular Sclerosis in children, with unusual anatomical localizations, more severe clinical manifestations, and poorer prognosis seems to indicate complex factors in the etiopathogenesis of the disease in the same geographical area.

Epidemiology of hodgkin's disease in the young

Many features of Hodgkin's disease (HD) among adolescents and young adults suggest that it has an infectious etiology. However, the proposal that HD is a contagious disease which can be transmitted by patients or their close contacts has not been substantiated. An alternative infectious disease model is suggested by analogy with paralytic poliomyelitis (PP). For both diseases, the peak age of incidence is delayed as living conditions improve. For both, increased risk is associated with higher social class and small family size. Like PP, HD may be a rare manifestation of a common infection with the probability of disease development increasing as age at infection is delayed. This analogy is supported by the report that the risk of HD is higher for persons who had a low frequency of childhood infectious diseases. If this model is valid, HD patients represent no hazard to their contacts. However, the incidence of HD among young adults may increase in the coming decade because of the current high standard of living and small family size.

Hodgkin's disease in siblings

An incidence survey of Hodgkin's disease in Greater Boston during 1959-1973 detected five sibling pairs under the age of 45. The expected number is 0.7; thus, siblings of young adults with Hodgkin's disease have about a sevenfold excess risk of the disease (P = 0.0008). Eight sibling pairs, not in the incidence series, were also identified. Among all 13 pairs, 12 were sex concordant; the number expected is 6.8 (P = 0.01). The literature includes 46 sibling pairs under 45 of which 30 are sex concordant. The expected number is 23.9 (P = 0.05). Combining the present and the literature series suggests that siblings of the same sex as an affected person have a risk of Hodgkin's disease double that of siblings of the opposite sex. The sex concordance suggests that the excess Hodgkin's disease among siblings of affected persons is due either to inter-personal transmission of an etiologic agent by prolonged or intimate contact or to common-source exposures.

Familial Hodgkin's disease and associated cancer. A clinical-pathologic study

The etiology of Hodgkin's disease is complex, as is evident in studies suggesting the importance of horizontal transmission, occupational factors, racial and ethnic background, and familial, genetic factors, or both, including HL-A associations. The present study is of a remarkable kindred in which Hodgkin's disease was histologically verified in two sibships involving second-cousins related through maternal great-grandparents. Cancer of the lung, breast, endometrium, ovary, pancreas, and brain, as well as leukemia and Wilms' tumor, occurred in first and second-degree relatives of the Hodgkin's patients. HL-A haplotypes in patients with Hodgkin's disease in this family showed HL-AB5 or HL-ABW35, an association confirmed in other reports. The findings of associated malignant neoplasms in familial Hodgkin's disease, here and elsewhere in the literature, suggest that in the quest for etiology of Hodgkin's disease one must view the disorder eclectically, with a painstaking search for multiple etiologies, genetic and environmental.

Multiple sclerosis and Hodgkin's disease in Denmark

There has been a hypothesis that Hodgkin's disease in young adults and multiple sclerosis may have related causes because the age of clinical onset and the geographic distribution of both are similar. This hypothesis was tested for data in Denmark. Detweeen 1943-62, the average annual incidence rate for Hoadgkin's disease in Denmark was 2.25 per 100,000 population (2.68 male and 1.83 female). Between 1951-69, the average annual death rate for Hodgkin's disease was 2.15 per 100,000 (2.66 male and 1.64 female). The average annual incidence rate for multiple sclerosis in Denmark was calculated from age at onset for 2,481 prevalent cases of 1949, the 1940 population, and an average annual incidence of 128.86 cases for 1939-45: the average annual incidence rate per 100,000 was then 3.35 (3.00 male and 3.69 female). Age specific incidence and death rate for Hodgkin's disease in Denmark each showed a bimodal curve, with one peak at age 25-29 and the other at age 70-74; this was found for each sex, with male rates consistently higher than female. The age specific incidence rates for multiple sclerosis were clearly unimodal with a peak at age 25-29 more definite in females than males. Rates for MS were notably higher for young females than males but about equal by sex for those over the age of 30. The geographic distribution of multiple sclerosis within the counties (amter) of Denmark was markedly non-random, with the major concentration of high prevalence areas middle Jutland and on to Fyn. Geographic distribution of Hodgkin's disease, whether for the young or the old, and whether from incident or death cases, showed no significant variation from a homogeneous distribution. In formal testing there was no correlation of any Hodgkin's distribution with that of MS. A review of the Hodgkin's data for distribution in the United States, on which the original hypothesis was based, suggests the variation there may be little more than reporting artifact. Accordingly, we conclude that there is no relation between distributions of these two disorders, and the factors they do appear to have in common are either quite non-specific or of questionable validity. Thus there is no reason to believe that multiple sclerosis and Hodgkin's disease, even in the young, share a common etiology.

Childhood Hodgkin's disease in Israel. A study of 17 cases

A study of 17 children suffering from Hodgkin's disease (H.D.) is presented. The special ethnic distribution with predominance in Arab and Oriental Jewish children is noted. A high incidence of mixed cellularity histology in Arab children is emphasized. A conservative approach to therapy, i.e. extended field regional radiotherapy only, resulted in a long first complete remission period in lymphocyte predominance and nodular sclerosis H.D. Stages IA and IIA. All children in Stage IIIB and IV were treated by six courses of combined chemotherapy, and were maintained either on chlorambucil and vinblastine or on MOPP. Patients with mixed cellularity H.D. Stage IIA and all patients in Stage IIIA were treated by four courses of MOPP after the completion of extended regional radiotherapy. The 5 children who did not receive the schedules treatment died. The remaining 12 are well, with a survival of 8 to 104 months.

Similar geographical distribution of multiple sclerosis and cancer of the colon

A search was made of all diseases listed in the Annual Statistics of the World Health Organization to determine if any disease had the peculiar geographical distribution of multiple sclerosis. Of the approximately 83 diseases listed, only cancer of the colon was similar in geographical distribution and in the slight preponderance of females dying with the disease. The epidemiology of both diseases is reviewed, particularly with regard to their appearance in certain migrant populations.