Primary and salvage chemotherapy in advanced Hodgkin's disease: the Milan Cancer Institute experience

The Role of Granulocyte Colony-Stimulating Factor (Filgrastim) in Maintaining Dose Intensity during Conventional-Dose Chemotherapy with Abvd in Hodgkin's Disease

Background

The aim of the study was to evaluate the role and potential benefit of granulocyte colony-stimulating factor (G-CSF, Filgrastim), administered following cytotoxic chemotherapy with the ABVD regimen in Hodgkin's disease, in maintaining cycle schedule and dose intensity and in decreasing neutropenia and number of infections.

Patients and Methods

Twenty-two patients affected by high-risk Hodgkin's disease (14 localized and 8 diffuse), aged 15 to 69 years (median, 34), were given ABVD chemotherapy for a total of 6 courses (for the purpose of this study, each single course of chemotherapy was considered as two 15-day periods). No patient was given G-CSF after the first cycle. After each cycle, G-CSF was administered only for: 1) absolute neutrophil count < 1 × 109/L between cycles; 2) delay in cycle schedule due to an absolute neutrophil count < 1 × 109/L on the planned day of treatment; or 3) fever or a documented infection, regardless the absolute neutrophil count. Once administered, G-CSF was maintained in the subsequent cycles.

Results

Seventeen of 22 patients (77%) required the administration of G-CSF (5 μg/kg b.w.; a median of 5 doses/cycle); most of them (13/17) before the 5th dose of chemotherapy. The main reason for introducing G-CSF into therapy was neutropenia during the interval between courses (n = 4) or on the planned day of treatment (n = 11). Comparing 112 courses where G-CSF was not administered with 124 where it was, in the latter group we observed: 1) a significantly lower (P = 0.0002) incidence of cycle delays (0 vs 13), with a median delay of 7 days (5 to 11). The main reason for cycle delay was neutropenia (n = 13); 2) a greater dose intensity delivered to the patients while on G-CSF (100% vs 95.2±8.8%; P = 0.0001); 3) an absolute neutrophil count significantly higher at day 8 (P<0.0001) and day 15 (P< 0.0001); 4) a significantly lower (P = 0.0003) incidence of neutropenia (2 vs. 17). No difference in the incidence of infections was observed between the two groups of cycles (P = 0.5889), but the duration and severity of the same were greater during chemotherapy without G-CSF, requiring antibiotic therapy and causing cycle delay.

Conclusions

In conclusion, our data suggest the use of Filgrastim in Hodgkin's disease also during conventional-dose chemotherapy with ABVD. It is not required from the first dose of therapy, but as soon as neutropenia appears between cycles or on the planned day of treatment. Then, its use allows maintenance of the chemotherapy schedule and dose intensity. It also decreases frequency, duration and severity of neutropenia and its sequelae.

Autologous hematopoietic stem cell transplantation in classical Hodgkin's lymphoma

Background

Hodgkin's lymphoma has high rates of cure, but in 15% to 20% of general patients and between 35% and 40% of those in advanced stages, the disease will progress or will relapse after initial treatment. For this group, hematopoietic stem cell transplantation is considered one option of salvage therapy.

Objectives

To evaluate a group of 106 patients with Hodgkin's lymphoma, who suffered relapse or who were refractory to treatment, submitted to autologous hematopoietic stem cell transplantation in a single transplant center.

Methods

A retrospective study was performed with data collected from patient charts. The analysis involved 106 classical Hodgkin's lymphoma patients who were consecutively submitted to high-dose chemotherapy followed by autologous transplants in a single institution from April 1993 to December 2006.

Results

The overall survival rates of this population at five and ten years were 86% and 70%, respectively. The disease-free survival was approximately 60% at five years. Four patients died of procedure-related causes but relapse of classical Hodgkin's lymphoma after transplant was the most frequent cause of death. Univariate analysis shows that sensitivity to pre-transplant treatment and hemoglobin < 10 g/dL at diagnosis had an impact on patient survival. Unlike other studies, B-type symptoms did not seem to affect overall survival. Lactic dehydrogenase and serum albumin concentrations analyzed at diagnosis did not influence patient survival either.

Conclusion

Autologous hematopoietic stem cell transplantation is an effective treatment strategy for early and late relapse in classical Hodgkin's lymphoma for cases that were responsive to pre-transplant chemotherapy. Refractory to treatment is a sign of worse prognosis. Additionally, a hemoglobin concentration below 10 g/dL at diagnosis of Hodgkin's lymphoma has a negative impact on the survival of patients after transplant. As far as we know this relationship has not been previously reported.

Phase II study of ABVd therapy for newly diagnosed clinical stage II-IV Hodgkin lymphoma: Japan Clinical Oncology Group study (JCOG 9305)

Although ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) therapy has been regarded as a standard of care for advanced-stage Hodgkin lymphoma (HL) since 1992, there has been no prospective data of ABVD therapy in Japan. To investigate the efficacy and safety of ABVd therapy with the lower dose of dacarbazine (250 mg/m(2)) in patients with newly diagnosed stage II-IV HL, Lymphoma Study Group of Japan Clinical Oncology Group conducted a phase II study. The primary endpoints were complete response rate (%CR) and progression-free survival (PFS). A total of 128 patients with age less than 70 years were enrolled and received 6-8 cycles of ABVd followed by radiation to initial bulky mass. The %CR in 118 eligible patients was 81.4% [95% confidence interval (CI) 73.1-87.9%]. Major toxicity was grade 4 neutropenia (45.3%). Grade 3 nausea/vomiting was the most frequent non-hematological toxicity (10.9%). Transient grade 4 constipation, infection (abscess), hypoxemia and hyperbilirubinemia were observed in 4 patients. No treatment-related death was observed. PFS and overall survival at 5 years were 78.4% (95% CI 70.9-85.9%) and 91.3% (95% CI 86.1-96.5%), respectively. In conclusion, ABVd is effective in Japanese patients with stage II-IV HL with acceptable toxicities (UMIN-CTR Number: C000000092).

Brazilian experience using high-dose sequential chemotherapy followed by autologous hematopoietic stem cell transplantation for relapsed or refractory Hodgkin lymphoma

PURPOSE

We evaluate the effectiveness and toxicity of high-dose sequential chemotherapy (HDS) as salvage therapy in patients with advanced-stage Hodgkin lymphoma.

PATIENTS AND METHODS

We performed a retrospective analysis on 77 patients receiving HDS between 1998 and 2006. Patients enrolled were in disease progression or relapsed disease, or did not achieve a complete remission after first-line treatment. HDS consisted of the sequential administration of cyclophosphamide and granulocyte colony-stimulating factor with stem cell harvesting, followed by methotrexate plus vincristine and etoposide.

RESULTS

The majority of patients had stage III/IV (64%) and B symptoms (71.4%). Disease status improvement after HDS was observed in 24 of 57 patients (42%) previously in disease progression or relapse. HDS-related deaths occurred in 8 of 77 patients (10.4%). Four patients (5.2%) developed acute myeloid leukemia/myelodysplastic syndrome. Overall, disease-free and progression-free survival was 27%, 57%, and 25%, respectively.

CONCLUSION

Despite the treatment-related mortality, HDS is feasible, with satisfactory response rates, even in patients with poor prognosis.

Salvage therapy for Hodgkin's lymphoma

Hodgkin's lymphoma (HL) is a clonal lymphoid malignancy that affects over 7000 patients in the United States annually. The disease remains one of the great success stories in the recent history of cancer treatment. More than 80% of HL patients will be expected to be long-term survivors because of recent advances in radiation therapy and combined chemotherapy. However, for the subset of patients who relapse after initial therapy, HL remains a challenging disease. Indeed, for patients who relapse after salvage high-dose chemotherapy and autologous stem cell transplant, effective therapeutic options remain limited, and further new therapies are warranted. This article provides a review of the current literature regarding salvage therapy for HL.

Clinical characteristics and treatment response of Hodgkin's lymphoma in Taiwan

BACKGROUND/PURPOSE

Hodgkin's lymphoma (HL) is particularly rare in Asia, including Taiwan. The report concerning its clinical features and treatment outcomes in Asians is limited. An exploration of the characteristics of HL in this area is of importance for future studies.

METHODS

In this study, 133 patients with HL diagnosed between January 1985 and December 2004 at National Taiwan University Hospital were analyzed retrospectively.

RESULTS

The age distribution revealed a young-adult peak at the age around 20 years. The nodular sclerosis type (NS-HL) was the most common histopathologic subtype (45%), followed by mixed cellularity (29%), lymphocyte predominant (13%), and lymphocyte depleted subtype (2%). The incidence of NS-HL was, however, lower compared with that in the West (around 70%). The male to female ratio was approximately 1:2 in patients with NS-HL, in contrast to the male predominance in patients with other subtypes. Induction therapy led to complete remission (CR) in 87% of patients. At a median follow-up of 78 months, the 10-year overall survival (OS) was 79% in all HL patients and was 90% in those who achieved first CR. In multivariate analysis, the achievement of CR was the only independent factor associated with good OS.

CONCLUSION

The treatment response of HL in Taiwan is good and comparable to that in Western countries. The epidemiologic differences between Taiwan and the West mandate further studies.

Stem cell transplantation in Hodgkin lymphoma

Hematopoietic stem cell transplantation is an effective treatment for patients with relapsed or refractory Hodgkin lymphoma. Treatment outcome is better among patients who demonstrate sensitivity to salvage chemotherapy. Approximately half of the patients undergoing autologous stem cell transplantation will be cured and sequential high-dose therapy has been proposed as a means of improving these results further. Lifelong medical surveillance is required following transplantation to monitor for late toxicity, including second malignancy. For young patients who relapse following transplantation, reduced-intensity allogeneic transplantation has shown encouraging response rates, while second autologous stem cell transplantation, radiotherapy and palliative single-agent chemotherapy are other options. For patients with multiple relapses and chemotherapy refractory disease, novel approaches are necessary.

State-of-the-art therapeutics: Hodgkin's lymphoma

Presently Hodgkin's lymphoma can be cured in at least 80% of patients. The major challenge to the clinician in 2005 is how to cure the disease while inducing the least irreversible toxicity. This review focuses on clinical trials and institutional experiences to identify the best choice of treatment, individualized to the stage of the lymphoma permitting minimization of late toxicity such as infertility, premature menopause, cardiac disease, and most importantly, risk of second neoplasms. More than 90% of patients with limited Hodgkin's lymphoma can be cured with either short-course chemotherapy alone or even briefer chemotherapy followed by involved-field radiation. Accumulating evidence suggests that chemotherapy alone is suitable for the large majority of patients with limited disease. For the 80% of patients with advanced disease but without a large number of adverse prognostic factors, standard multi-agent chemotherapy with the well-established ABVD regimen (doxorubicin, bleomycin, vinblastine, and dacarbazine) provides the best balance of effectiveness and minimization of toxicity. More intensified regimens currently under investigation are appropriate for the 20% with numerous adverse prognostic factors. In 2005 it is insufficient to focus solely on cure of Hodgkin's lymphoma. The treatment program must maximize chance of cure and minimize late toxicity. Fortunately, brief chemotherapy alone or with radiation for patients with limited disease and standard ABVD chemotherapy for patients with advanced disease offer the appropriate balance of these two requirements. Patients with advanced disease plus multiple indicators of a poor prognosis and patients with disease that persists despite optimized primary treatment require specially intensified treatment.

Evolving Approaches to Primary Treatment of Hodgkin Lymphoma

Two challenges confront the clinician treating Hodgkin lymphoma today: achieving a high level of effectiveness while minimizing toxicity. At least 80% of patients can be cured with currently available chemotherapy regimens, augmented in selected patients with the addition of involved field radiation or intensified chemotherapy assisted by granulocyte growth factors or stem cell transplantation. Major late toxicity including infertility, premature menopause, cardiovascular disease and second neoplasms can be avoided in most patients if the treatment program is chosen carefully.

The extent of disease (stage) and, for advanced stage lymphoma, the presence of well-characterized prognostic factors can be established with readily available clinical, laboratory and imaging techniques. Results from carefully designed and analyzed clinical trials have identified optimal treatment approaches for patients with limited and advanced stage disease. Those with limited stage Hodgkin lymphoma should be treated with brief chemotherapy, only augmented with involved field irradiation if an early complete remission is not achieved. Most patients with advanced stage lymphoma can be cured with an extended course of ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine). The small minority under the age of 60 years with an International Prognostic Factors Project score of 5 or greater should be considered for intensified chemotherapy. Patients known to have bulky tumor(s) (> 10 cm) at diagnosis may require adjuvant irradiation at the conclusion of chemotherapy, but its utility has not been unequivocally established and radiation should be avoided in those who achieve a complete remission, where it is known to be ineffective.

With careful selection of treatment program most patients found to have Hodgkin lymphoma today can be offered a high probability of cure and a low likelihood of major late toxicity. However, without detailed attention to the extent of lymphoma and other prognostic factors, there is as much danger of over-treatment as under-treatment. Only by thoughtfully adjusting the treatment program to the extent of disease and response to treatment can the clinician determine the optimal approach, maximizing likelihood of cure and minimizing late toxicity.

High-dose therapy and autologous hematopoietic stem-cell transplantation for recurrent or refractory pediatric Hodgkin's disease: results and prognostic indices

PURPOSE

To evaluate the outcome of pediatric patients with refractory or relapsed Hodgkin's disease (HD) who undergo high-dose therapy and autologous hematopoietic stem-cell transplantation (AHSCT).

PATIENTS AND METHODS

From 1989 to 2001, 41 pediatric patients with relapsed or primary refractory HD underwent high-dose therapy followed by AHSCT according to one of four autologous transplantation protocols at Stanford University Medical Center (Stanford, CA). Pretreatment factors were analyzed by univariate and multivariate analysis for prognostic significance for 5-year overall survival (OS), event-free survival (EFS), and progression-free survival (PFS).

RESULTS

At a median follow-up of 4.2 years (range, 0.7 to 11.9 years), the 5-year OS, EFS, and PFS rates were 68%, 53%, and 63%, respectively. Multivariate analysis determined the following three factors to be significant predictors of poor OS and EFS: extranodal disease at first relapse, presence of mediastinal mass at time of AHSCT, and primary induction failure. Two of these factors also predicted for poor PFS (extranodal disease at time of first relapse and presence of mediastinal mass at time of transplantation).

CONCLUSION

More than half of children with relapsed or refractory HD can be successfully treated with the combination of high-dose therapy and AHSCT, confirming the efficacy of this approach. Further investigation is now required to determine the optimal timing of AHSCT, as well as to develop alternative regimens for those patients with factors prognostic for poor outcome after AHSCT.

Outcome after autologous hemopoietic stem cell transplantation in relapsed or refractory childhood Hodgkin disease

OBJECTIVES

To determine the clinical outcome and prognostic factors for overall survival in children with recurrent and/or primary refractory Hodgkin disease (HD) after high-dose therapy and autologous hemopoietic stem cell transplantation (AHSCT). The survival outcome of this treatment was compared with conventional salvage therapy without stem cell transplantation.

METHODS

Clinical records of 51 patients with relapsed or refractory HD who underwent AHSCT were reviewed. The source of the stem cells was bone marrow (n = 22) or peripheral blood (n = 29). At the time of high-dose therapy, 39 patients were in complete remission and 1 was in partial remission, while the remaining 11 had refractory disease. The records of 78 patients from the HD 1 trial who underwent conventional salvage treatment but without AHSCT for relapsed or refractory HD were also reviewed. All patients received HDT without radiation for conditioning.

RESULTS

Overall survival from diagnosis of patients treated with AHSCT did not differ significantly from that of those treated with conventional salvage therapy (hazard ratio = 1.5; 95% confidence interval = 0.9-8.2; P = 0.4). There were also no statistically significant differences in survival data between the two approaches for patients whose duration of first remission was less than or greater than 1 year (P = 0.5; stratified log-rank). Of the 11 patients who received AHSCT for refractory disease, 9 remain alive and well with followups ranging from 2 to 18 years. No deaths due to treatment-related complications were seen in the AHSCT group.

CONCLUSIONS

Stem cell transplantation does not offer any significant survival advantage over conventional salvage therapy in children with relapsed HD, although it may be of benefit for patients with primary refractory disease.

Hodgkin's lymphoma: biology and treatment strategies for primary, refractory, and relapsed disease

Hodgkin's lymphomas belong to the most curable tumor diseases in adults. About 80% of patients in all anatomical stages and of all histological subtypes can be cured with modern treatment strategies. In spite of the great clinical progress, the pathogenesis of this peculiar lymphoproliferative entity has not been elucidated completely up until now. In Section I Drs. Stein, Hummel, and Zollinger describe the different pro-proliferative and antiapoptotic pathways and molecules involved in the transformation of the germinal center B-lymphocyte to the malignant Hodgkin-Reed-Sternberg cell. They use a comprehensive gene expression profiling (Affymetrix gene chip U133A) on B- and T-Hodgkin cell lines and state that the cell of origin is not the dominant determinant of the Hodgkin cell phenotype, but the transforming event. H-RS cells lack specific functional markers (B-T-cell receptors) and physiologically should undergo apoptosis. Why they do not is unclear and a matter of intensive ongoing research. In Section II Dr. Diehl summarizes the commonly used primary treatment strategies adapted to prognostic strata in early, intermediate and advanced anatomical stages using increasing intensities of chemotherapy (two, four, eight courses of chemotherapy such as ABVD) and additive radiation with decreased doses and field size. ABVD is without doubt the gold standard for early and intermediate stages, but its role as the standard regimen for advanced stages is challenged by recent data with time- and dose-intensified regimens such as the escalated BEACOPP, demonstrating superiority over COPP/ABVD (equivalent to ABVD) for FFTF and OS in all risk strata according to the International Prognostic Score. In Section III, Dr. Connors states that fortunately there is a considerably decreased need for salvage strategies in Hodgkin's lymphomas since primary treatment results in a more than 80% tumor control. Nevertheless, a significant number of patients experience either a tumor refractory to therapy or an early or late relapse. Therefore, one of the continuing challenges in the care for Hodgkin's lymphomas today is to find effective modes for a second tumor control. High-dose chemotherapy followed by autologous stem cell support has proved to be the treatment of choice when disseminated tumors recur after primary chemo- and or radiotherapy. Nodal relapses respond well to local radiation when they recur outfield of primary radiation without B-symptoms and in stages I-II at relapse. Allogeneic stem cell support needs further intensive evaluation in controlled studies to become an established alternative.

Approach to Hodgkin's lymphoma in the new millennium

Approximately 75% of patients with Hodgkin's lymphoma can be cured with modern chemotherapy and radiation. Most patients are treated according to clinical stage and the associated prognostic factors. For patients with limited stage Hodgkin's lymphoma, combined modality treatment has replaced subtotal nodal irradiation as the preferred treatment option. This approach eliminates laparotomy and potentially decreases the long-term toxicity secondary to extended field irradiation and splenectomy. Furthermore, recent studies suggest that it may improve disease control and possibly survival. Multiple novel regimens have been tested in the past 20 years in patients with advanced Hodgkin's lymphoma including dose-intense regimens, but current evidence suggests that ABVD remains the treatment of choice outside clinical trials. Over the past decade, the treatment-related morbidity and mortality associated with autologous stem cell transplantation have reduced significantly and stem cell transplant is becoming the treatment of choice for most patients with primary refractory or recurrent Hodgkin's lymphoma. With longer follow-up, long-term complications, in particular secondary malignancy have become the leading cause of late treatment failure for patients with Hodgkin's lymphoma. To improve the overall outcome of patients with Hodgkin's lymphoma, future studies need to focus on reducing the therapy-related toxicity for patients with good risk disease as well as improving disease control for patients with poor risk disease through a risk-adapted approach.

Autotransplants for Hodgkin's disease in first relapse or second remission: a report from the autologous blood and marrow transplant registry (ABMTR)

Although patients with relapsed Hodgkin's disease have a poor prognosis with conventional therapies, high-dose chemotherapy and autologous hematopoietic stem cell transplantation (autotransplantation) may provide long-term progression-free survival. We reviewed data from the Autologous Blood and Marrow Transplant Registry (ABMTR) to determine relapse, disease-free survival, overall survival, and prognostic factors in this group of patients. Detailed records from the ABMTR on 414 patients with Hodgkin's disease in first relapse (n = 295) or second complete remission (CR) (n = 119) receiving an autotransplant from 1989 to 1995 were reviewed. Median age was 29 (range, 7-64) years. Median time from diagnosis to relapse was 18 (range, 6-219) months; median time from relapse to transplant was 5 (range, <1-215) months. Most patients received high-dose chemotherapy without total body irradiation for conditioning (n = 370). The most frequently used high-dose regimen was cyclophosphamide, BCNU, VP-16 (CBV) (n = 240). The graft consisted of bone marrow (n = 246), blood stem cells (n = 112), or both (n = 56). Median follow-up was 46 (range, 5-96) months. One hundred-day mortality (95% confidence interval) was 7 (5-9)%. One hundred and sixty-five of 295 patients (56%) transplanted in relapse achieved CR after autotransplantation. Of these, 61 (37%) recurred. Twenty-four of 119 patients (20%) transplanted in CR recurred. The probability of disease-free survival at 3 years was 46 (40-52)% for transplants in first relapse and 64 (53-72)% for those in second remission (P < 0.001). Overall survival at 3 years was 58 (52-64)% after transplantation in first relapse and 75 (66-83)% after transplantation in second CR (P < 0.001). In multivariate analysis, Karnofsky performance score <90% at transplant, abnormal serum LDH at transplant, and chemotherapy resistance were adverse prognostic factors for outcome. Progression of Hodgkin's disease accounted for 69% of all deaths. Autotransplantation should be considered for patients with Hodgkin's disease in first relapse or second remission. Future investigations should focus on strategies designed to decrease relapse after autotransplantation, particularly in patients at high risk for relapse.

Advances in the treatment of Hodgkin's lymphoma

Given the successful treatment for most patients with Hodgkin's lymphoma, efforts have been directed primarily toward improving outcomes for the minority of patients with poor prognosis or relapsed disease or reducing the late effects of therapy for long-term survivors. Recently, a simple and clinically useful prognostic scoring system was developed for patients with advanced disease. This system allows better risk assessment for individual patients and more uniformity among patients participating in clinical trials. In addition, trials using newer chemotherapeutic regimens such as Stanford V or BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) are maturing with promising results. Other studies are helping to define the role of high-dose therapy for patients with Hodgkin's lymphoma, although biologic treatments such as cellular or antibody-based therapies are still in early phases of development. Lastly, positron emission tomographic scanning is emerging as a useful tool in staging and following Hodgkin's lymphoma.

Autotransplants for Hodgkin's disease in patients never achieving remission: a report from the Autologous Blood and Marrow Transplant Registry

PURPOSE

Hodgkin's disease patients who never achieve complete remission with conventional chemotherapy (i.e., those with primary induction failure) have a poor prognosis. Some subjects who receive high-dose therapy with autologous hematopoietic progenitor-cell infusion experience prolonged progression-free survival.

PATIENTS AND METHODS

Detailed records from the Autologous Blood and Marrow Transplant Registry (ABMTR) on 122 Hodgkin's disease patients who failed to achieve complete remission after one or more conventional therapy regimens and subsequently received an autotransplant between 1989 and 1995 were reviewed.

RESULTS

Median age was 27 years (range, 7 to 57 years). Median time from diagnosis to transplantation was 14 months (range, 5 to 38 months). Most patients received high-dose chemotherapy without radiation for pretransplantation conditioning (n = 107). The regimen most frequently used was cyclophosphamide, carmustine, and etoposide (n = 47). Fifteen patients received total-body irradiation (n = 15). The graft consisted of bone marrow (n = 86), blood stem cells (n = 25), or both (n = 11). The 100-day mortality was 12% (95% confidence interval, 7% to 19%). Sixty patients (50%) were considered to have achieved complete remission after autotransplantation; 37 of these had negative imaging studies, whereas scan abnormalities of unknown significance persisted in 23 patients. Twenty-seven patients (22%) had no response or progressive disease after transplantation. Probabilities of progression-free and overall survival at 3 years were 38% (95% confidence interval, 28% to 48%) and 50% (95% confidence interval, 39% to 60%), respectively. In multivariate analysis, "B" symptoms at diagnosis and poor performance score at transplantation were adverse prognostic factors for outcome.

CONCLUSION

Autotransplants should be considered for patients with Hodgkin's disease who do not achieve complete remission with conventional therapy.

A prognostic score for advanced Hodgkin's disease. International Prognostic Factors Project on Advanced Hodgkin's Disease

BACKGROUND

Two thirds of patients with advanced Hodgkin's disease are cured with current approaches to treatment. Prediction of the outcome is important to avoid overtreating some patients and to identify others in whom standard treatment is likely to fail.

METHODS

Data were collected from 25 centers and study groups on a total of 5141 patients treated with combination chemotherapy for advanced Hodgkin's disease, with or without radiotherapy. The data included the outcome and 19 demographic and clinical characteristics at diagnosis. The end point was freedom from progression of disease. Complete data were available for 1618 patients; the final Cox model was fitted to these data. Data from an additional 2643 patients were used for partial validation.

RESULTS

The prognostic score was defined as the number of adverse prognostic factors present at diagnosis. Seven factors had similar independent prognostic effects: a serum albumin level of less than 4 g per deciliter, a hemoglobin level of less than 10.5 g per deciliter, male sex, an age of 45 years or older, stage IV disease (according to the Ann Arbor classification), leukocytosis (a white-cell count of at least 15,000 per cubic millimeter), and lymphocytopenia (a lymphocyte count of less than 600 per cubic millimeter, a count that was less than 8 percent of the white-cell count, or both). The score predicted the rate of freedom from progression of disease as follows: 0, or no factors (7 percent of the patients), 84 percent; 1 (22 percent of the patients), 77 percent; 2 (29 percent of the patients), 67 percent; 3 (23 percent of the patients), 60 percent; 4 (12 percent of the patients), 51 percent; and 5 or higher (7 percent of the patients), 42 percent.

CONCLUSIONS

The prognostic score we developed may be useful in designing clinical trials for the treatment of advanced Hodgkin's disease and in making individual therapeutic decisions, but a distinct group of patients at very high risk could not be identified on the basis of routinely documented demographic and clinical characteristics.

Early intensive therapy with autologous stem cell transplantation in high-risk Hodgkin's disease: long-term follow-up in 35 cases

Thirty-five adult patients with high-risk HD (HD) defined by (1) Ann Arbor stage IV or bulky nodal disease (tumor/thorax ratio > 0.45) and (2) no or partial response (PR) (< 75%) to the initial 3 courses of ABVD, received an early intensive therapy with autologous stem cell transplantation (ASCT). Thirty patients were considered as partial responders and 5 as refractory to initial chemotherapy. Conditioning regimen consisted of chemotherapy alone (CBV in 11 patients before 1993, BEAM in 13 patients since 1993) followed by adjuvant radiotherapy: 40 Gy) on the initial sites of bulky disease, or 12 Gy total body irradiation plus 120 mg/kg cyclophosphamide in 11 patients with disseminated extra-nodal disease. All 30 patients in PR at the time of ASCT experienced prolonged complete remission (CR). One patient died in CR from an acute myocardial infarction 48 months after ASCT. Four out of the 5 patients with refractory disease at the time of ASCT experienced rapid progression of HD leading to death in 3 cases. After 6 years of CR post-ASCT, the last refractory patient died of myelodysplastic syndrome diagnosed 2 years after intensive therapy. With a median follow-up for surviving patients of 51 months (range: 11-111), the cumulative probability of 8-year overall survival is 75.6% for the entire group of patients, 94.1% for the chemosensitive ones, and 0% for the primary refractory (P < .0001). The cumulative probability of 8-year event-free survival is 79.9% for the entire group of patients, 94.1% for the chemosensitive ones, and 0% for the primary refractory (P < .0001). We conclude that early intensive therapy with ASCT is feasible in patients with high-risk HD and induces a high cure rate in chemosensitive patients. In primary refractory patients, new therapeutic approaches are warranted.

Comparison Between Conventional Salvage Therapy and High-Dose Therapy With Autografting for Recurrent or Refractory Hodgkin's Disease

Sixty patients with Hodgkin's disease, refractory to or at first recurrence after chemotherapy, received cytoreductive therapy followed by high-dose etoposide, cyclophosphamide and either total body irradiation or carmustine and autografting (median follow-up, 3.6 years; range, 1.1 to 7.5 years). A matched conventional salvage group of 103 patients was selected from patients treated at Stanford University Medical Center between January 1976 and January 1989 (median follow-up, 10.3 years; range, 3.0 to 15.7 years). Overall survival (OS), event-free survival (EFS), and freedom from progression (FFP) at 4 years follow-up favored patients who received high-dose therapy compared with conventional salvage treatment (OS: 54% v 47%, P = .25; EFS: 53% v 27%, P < .01; FFP: 62% v 32%, P < .01). In Cox regression analysis, response to cytoreductive or salvage therapy and B symptoms at relapse were the most important predictors of OS. The use of high-dose therapy at relapse, a longer duration of remission, and favorable response to cytoreductive or salvage therapy were most predictive of superior FFP and EFS. These data from a single institution comparing conventional and high-dose therapy in matched patients demonstrate an advantage for high-dose therapy and autografting in the sustained control of Hodgkin's disease. As with primary therapy, it is difficult to demonstrate a statistically significant survival advantage, despite an apparently superior cure rate. However, patients failing induction therapy or relapsing within 1 year benefited significantly from high-dose therapy by all outcome measures (OS, EFS, FFP). As the transplant-related mortality rates decline in Hodgkin's disease, it is predicted that cure rates and late effects will become ultimate determinants of the success of high-dose therapy and autografting.

High-Dose Therapy and Autologous Hematopoietic Progenitor Cell Transplantation for Recurrent or Refractory Hodgkin's Disease: Analysis of the Stanford University Results and Prognostic Indices

One hundred nineteen patients with relapsed or refractory Hodgkin's disease (HD) received high-dose therapy followed by autologous hematopoietic progenitor cell transplantation. Three preparatory regimens, selected on the basis of prior therapy and pulmonary status, were employed. Twenty-six patients without a history of prior chest or pelvic irradiation were treated with fractionated total body irradiation, etoposide (VP) 60 mg/kg and cyclophosphamide (Cy) 100 mg/kg. Seventy-four patients received BCNU 15 mg/kg with identical doses of VP and Cy. A group of 19 patients with a limited diffusing capacity or history of pneumonitis received a novel high-dose regimen consisting of CCNU 15 mg/kg, VP 60 mg/kg and Cy 100 mg/kg. Twenty-nine patients (24%) had failed induction therapy and 35 (29%) had progressive HD within 1 year of initial chemotherapy. At 4 years actuarial survival was 52%, event-free survival was 48% and freedom from progression (FFP) was 62%. No significant differences were seen in survival data with the three preparatory regimens. Six patients died within 100 days of transplantation and 5 died at a later date of transplant-related complications. Secondary malignancies have developed in 6 patients, including myelodysplasia/leukemia in four patients and solid tumors in two patients. Regression analysis identified systemic symptoms at relapse, disseminated pulmonary or bone marrow disease at relapse and more than minimal disease at the time of transplantation as significant prognostic factors for overall and event-free survival and FFP. Patients with none of these factors enjoyed an 85% FFP at 4 years compared with 41% for patients with one or more unfavorable prognostic factors (P = .0001). Our results confirm the efficacy of high-dose therapy and autografting in recurrent or refractory HD. Although longer follow-up is necessary to address ultimate cure rates and toxicity, our data indicate that a desire to reduce late effects should drive future research efforts in favorable patients whereas new initiatives are needed for those with less favorable prognoses.

Autologous stem cell transplants in lymphomas

Hodgkin's disease and non-Hodgkin's lymphomas can be treated and, in a large number of cases, cured by first-line chemotherapy or radiotherapy. Unlike many other malignancies, relapse is not uniformly fatal but the treatment is usually markedly myelotoxic with the high doses of chemotherapy used in relapse. Haematopoietic reconstitution with either autologous marrow or peripheral stem cells postchemotherapy has made high-dose chemotherapy relatively safe with mortality rates as low as 2% in some centres. The clinical indications for high-dose therapy in lymphoma management for patients with relapsed and bad prognosis disease are reviewed. The advantages of autologous bone marrow and peripheral stem cell transplants are compared and current peripheral stem cell mobilization and harvesting practice is discussed.

Intensive therapy and autologous stem cell transplantation for Hodgkin's disease in first relapse after combination chemotherapy

Data from a number of transplant centers has shown that several intensive therapy regimens, supported by autologous stem cell transplantation, have the capability to produce durable responses in a proportion of patients with Hodgkin's disease progressive after combination chemotherapy. Although many questions regarding the optimal use of autotransplantation remain unanswered, the issue of the preferred timing at which to apply transplantation is of critical importance in planning therapeutic strategies for patients with this disease. This paper will focus on the timing options for autotransplantation in Hodgkin's disease. In the absence of a formal Phase III study comparing conventional salvage therapy versus autotransplantation in first relapse patients, the encouraging results from our center and others support the use of transplantation at the time of first relapse after combination chemotherapy. Non-relapse mortality is low in this setting, and the primary problem has been recurrent disease despite transplantation. Risk factors for both disease recurrence, as well as for the probability of progression-free survival, can be defined based on biologic features present at the time of first relapse after chemotherapy, and may provide a basis for improving the current transplant results for first relapse patients. Prolonged follow-up will be important to define the incidence and risk of late toxicities in autografted patients.

High-dose chemotherapy followed by autologous hematopoietic rescue for Hodgkin's disease patients following first relapse after chemotherapy

BACKGROUND

The best results of conventional-dose salvage chemotherapy for Hodgkin's disease have been reported after first relapse. We evaluated the results of high-dose chemotherapy and autologous hematopoietic rescue for Hodgkin's disease patients who had relapsed from an initial chemotherapy-induced complete remission.

PATIENTS AND METHODS

Eighty-five patients received high-dose cyclophosphamide, carmustine, and etoposide (CBV) followed by autologous bone marrow or peripheral blood stem cell transplantation.

RESULTS

Actuarial survival at five years was 51%, and failure-free survival was 40%. Failure-free survival at five years was 90% for patients who received no conventional-dose salvage chemotherapy prior to CBV. Failure-free survival of patients treated initially with a four-drug regimen was not significantly different than patients treated with seven/eight-drug regimens.

CONCLUSION

These results appear to be better than those reported for conventional-dose salvage chemotherapy. High-dose therapy followed by autologous bone marrow or peripheral blood stem cell transplantation should be considered for any patient with relapsed Hodgkin's disease, regardless of the length of initial remission, or type of initial chemotherapy. Certain patients, especially those with minimal disease, may benefit by proceeding directly to transplantation after relapse, without first receiving conventional-dose salvage chemotherapy.

High-dose therapy and autologous bone marrow transplantation in first complete or partial remission for poor prognosis Hodgkin's disease

We report the experience of three French centres which evaluated high-dose therapy (HDT) as consolidation therapy for poor prognosis Hodgkin's disease (HD). From March 1986 to April 1990, 23 consecutive patients with poor prognosis stage IV HD underwent HDT followed by autologous bone marrow transplantation (ABMT) after achieving either complete remission (CR1) or good partial response (GPR1) (reduction mass> 75%). The median age was 31 years (range 18 to 55 years), 14 were male. All patients except one initially had at least 2 poor prognosis factors such as: systemic symptoms (n = 19), bulky tumor (n = 16), more than one extranodal site (n = 9), bone marrow involvement (n = 5), lymphocyte count < or = 1.10(9)/1 (n = 8) and biological stage B (n = 21). All patients had previously been treated with alternating MOPP/ABVD. Ten patients were in GPR1 and 13 in CR1 before transplant. The conditioning regimens were: CBV (n = 17), BEAM (n = 5), BEAC (n = 1) followed by bone marrow rescue. Radiotherapy was introduced just before the conditioning regimen for 6 patients or after ABMT for 5 patients. Nine of 10 patients in GPR1 achieved CR after ABMT but one died early of treatment-related toxicity. Five of 22 patients who were in CR posttransplant, relapsed (3, 4, 4, 18, 36 months). Seventeen patients remain alive in continuous CR with a median follow-up of 60 months (range: 30-100 months). The overall survival (OS) and disease-free survival (DFS) projected at 5 years are 92% and 77% respectively. Consolidation by HDT and ABMT proved to be well tolerated. An international trial is currently underway to attempt to demonstrate a clear benefit on survival for this subset of poor prognosis HD patients.

High-dose therapy and autologous bone marrow transplantation for Hodgkin's disease patients with relapses potentially treatable by radical radiation therapy

PURPOSE

A retrospective review evaluated the results of autologous bone marrow transplantation (A-BMT) for patients with relapsed Hodgkin's disease (HD) who were potentially treatable by radical radiation therapy (RRT).

METHODS AND MATERIALS

Evaluated patient cases met the following criteria: initial treatment with chemotherapy (with or without involved field radiation therapy < 25 Gy); no history of bone marrow or extensive lung involvement; no current or previous evidence of systemic metastases except liver; radiation therapy used with salvage chemotherapy for prior relapse would not preclude use of RRT (e.g., > 20 Gy to spinal cord); HD at time of salvage therapy limited to lymph nodes, Waldeyer's ring, liver, spleen, direct extension sites, and/or one lung.

RESULTS

There were 23 A-BMT patients treated between 1986 and 1991 who fulfilled the criteria. Three (13%) patients died from treatment-related complications and eight (35%) developed nonfatal Grade 3-4 complications. The 3-year actuarial disease-free survival rate was 61%. The 3-year disease-free survival rate was 55% for the nine patients with at least one prior disease-free interval (DFI) > 12 months, 67% for nine patients with DFI < 12 months, and 60% for five induction failure patients (p > 0.10). These results are comparable to retrospective studies of RRT results in selected relapsed HD patients.

CONCLUSIONS

Long-term disease-free survival is frequently possible with either A-BMT or RRT in appropriately selected relapsed HD patients. In considering treatment options, important prognostic factors include initial stage of disease, number of prior relapses, DFI, and extent of relapsed disease.

Involved field radiation therapy for Hodgkin's disease autologous bone marrow transplantation regimens

From 1986 through 1992, involved-field radiation therapy (IF-RT) was administered to 29 of 86 patients with recurrent Hodgkin's disease (HD) who received a high-dose cyclophosphamide/etoposide regimen with autologous bone marrow transplantation (A-BMT). Patients without a significant history of prior RT received total body irradiation (TBI), initially as a single dose 5-7.5 Gy, and subsequently with fractionated TBI (F-TBI) delivering 12 Gy. Previously irradiated patients received a high-dose BCNU regimen instead of TBI. IF-RT was employed selectively, usually for sites of bulky disease (> 5 cm). IF-RT doses were typically 20 Gy at 2 Gy per fraction for TBI patients and 30-40 Gy at 1.8-2.0 Gy per fraction for non-TBI Patients. Fatal complications developed in four patients while second malignancies have developed in two. The region which received IF-RT was the site of first recurrence in only two cases (7%). With a median follow-up of 28 months, the two-year disease-free survival rate was 44%. For the 22 patients treated by either F-TBI or high-dose BCNU, the 2-year disease-free survival rate was 50% with a median follow up of 29 months. Selective use of IF-RT may increase the chances of complete remission and disease free survival in HD patients with a history of bulky disease.

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.

Radical radiotherapy as salvage treatment for relapse of Hodgkin's disease initially treated by chemotherapy alone: prognostic significance of the disease-free interval

PURPOSE

A study was performed to determine the effectiveness of radical radiation therapy (RT) in the treatment of patients with Hodgkin's disease who relapsed following initial treatment with chemotherapy alone.

METHODS AND MATERIALS

A retrospective review of patients treated at City of Hope National Medical Center between 1970 and 1987 revealed a total of 10 patients who received radical RT with curative intent as salvage therapy.

RESULTS

Complete remission was achieved in eight of the ten patients. Patients had an overall 5-year actual survival of 60% and 10-year actuarial survival of 38%. Relapse-free survival was 30% at 5 years and at 10 years. For the five patients with a disease-free interval (DFI) of at least 12 months prior to radical RT, overall actual survival at 5 years was 100% and relapse-free survival was 60%. Three of the ten patients, all with a DFI > 12 months and in first relapse when undergoing radical RT, were long-term relapse-free survivors.

CONCLUSION

Radical RT is an effective salvage regimen for select patients with advanced stage Hodgkin's disease who relapse following initial treatment with chemotherapy alone provided that relapse is limited to sites which can be encompassed by radical RT fields and the DFI is greater than 12 months. Review of other published series supports DFI > 12 months as a favorable prognostic factor. Comparison to other salvage regimens such as autologous bone marrow transplantation is limited. Reviews of other treatment modalities should perform subset analysis on patients with similar presentations to compare the relative effectiveness of various salvage approaches.

Vinorelbine: an active drug for the management of patients with heavily pretreated Hodgkin's disease

BACKGROUND

This study evaluated the therapeutic effect of the weekly administration of vinorelbine (5'-nor-anhydrovinblastine), a semisynthetic vinca alkaloid, in heavily pretreated patients with Hodgkin's disease.

PATIENTS AND METHODS

Twenty-four patients with Hodgkin's disease refractory or resistant to at least two chemotherapy regimens were enrolled in this study. Vinorelbine was administered in a weekly dose of 30 mg/m2 i.v. bolus and patients were evaluated after four courses. All but two were considered evaluable for drug response. The reasons for their exclusion were early death due to pancytopenia and loss to follow-up after two courses. In complete responders, six additional courses were administered; in all other patients, treatment was continued until their diseases progressed. Toxicity was evaluated in 23 patients according to the Common Toxicity Criteria.

RESULTS

Eleven of 22 evaluable patients (50%) showed objective response (complete 14% and partial 36%). The median duration of response was six months for both complete and partial responders (range 2-10 months). Thirteen patients are still alive and five are still on therapy. Grade 3-4 granulocytopenia was documented in 53% of patients and grade 3 infections in 13%. Anemia and thrombocytopenia were negligible. Nausea and vomiting were not observed; grade 2 alopecia occurred in only one patient. There were grade 3 reactions at the injection site in the first five patients, so a venous central access was utilized in the subsequent patients. Two patients had grade 1 constipation and only one developed an adynamic ileum. Although all patients had previously been treated with vinca alkaloid analogs, peripheral neuropathy was mild.

CONCLUSIONS

Our data indicate that vinorelbine is active as a single agent in heavily pretreated patients with Hodgkin's disease. The efficacy in patients pretreated with at least two vinca alkaloids suggests a possible absence of cross-resistance between vinorelbine and other vinka analogs. Toxicity is mild and reversible. The inclusion of vinorelbine in secondline combination chemotherapy regimens for Hodgkin's disease is strongly recommended.

The hematopoietic stem cell transplantation in Hodgkin's disease: questions and controversies

Most patients with Hodgkin's disease (HD) are cured with chemotherapy and/or radiotherapy. However, half of those with advanced stage disease (IIIB, IV) do not respond adequately to treatment or relapse. Salvage therapy used in such cases gives from 10% to 50% complete remission but only 10% long term survival. The results of bone marrow transplantation reported in acute leukemia and non-Hodgkin's lymphoma encouraged some authors to develop this new therapeutic strategy in Hodgkin's disease. In the early 1980's promising results were achieved when refractory and relapsed patients were selected to receive myeloablative therapy followed by bone marrow transplantation. Today, high dose chemotherapy with hematopoietic stem cell transplantation (HSCT) is used more and more often in poor prognosis Hodgkin's disease. After a review of the literature concerning the results of transplantation in Hodgkin's disease, we develop the numerous problems associated with this procedure which remain to be solved such as: the optimal indication, the timing of HSCT, the type of graft, the conditioning regimen, the place of radiotherapy and the optimal use of hematopoietic growth factors. We conclude with future prospects.

Intensive therapy and autotransplantation in Hodgkin's disease

Intensive therapy and autologous marrow or peripheral blood stem cell transplantation is often utilized in Hodgkin's disease patients whose disease has progressed after primary conventional chemotherapy. A number of studies have described long-term disease-free survival in up to 50% of transplanted patients. High-dose chemotherapy conditioning regimens such as "CBV" or "BEAM" have been used more often than regimens containing total body irradiation. Usually unpurged autologous bone marrow has been utilized as the source of hematopoietic stem cell reconstitution, although recently the use of "primed" peripheral blood stem cells has increased markedly. The challenges of transplant-related toxicity and recurrence of disease post-transplant are discussed, as well as possible strategies to reduce these problems. The use of autologous transplantation is discussed in three clinical settings: patients who have failed to enter a complete remission (CR) after primary chemotherapy, those who have relapsed within 12 months of attaining a CR and those who have relapsed after a longer (i.e., > or = 12 months) first CR. When compared with conventional salvage chemotherapy, transplantation appears to produce a higher long-term disease-free survival rate in all of these patient groups. However, assessment of an advantage for autotransplantation, particularly in patients with long first remissions, is difficult without a Phase III trial. On the other hand, recently updated results from our center indicate that 72% of patients relapsing after long initial remissions benefit from autotransplantation at this point in their disease course, and that transplant-related mortality is low in this setting. Other issues addressed include the potential role of autologous transplantation as consolidation therapy in selected high-risk patients in an initial CR, as well as the utility of conventional chemotherapy and involved-field radiotherapy in conjunction with autotransplantation.

Results of CAV regimen (CCNU, melphalan, and VP-16) as third-line salvage therapy for Hodgkin's disease

BACKGROUND

A prospective study was conducted to assess the efficacy and toxicity of a salvage regimen consisting of CCNU, Melphalan, and VP-16 (CAV) given at 28-day intervals in patients with Hodgkin's disease (HD) relapsing after primary therapy or refractory to the alternating MOPP/ABVD regimen.

PATIENTS AND METHODS

This study included 58 patients (median age: 34 years), with resistant or relapsing HD. Primary therapy had consisted of alternating MOPP/ABVD (81%) or MOPP alone (19%); 38% of patients were relapsing from prior complete remission (CR) while 62% had resistant disease. Extranodal disease was present in 55% and B-symptoms in 72% of patients; one-fifth had bulky disease and/or bone marrow involvement. The CAV was used as first salvage in half of the patients.

RESULTS

Complete remission was obtained in 17 patients (29%); unfavorable factors for CR in univariate analysis were the presence of bulky disease and the failure to achieve CR with prior therapy. Nine patients (53% of remitters) have subsequently relapsed with a 10-month median duration of CR. The 3-year overall survival after CAV was 25% with an 18-month median survival; significant differences in survival were found according to the extent of disease, the presence of B-symptoms and the HD status (prior sensitive or resistant disease, first or subsequent relapse). Seven patients are long-term remitters (12%), and one of them has been given high-dose chemotherapy and autologous bone marrow transplantation at relapse after CAV. The CAV toxicity was mostly hematological; severe pancytopenia occurred in six cases with two cases of fatal infections and one of fatal hemorrhage.

CONCLUSION

CAV therapy was moderately effective as third-line salvage in patients with HD resistant to alternating MOPP/ABVD or previously given two different regimens for relapse; the toxicity was mostly hematological and supportive therapy was needed in one-third of the patients.

Autologous bone marrow transplantation for Hodgkin's disease--a five-year single centre experience

The results from 40 patients who have undergone autologous bone marrow transplantation (ABMT) for relapsed or refractory Hodgkin's disease between March 1988 and September 1992 have been analysed. In contrast to our results in patients with relapsed HD, our results in patients with refractory HD are comparatively poor. Conventional salvage chemotherapy also seems inappropriate in these patients and we therefore believe they should be offered high-dose chemotherapy before their disease becomes refractory to conventionally scheduled regimens. Peripheral blood stem cell (PBSC) transplant now offers an attractive alternative to ABMT and may replace both intensive salvage chemotherapy and ABMT as the optimum treatment for patients who fail to respond to conventional chemotherapy regimens.

Analysis of long-term results and prognostic factors among 138 patients with advanced Hodgkin's disease treated with the alternating MOPP/ABVD chemotherapy

BACKGROUND

A prospective study was conducted to assess (a) the long-term results and toxicity of the alternating MOPP/ABVD regimen in advanced Hodgkin's disease; (b) the prognostic value of pretreatment variables and of drug dose intensity.

PATIENTS AND METHODS

A total 138 consecutive patients with advanced Hodgkin's disease entered this study; patient selection included stages IIB (33% of total), IIIB (26%), IV (25%), and stages IIA-IIIA (16%) with bulky disease and pulmonary hilum involvement. The MOPP/ABVD program was delivered in an 8-month program; adjuvant radiotherapy on sites of bulky disease was delivered in 24 patients.

RESULTS

Complete remission was obtained in 106 (77%) patients; significant factors for CR in univariate analysis were stage, symptoms, histology, and bone marrow involvement. The five-year relapse-free survival (RFS) was 83%; in a multivariate analysis, histology only correlated with RFS (p = 0.04). The five-year freedom from tumor mortality and overall survival (OS) were 79% and 67%, respectively. An adverse prognostic significance for OS was observed for B symptoms and bone marrow involvement. The median percentage of relative dose intensity (RDI) was as follows: Adriamycin 86, mechlorethamine 85, vincristine 73, vinblastine 84, bleomycin 79, procarbazine 74, dacarbazine 81. No significant association was found between RDI and clinical outcome. No severe pancytopenia or life-threatening complications occurred during therapy.

CONCLUSIONS

Alternating MOPP and ABVD cured more than 65% of patients with advanced HD; acute and late toxicity were acceptable. Prognostic analysis defined subgroups with a lower chance of cure which may deserve a more intensive initial therapy.

Hybrid LOPP/EVA is not better than LOPP alternating with EVAP: a prematurely terminated British National Lymphoma Investigation randomized trial

In a British National Lymphoma Investigation (BNLI) trial, patients with advanced Hodgkin's disease (stages IB, IIB, III, and IV) were randomized between initial treatment with a LOPP alternating with EVAP regimen and a LOPP/EVA hybrid regimen. The two regimens contained identical drug dosages and varied only in their scheduling. The complete remission (CR) rate in the hybrid regimen was significantly less than that in the alternating regimen, and the trial was terminated after approximately 18 months since there appeared to be no chance of the hybrid regimen ever proving superior to the alternating regimen. A total of 160 patients were entered into the trial before recruitment was terminated, 86 being randomized to the alternating regimen and 83 to the hybrid regimen. The CR rates for the alternating and hybrid arms were 65% and 40%, respectively (p < 0.002). The CR relapse-free survivals at 2 years in these two arms were 85% and 79%, respectively (p = 0.7); the overall disease-free survivals at 2 years were 57% and 32%; and the overall survivals at 2 years were 88% and 78% (p = 0.5). This trial emphasizes the impact of drug scheduling, which should be taken into account in the design of future hybrid regimens.

Pediatric stage IV Hodgkin disease. Long-term survival

BACKGROUND

The optimal treatment for Stage IV Hodgkin disease (HD) remains uncertain, particularly the role of radiation therapy (RT).

METHODS

A retrospective review of 43 children, 18 years of age or younger, who were seen and treated for Stage IV HD between June 1970 and June 1988, was performed. All patients were treated with combination chemotherapy (CT), and 20 patients received RT after CT (combined-modality therapy, CMT). CT consisted of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) in 41 patients and both MOPP and doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH), bleomycin, vinblastine, and dacarbazine in two patients. RT was added for patients who had a partial response (PR) to CT (n = 11) and/or for initial bulky thoracic disease (n = 12).

RESULTS

With a median follow-up of 83 months, the 7-year actuarial freedom from progression (FFP) and survival rates for all patients were 69% and 78%, respectively. For patients achieving a complete response (CR) to CT, the 7-year FFP rate was 73% and for patients with a PR it was 90% (P value not significant). The actuarial overall survival rates at 7 years were 88% for patients with CR versus 80% for patients with PR. In contrast, patients with either no response (one patient) or progressive disease (four patients) after CT had a significantly worse prognosis than patients with CR, with a 7-year actuarial survival rate of 40% (P = 0.006). FFP after CT alone was significantly more prevalent in patients with Stage IVA (11 of 13 patients) than in patients with Stage IVB disease (2 of 10 patients; P = 0.003). For these symptomatic patients, failures were almost exclusively (seven of eight patients) in sites of initial nodal disease. The addition of adjuvant RT improved the progression-free survival for patients with B symptoms: 2 of 13 patients had relapses after CMT versus 8 of 10 patients treated with CT alone (P = 0.003).

CONCLUSIONS

This retrospective analysis of MOPP alone compared with MOPP plus RT showed a significant difference in FFP in patients with Stage IVB HD favoring CMT.

Wide-field radiation therapy with or without chemotherapy for patients with Hodgkin disease in relapse after initial combination chemotherapy

BACKGROUND

Patients with Hodgkin disease who have relapses after initial chemotherapy (CT) appear to have a poor prognosis, especially if the duration of the first complete remission (CR) was short. The authors performed a retrospective analysis of patients with Hodgkin disease whose relapse after combination CT was limited to nodal sites; their aim was to study the prognosis of this selected subgroup of patients.

METHODS

In 28 patients with Hodgkin disease who had relapses in nodal sites after combination CT alone, the disease was restaged carefully to rule out simultaneous extranodal recurrences. Then the patients were treated with wide-field, high-dose radiation therapy (RT) with or without additional CT with curative intent between 1971 and 1987 at the Joint Center for Radiation Therapy. Fourteen patients were in first relapse and were treated with combination CT followed by RT. The remaining 14 patients (8 who were in first relapse and 6 who were in second relapse) were treated with RT alone. RT techniques were similar to those recommended for early-stage disease.

RESULTS

The 7-year actuarial freedom from relapse and survival rates for the patients retreated with CT and RT were 93% and 85%, respectively, as compared with 36% and 36% for patients retreated with RT alone. There was a significant difference for freedom from relapse (P = 0.002) and survival (P = 0.03), favoring patients retreated with both CT and RT.

CONCLUSIONS

This retrospective study demonstrates that RT combined with second-line CT can result in a high percentage of durable remissions in patients who have relapses primarily in nodal sites after original treatment with combination CT alone. These durable remissions are seen even in patients who have only a brief CR after initial CT.

Patterns of survival in patients with Hodgkin's disease: long follow up in a single centre

BACKGROUND

Prolonged remission can now be induced in the majority of patients with Hodgkin's disease with chemotherapy and/or irradiation. However, there is a significant proportion of patients in whom this approach fails, either at presentation or subsequently. Survival is the definitive endpoint to assess treatment efficacy. In this study, the survival patterns of a large group of consecutive patients treated in a single institution are presented.

RESULTS

The overall median survival was 18.3 years. Clinical remission (complete remission plus good partial remission) was induced in 443 (85%); the median survival of patients in remission has not been reached. Fifty-eight patients achieved responses less than clinical remission with initial therapy (partial response) or had progressive disease, the median survival of this group being 1.4 years. With further therapy, remission was subsequently induced in 10; 5 are still alive, 5 have died between 1.9 years and 14.3 years. Twenty patients died before completion of therapy. Recurrence has been documented in 147 of the patients in remission (following initial therapy) over a median follow up period of 13 years (minimum 5 years). One hundred forty-three of these patients were retreated following recurrence (105 chemotherapy, 28 radiotherapy, 6 combined modality treatment and 4 surgery). Second remission was induced in 109/143 (76%). There was a trend towards better second remission induction in patients whose first remission was longer than 1 year (p = 0.06). The median duration of second remission was inferior to first remission duration (p < 0.001). There was no correlation between duration of first remission and survival following recurrence (p = 0.8) or with duration of second remission (p = 0.54). There was no significant difference in duration of second remission between patients who were initially treated with radiotherapy or chemotherapy (p = 0.3). The median survival following second remission was 12.0 years, being the same for patients with initially localized disease (stages I and II) treated with radiation alone and for patients with advanced Hodgkin's disease (stages III and IV) treated with chemotherapy. Survival after recurrence is significantly better for patients under 50 years at the time of recurrence (p < 0.001). Second recurrence was documented in 46 patients, third remission being reinduced in 22, the median survival of the latter being 5.1 years.

CONCLUSION

These results illustrate the importance of prolonged follow up in defining the clinical course of patients with HD and are vital for planning experimental chemotherapy at the time of treatment failure or recurrence.

Testicular cancer and Hodgkin disease in the same patient

BACKGROUND

Although testicular cancer and Hodgkin disease are the neoplasms with the highest incidence in young men, only 13 cases of metachronous and 2 cases of synchronous occurrence in the same person were reported before 1991.

METHODS

A 30-year-old man is described, in whom, 2 years after radiation therapy for Stage IIIA Hodgkin disease, a testicular nonseminomatous germ cell tumor developed with metastatic spread to the retroperitoneal lymph nodes, lung, and left supraclavicular fossa. The second case report describes a 31-year-old man in whom a metastasizing nonseminomatous testicular cancer, with elevation of levels of the serum tumor markers alpha-fetoprotein and human chorionic gonadotropin, developed simultaneously with axillary lymphadenopathy that was histologically confirmed Hodgkin disease.

RESULTS

After five cycles of cisplatin-based chemotherapy and secondary retroperitoneal lymphadenectomy, the patient with metachronous disease has remained in complete remission for 8 years. The patient with synchronous occurrence has been disease-free for 14 months after five cycles of chemotherapy consisting of cisplatin, etoposide, and doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH).

CONCLUSIONS

The metachronous and synchronous occurrence of testicular cancer and Hodgkin disease is a rare association of two curable neoplasms. The presence of both malignant neoplasms should be taken into consideration in young male patients, especially if disease distribution diverges from a regular pattern.