Hodgkin's Disease in Denmark: A National Clinical Study by the Danish Hodgkin Study Group, LYGRA

Second malignancy risk associated with treatment of Hodgkin's lymphoma: meta-analysis of the randomised trials

BACKGROUND

Despite several investigations, second malignancy risks (SMR) following radiotherapy alone (RT), chemotherapy alone (CT) and combined chemoradiotherapy (CRT) for Hodgkin's lymphoma (HL) remain controversial.

PATIENTS AND METHODS

We sought individual patient data from randomised trials comparing RT versus CRT, CT versus CRT, RT versus CT or involved-field (IF) versus extended-field (EF) RT for untreated HL. Overall SMR (including effects of salvage treatment) were compared using Peto's method.

RESULTS

Data for between 53% and 69% of patients were obtained for the four comparisons. (i) RT versus CRT (15 trials, 3343 patients): SMR were lower with CRT than with RT as initial treatment (odds ratio (OR) = 0.78, 95% confidence interval (CI) = 0.62-0.98 and P = 0.03). (ii) CT versus CRT (16 trials, 2861 patients): SMR were marginally higher with CRT than with CT as initial treatment (OR = 1.38, CI 1.00-1.89 and P = 0.05). (iii) IF-RT versus EF-RT (19 trials, 3221 patients): no significant difference in SMR (P = 0.28) although more breast cancers occurred with EF-RT (P = 0.04 and OR = 3.25).

CONCLUSIONS

Administration of CT in addition to RT as initial therapy for HL decreases overall SMR by reducing relapse and need for salvage therapy. Administration of RT additional to CT marginally increases overall SMR in advanced stages. Breast cancer risk (but not SMR in general) was substantially higher after EF-RT. Caution is needed in applying these findings to current therapies.

Chemotherapy, radiotherapy and combined modality for Hodgkin's disease, with emphasis on second cancer risk

BACKGROUND

Second malignancies (SM) are a major late effect of treatment for Hodgkin's disease (HD). Reliable comparisons of SM risk between alternative treatment strategies are lacking.

OBJECTIVES

Radiotherapy (RT), chemotherapy (CT) and combined chemo-radiotherapy (CRT) for newly-diagnosed Hodgkin's disease are compared with respect to SM risk, overall (OS) and progression-free (PFS) survival. Further, involved-field (IF-)RT is compared to extended-field (EF-)RT.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, PubMed, EMBASE, CancerLit, LILACS, relevant conference proceedings, trials lists and publications.

SELECTION CRITERIA

RCTs accruing 30+ patients and completing accrual before/during 2000, comparing at least two treatment modalities for newly-diagnosed HD.

DATA COLLECTION AND ANALYSIS

Individual patient data were collected and assessed for data quality. Trialists submitted additional information concerning methods and data quality. Peto Odds Ratios (OR) with 95% confidence intervals (CI) were calculated for OS, PFS and SM-free survival. Secondary acute leukemia (AL), non-Hodgkin's lymphoma (NHL) and solid tumours (ST) were also analysed separately.

MAIN RESULTS

37 trials (9312 patients) were analysed: 15 (3343) for RT vs. CRT, 16 (2861) for CT vs. CRT, 3 (415) for RT vs. CT and 10 (3221) for IF-RT vs. EF-RT.CRT was superior to RT in terms of OS (OR=0.76, CI=0.66 to 0.89, p=0.0004), PFS (OR=0.49, CI=0.43 to 0.56, p<0.0001) and SM (OR=0.78. CI=0.62 to 0.98, p=0.03). The superiority of CRT also applied to early and advanced stages (mainly IIIA) separately. Excess SM with RT is due mainly to ST and is apparently caused by greater need for salvage therapy after RT.CRT was superior to CT in terms of PFS (OR=77, CI 0.68 to 0.77, p<0.0001). OS was better with CRT for early stages only (OR=0.62, CI 0.44 to 0.88, p=0.006). SM risk was higher with CRT (OR=1.38, CI 1.00 to 1.89, p=0.05), although not significant for early stages alone. This effect, also seen in AL and ST separately, was due directly to first-line treatment. Data were insufficient to compare RT to CT.EF-RT was superior to IF-RT (each additional to CT in most trials) in terms of PFS (OR=81, CI 0.68 to 0.95, p=0.009) but not OS. No significant difference in SM was observed.

AUTHORS' CONCLUSIONS

CRT seems to be optimal for most early stage (I-II) HD patients. For advanced stages (III-IV), CRT better prevents progression/relapse but CT alone seems to cause less SM. RT alone gives a higher overall SM risk than CRT due to increased need for salvage therapy. Reduced SM risk after IF-RT instead of EF-RT could not be demonstrated. Due to the large number of studies excluded because no IPD were received, to the inclusion of many outdated treatments and to the limited amount of long-term data, one must be cautious in applying these results to current therapies.

Chromosome aberrations in adult Hodgkin disease in a Danish population-based study

During a 6-year period, 31 patients with Hodgkin disease (HD) were analyzed for chromosome aberrations on lymphoid tissue. We obtained metaphases in 87% (27/31). The number of cells analyzed per case ranged from 17 to 31 (median 25), and the number of abnormal mitoses was between 1 and 17 (median 6). Chromosome aberrations were found in 59% (16/27). Numerical aberrations involved all chromosomes. The most frequently gained chromosomes were numbers 2 and 9, and the most frequently lost were numbers 10, 16, 21, 22, and X. Chromosomes most frequently involved in structural aberrations were numbers 1 and 6. The most frequent subgroups were nodular sclerosis (NS) (n = 16) and mixed cellularity (MC) (n = 10). Six NS patients and 8 patients with MC showed an abnormal clone. For the NS patients with an abnormal karyotype, 4 of 6 had a gain of chromosome 2, and all had structural aberrations of chromosome 1. Of the 6 MC patients, where a partial analysis was possible, 4 had a gain of chromosome 9, 2 had structural aberrations involving chromosome 6 and 2 of chromosome 14. In 1 case a translocation normally associated with non-Hodgkin lymphoma (NHL) was found (t[11;14]), whereas other translocations characteristic of NHL, such as t(8;14), t(14;18), and t(2;5) were not observed. A review of the literature on cytogenetic investigations in HD performed on lymphoid tissue showed that the most frequently gained or lost chromosomes were 1, 2, 5, 9, and 12 for NS and 2, 5, and 9 for MC. The most frequently affected chromosomes in structural aberrations were 1 and 6 for NS, and 1, 7, and 14 for MC. Involvement of chromosome 1, 6, and 14 in structural aberrations is characteristic of lymphoid neoplasms, as are the most frequently involved bands (1p36, 6q21-q26, 14q11, and 14q32) further supporting a B- or T-cell origin of the neoplastic cell in HD. The high hyperploidy seen in HD is not a frequent observation in NHL. Although certain chromosome aberrations seem to be characteristic of HD as opposed to NHL, specific nonrandom aberrations have yet to be identified. The rather low number of abnormal mitoses found in most HD cases underlies the importance of analyzing a large number of metaphases.

Clinical presentation, course, and prognostic factors in lymphocyte-predominant Hodgkin's disease and lymphocyte-rich classical Hodgkin's disease: report from the European Task Force on Lymphoma Project on Lymphocyte-Predominant Hodgkin's Disease

PURPOSE

Recent studies have suggested that lymphocyte-predominant Hodgkin's disease (LPHD) is both clinically and pathologically distinct from other forms of Hodgkin's disease, including classical Hodgkin's disease (CHD). However, large-scale clinical studies were lacking. This multicenter, retrospective study investigated the clinical characteristics and course of LPHD patients and lymphocyte-rich classical Hodgkin's disease (LRCHD) patients classified according to morphologic and immunophenotypic criteria.

MATERIALS AND METHODS

Clinical data and biopsy material of all available cases initially submitted as LPHD were collected from 17 European and American centers, stained, and reclassified by expert pathologists.

RESULTS

The 426 assessable cases were reclassified as LPHD (51%), LRCHD (27%), CHD (5%), non-Hodgkin's lymphoma (3%), and reactive lesion (3%); 11% of cases were not assessable. Patients with LPHD and LRCHD were predominantly male, with early-stage disease and few risk factors. Patients with LRCHD were significantly older. Survival and failure-free survival rates with adequate therapy were similar for patients with LPHD and LRCHD, and were stage-dependent and not significantly better than stage-comparable results for CHD (German trial data). Twenty-seven percent of relapsing LPHD patients had multiple relapses, which is significantly more than the 5% of relapsing LRCHD patients who had multiple relapses. Lymphocyte-predominant Hodgkin's disease patients had significantly superior survival after relapse compared with LRCHD or CHD patients; however, this was partly due to the younger average age of LPHD patients.

CONCLUSION

The two subgroups of LPHD and LRCHD bore a close clinical resemblance that was distinct from CHD; the course was similar to that of comparable nodular sclerosis and mixed cellularity patients. Thorough staging is necessary to detect advanced disease in LPHD and LRCHD patients. The question of how to treat such patients, either by reducing treatment intensity or following a "watch and wait" approach, remains unanswered.

Management of Hodgkin's disease patients with mediastinal adenopathy and pulmonary involvement (stage IIE)

Two hundred and fifty-five patients with Hodgkin's disease and with localized pulmonary involvement (Stage IIE) were retrospectively assessed for their response to different treatment programmes while considering the size of mediastinal lymph nodes and the extent of pulmonary disease (involvement of lung subsegment, segment or lobe). Five-year overall and disease-free survival rates in 255 patients were 89.6% and 72.3%, respectively. In patients with mediastinal index < 1/3 and lung segment and/or subsegment involvement, 5-year overall and disease-free survival rates were 96.6%. For patients with mediastinal index > 1/3 and similar lung involvement the corresponding values were, respectively, 88.6% and 73.5%; and for those with a lung lobe involvement the values were 76.4% and 56.7%, respectively. Patients were treated according to the following programmes: 1 combination chemotherapy cycle + radiotherapy (RT) + 4-5 combination chemotherapy cycles; 3 combination chemotherapy cycles + RT; 6 combination chemotherapy cycles + RT. The best results were obtained with the programme consisting of 1 combination chemotherapy cycle + lymphoid irradiation above the diaphragm and irradiation of the spleen to a total tumour dose of 40 Gy and irradiation of involved lung sites to a total tumour dose of 20 Gy + 4-5 combination chemotherapy cycles.

Lymphoma incidence in a Swedish county during 1969-1987

The incidence of lymphoid malignancies (acute leukemias and myelomatosis excluded) during 1969-1987 in the County of Uppsala was calculated on the basis of the regional cancer register and local registers from the only oncological, hematological, dermatological and pathological departments in this well-defined geographical area. Of the 774 patients included, 639 had histopathological specimens available, all of which were re-examined. Seventy-nine patients were diagnosed on the basis of bone marrow investigations (greater than 70% re-examined, all had a low-grade non-Hodgkin's lymphoma = NHL) and 54 on fine-needle aspiration biopsies (not re-examined). Seventy-nine of the lymphoma diagnoses were based on autopsy specimens. The overall age standardized incidence was 16.2/100,000/year (NHL: 13.6, Hodgkin's disease = HD: 1.5) according to the Swedish 1970 census (according to world standard population: 10.2); male: 20.9 (12.9) and female: 12.4 (7.9). The annual change in trend was +3.0% +/- 2.6 (NHL: +3.6% +/- 2.4, HD: no change). The omission of the 54 'fine needle cases' led to an overall incidence of 15.0 (9.7) and an annual change in trend of +3.5% +/- 1.9. Among the histopathological specimens, an NHL was found in 524 patients and HD in 69. In 46 registered patients, the diagnosis malignant lymphoma was wrong. The diagnosis changed to NHL in 43 patients registered as HD.

Treatment outcome in Hodgkin's disease in patients above the age of 60: a population-based study

All persons in three Swedish counties afflicted with Hodgkin's disease between 1979 and 1988 were traced. The objective was to analyze, in unselected, population-based material, whether an assumed worse prognosis in the elderly could be due to differences in staging procedures, treatment intensity, decreased tolerance to therapy or to a more aggressive disease. After histopathological revision, 163 of 202 patients (autopsy cases excluded) were accepted as HD, 61 (37%) of them above the age of 60. Although staging procedures had been more intense in the young, the elderly patients had a more advanced stage at diagnosis, and tended more often to have B-symptoms. The intensity of staging procedures did not seem to influence survival. The 5-yr relative survival was 37% above and 85% below the age of 60. Radiotherapy was the primary treatment in 12 (20%) above and 41 (41%) below the age of 60 with 5-yr relative survival figures of 84% and 85%, respectively. Thirty-seven patients (61%) above and 61 (59%) below 60 were treated with combination chemotherapy (MOPP/ABVD, MOPP, ChlVPP/OPEC) with curative intent. The 5-yr relative survival was 33% and 86%, respectively. The majority of the elderly patients (54%) received less than 40% of the planned chemotherapy dose. The main reason for this pronounced reduction was intolerance to therapy, with 8 treatment-related deaths. We conclude that tolerance to combination chemotherapy in the elderly patients with HD is poor and could be the major reason for poor treatment outcome in this age group.

Hodgkin's disease in northern Sweden 1971-1981. I. A histopathological reevaluation of 223 cases

A histopathological reexamination was made of diagnostic material in 223 patients with Hodgkin's disease (HD) collected between 1971 and 1981. The diagnosis of HD was considered to be incorrect in 90 cases (40%). Change of diagnosis to non-Hodgkin's lymphoma was made in 56 cases, of which 23 were high-grade and 26 were low-grade lymphomas (7 not determined), and to angioimmunoblastic lymphadenopathy in 10 cases. These discrepancies were considered to be due mainly to progress in the understanding and classification of malignant lymphomas, which stresses the importance of review of histologic material in retrospective studies on Hodgkin's disease.

Hodgkin's disease in northern Sweden 1971-1981. II. A retrospective analysis of prognostic factors

Factors relevant for prognosis were retrospectively studied in a series of 133 morphologically reviewed patients with Hodgkin's disease collected between 1971 and 1981. For the whole material complete remission rate was 74% and 5-year survival was 62%. These seemingly rather poor results could be explained by a high mean age (48 years) in this relatively unselected material, in combination with a very unfavourable outcome for the elderly patients. In a multivariate analysis of prognostic factors age of the patient turned out to be the only independent factor with a significant bearing on the prognosis.

Late effects on pulmonary function of mantle-field irradiation, chemotherapy or combined modality therapy for Hodgkin's disease

The aim of the present study was to assess late pulmonary sequelae after treatment for Hodgkin's disease with various treatment modalities. Pulmonary function was studied in 142 patients per median 8 years after treatment for Hodgkin's disease with mantle-field irradiation (54 patients), chemotherapy (26 patients) or mantle-field irradiation followed by chemotherapy (62 patients). Mantle-field irradiation was associated with a primary obstructive and minor restrictive lung function impairment, whereas chemotherapy and combined modality therapy were associated with a restrictive lung function impairment. The number of patients with impaired lung function and the number of patients with complaints of dyspnea, however, were almost the same in the three treatment groups. 5% of the 142 patients had a pathologically low total lung capacity, i.e. values less than 2 standard deviations below predicted values. Pathologically low values of forced vital capacity and forced expiratory volume in 1 second were seen in 33% and 27% of the patients. 33% of the smokers (n = 80) had a pathologically low diffusion capacity in contrast to 8% of the non-smokers (n = 62). Dyspnea on exertion was present in 24% of the 142 patients and was more frequent among patients with pulmonary functional abnormalities. In conclusion, late pulmonary sequelae after treatment for Hodgkin's disease do not provide a basis for choice between otherwise equally effective treatment regimes.

Hodgkin's disease, clinical stages IA to IIIB: combined modality therapy (3 MOPP followed by curative and prophylactic radiotherapy including the spleen). Six-year results

From January 1980 to September 1985, 82 patients with IA to IIIB clinical stage (CS) Hodgkin's disease were treated by three MOPP chemotherapy (CT) cycles followed by extended field radiotherapy (RT) including the spleen (30-40 Gy). 2 patients died during the treatment (medullary aplasia, pulmonary edema). 6 were in failure after three MOPP cycles; they received other CT; 3 died and 3 are alive in remission (survival: 2.5 to 3.5 yr). 74 were in complete remission (CR) after completion of treatment. 4 patients relapsed (all alive after re-treatment) and 4 died in first CR (tuberculosis, hepatitis, myeloma, unknown cause). At 6 yr, actuarial survival and relapse-free survival are respectively 89.8% for the 82 patients and 93% for those in CR. These good results are due to: the administration of CT before RT, limited to three cycles; identification of failures after CT; inclusion of the spleen in RT ports in all cases; and a short lumbo-aortic port in CS I and II.

Clinical and laboratory findings in untreated patients with Hodgkin's disease with special reference to age

During a 6-yr period 258 adult patients (greater than or equal to 15 yr) with biopsy verified Hodgkin's disease (HD) were reported to the Stockholm-Gotland Oncologic Center. In 57 elderly patients (mean age 74 yr) the diagnosis was established shortly before death or at autopsy. One hundred and eighty-two of remaining 201 patients (118 men and 64 women, mean age 47 yr) were investigated. They were evenly distributed in stages I-IV and 43% had B symptoms. NS, 38% and MC, 38% were the most common histological subtypes in contrast to LP, 14% and LD, 10%. Stage II disease and NS histopathology dominated among patients below 50 yr. Patients with hilar/mediastinal lymphomas were often young and had NS histopathology with B symptoms. The diagnosis was established within 3 months after the first symptoms in 52% while 15% had symptoms for more than one year. Eleven patients reported a previous malignancy which is similar to the expected number of 13.8. The results support the concept that in unselected patient series HD seems to be at least as common among elderly as in young people. In the investigated series advanced disease and MC and LD histopathology did not dominate among patients above 50 yr which has been reported previously.

MOPP chemotherapy plus irradiation for Hodgkin's disease, stages IA to IIIB. Long-term results of the prospective trial H72 (1972-1976, 334 patients)

From April 1972 to December 1976, 334 patients with Hodgkin's disease, CS IA-IIIB, were prospectively treated with combined chemotherapy and radiation. The 166 stages IA and II2A were clinically staged only; the 168 other patients were randomized to clinical or pathological staging. All patients received 3 or 6 cycles of MOPP followed by Mantle field with or without mediastinal irradiation and/or inverted Y or lumbo-aortic field according to initial stage, presentation and protocol. At completion of therapy, 317 patients were in complete remission. Twenty-six patients relapsed and 43 died including 5 with leukemia and 6 with infection. Overall 12-year survival and relapse-free rates are 86.6 +/- 3.08 per cent and 91.5 +/- 3.2 per cent respectively (IA: 95.3 and 95.3 per cent; IIA: 87.8 and 92.1 per cent; IIIA: 83.3 and 100 per cent; IB, IIB: 81.7 and 89.2 per cent; IIIB: 67.8 and 73.7 per cent). The randomized comparison between clinical staging plus 6 cycles of MOPP and laparotomy staging plus 3 cycles of MOPP in final stage II3+A, IB, IIB patients showed no significant 12-year survival differences (90.8 versus 85.6 per cent). With this combined modality treatment policy, high survival rates are obtained using only 3 cycles of MOPP and radiotherapy in CS IA, II2A and in PS II3+, IB, IIB. Laparotomy staging may be unnecessary if 6 cycles of MOPP are employed before irradiation in CS IIA, IB, IIB disease and if 3 cycles of MOPP are followed by irradiation in CSIA and II2A disease. Mediastinal irradiation can be avoided in patients with supradiaphragmatic disease without mediastinal involvement.

Prognostic factors in Hodgkin's disease with special reference to age

A series of 182 patients with Hodgkin's disease, diagnosed between January 1973 and December 1978 was used to identify prognostic factors with special reference to age. There were 118 men and 64 women (mean age, 47 years; r = 15-92). During the same period 57 elderly patients who were never referred, were reported to the Local Cancer Registry. The diagnosis had been established shortly before death or at autopsy. The 182 patients under study were evenly distributed in Stages I-IV. Nodular sclerosis (38%) and mixed cellularity (38%) were the most common histologic subtypes. The 5-year survival probability estimate was 28% in patients above 50 years as compared to 74% in the remainder. Survival was significantly better in patients with Stage I-II disease and lymphocyte predominance/nodular sclerosis histopathology. Age was the main prognostic factor in the whole series as well as in patients older than 50 years. However, in young patients advanced clinical stage and B-symptoms were related to a poor prognosis. Biologic indicators such as ESR, hemoglobin and albumin were intimately linked to the extent of disease and did not add prognostic information besides that given by the clinical stage. It is concluded that the prognosis in elderly remains poor and appears to be partly unrelated to those factors which determine the prognosis in the young, assumingly reflecting a depressed host-response and/or a decreased tolerance to intensive treatment.

Experiences from the National Danish Hodgkin's Study Group (LYGRA) with respect to diagnosis, classification and treatment of Hodgkin's disease

From September 1971 to April 1983, 1200 patients with newly diagnosed Hodgkin's disease were admitted to the centres which had founded LYGRA (the Danish Hodgkin's Study Group), to undergo uniform staging procedures and treatment. Present problems concerning staging, treatment, and complications, such as the risk of pneumococcal infection following splenectomy, the loss of fertility, and the risk of secondary malignancies, in particular leukaemia, are discussed.

Incidence of acute nonlymphocytic leukemia, preleukemia, and acute myeloproliferative syndrome up to 10 years after treatment of Hodgkin's disease

During the period from 1970 to 1981, 391 nonselected patients with Hodgkin's disease were staged and treated with chemotherapy or radiotherapy or both at the Finsen Institute, Copenhagen. Secondary acute nonlymphocytic leukemia or its earlier stages--preleukemia or an acute myeloproliferative syndrome with cytopenia and specific cytogenetic abnormalities of the bone marrow--were observed in 17 patients. A Kaplan-Meier estimate of the cumulative probability of leukemic complications was 3.9 +/- 1.3 per cent (mean +/- S.E.M.) five years after the start of treatment, and 9.9 +/- 2.9 per cent at nine years. All 17 cases of leukemic complications occurred among the 312 patients treated with chemotherapy or combined-modality therapy, whereas no case was observed among 79 patients treated exclusively with radiotherapy (P = 0.003). A significantly increased risk of leukemic complications was observed in chemotherapy-treated patients 40 years old or older (P = 0.001). Despite the observed relatively high risk of secondary leukemia, the rate of death from progressive Hodgkin's disease, nonleukemic complications, and unrelated causes still far exceeds the rate of leukemia-related deaths in these patients.

Cellular and humoral immunity in Hodgkin's disease. I Patients in continuous long-term remission

Cell-mediated and humoral immunity to herpes simplex virus (HSV), cytomegalovirus (CMV) and varicella zoster virus (VZV) were examined in 37 patients with Hodgkin's disease in continuous long term remission. This group had lower blast-transformation than a matched control group to all 3 antigens. Patients originally showing B-symptoms had higher transformation to VZV than those with A-symptoms. Patients treated with irradiation only had higher transformation than those treated with either chemotherapy or a combination of chemotherapy and irradiation. There was a clear tendency towards lower transformation in patients having been in remission for 2 years or less. Phytohaemagglutinin (PHA) stimulation gave lower response in the patient group than in the control group. Patients with B-symptoms had lower response than those with A-symptoms. Interferon production was specially impaired in patients with B-symptoms. The patient group had higher CF titers against HSV and CMV while the control group had higher titers against VZV. B-symptom patients had higher titers against VZV than A-symptom patients. It is concluded that HD patients have impaired immune function many years after discontinuation of therapy, but there are certain differences regarding the in vitro immunity within the patient groups.