Radiotherapy of stage I and II Hodgkin disease with inguinal presentation

Outcome of Patients With Early-Stage Infradiaphragmatic Hodgkin Lymphoma: A Comprehensive Analysis From the German Hodgkin Study Group

Purpose The prognostic effect of isolated infradiaphragmatic involvement in Hodgkin lymphoma (HL) is controversial, and there are little data about patients treated with current therapies. Therefore, we performed a risk factor analysis to focus on isolated nodal infradiaphragmatic disease in patients treated within the German Hodgkin Study Group trials HD13 (clinical trial information: ISRCTN63474366) and HD14 (clinical trial information: ISRCTN04761296) for early-stage HL. Patients and Methods Characteristics and outcomes of patients who had infradiaphragmatic HL were compared with patients who had supradiaphragmatic disease. Progression-free survival (PFS) and overall survival (OS) were estimated according to Kaplan-Meier methods and were compared between groups using the log-rank test and Cox proportional hazards regression, which was also applied for multivariable analyses that adjusted for relevant baseline characteristics. Results Of 2,903 qualified patients, 223 (7.7%) were diagnosed with isolated nodal infradiaphragmatic disease. In general, these patients were older, had a poorer performance status, were more often male, and had the nodular sclerosis subtype less often than those with supradiaphragmatic disease. After a median follow-up time of 51 months, PFS and OS were significantly worse in patients with infradiaphragmatic disease (5-year PFS and OS, 80.1% and 91.5% v 91.2% and 97.6% in patients with supradiaphragmatic disease; each P < .001). In multivariable analyses, infradiaphragmatic HL remained a significant risk factor in terms of PFS (hazard ratio [HR], 1.5; 95% CI, 1.04 to 2.2; P = .03) and OS (HR, 2.0; 95% CI, 1.2 to 3.5; P = .01). However, inferior PFS and OS could not be observed among those patients treated with the more intensive chemotherapy (two cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine [ABVD] in HD13, and two cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone [BEACOPP_escalated] plus two cycles of ABVD in HD14; all patients received 30 Gy of involved-field radiotherapy). Conclusion Early-stage HL that presents with infradiaphragmatic disease only represents a distinct patient group with an inferior outcome. However, this adverse outcome can be outweighed by appropriate combined modality treatment.

Hodgkin's Disease Stage I and II with Exclusive Subdiaphragmatic Presentation. The Experience of the Departments of Radiation Oncology and Hematology, University “La Sapienza” of Rome

During the period 1978 to 1994, 1054 patients with Hodgkin's disease were evaluated and treated at the Departments of Radiation Oncology and Hematology, University “La Sapienza”, Rome. A total of 549 patients presented with clinical or pathological stage I and II; 37 of these had Hodgkin's disease below the diaphragm (BDHD), and 512 above the diaphragm (ADHD). A comparison of patients with BDHD versus those with ADHD showed that the first group had a higher male to female ratio. A comparison of cases with stage II BDHD versus those with stage II ADHD showed that patients with BDHD were older (48 years vs 28 years), had different histologic features and a higher incidence of systemic symptoms (67% vs 33%). Stage II BDHD patients had a worse prognosis; in fact, there were significant differences in the overall survival and relapse-free-survival rates for cases with stage II BDHD versus those with stage II ADHD (overall survival, 46% vs 80%, P<0.001; relapse-free survival, 44% vs 69%, P<0.005). Stage was found to be the most important prognostic factor for BDHD cases without systemic symptoms treated with radiation therapy alone. The type of infradiaphragmatic presentation (intra-abdominal vs peripheral disease) did not influence outcome, probably due to the more aggressive therapy received by the intra-adbominal group. Treatment recommendations for BDHD cases should be tailored to the stage and the presence or absence of intra-abdominal localization. For patients with stage IA extended fields, irradiation (inverted Y) is sufficent. However, combined modality therapy should be the treatment of choice for stage II cases, particularly in the presence of intra-abdominal disease. Patients with systemic symptoms also require combined modalities.

Subdiaphragmatic stage I & II Hodgkin's disease: long-term follow-up and prognostic factors

PURPOSE

To report long-term follow-up results and to analyze prognostic factors for overall and disease-free survival in patients with subdiaphragmatic Stage I & II Hodgkin's disease.

METHODS AND MATERIALS

From September 1962 to April 1995, 109 patients presented at the M. D. Anderson Cancer Center with subdiaphragmatic Hodgkin's disease. The medical records of these patients were retrospectively reviewed; 22 patients who received no treatment at the M. D. Anderson Cancer Center or who had radiation therapy at other institutions were excluded. The remaining 87 patients formed the basis of this study. The median age of our group was 33 years with a male: female ratio of 3.3:1. The histological subtypes were nodular sclerosis in 21 (24.1%) patients, mixed cellularity in 31 (35.6%), lymphocyte predominance in 33 (37.9%), lymphocyte depletion in 1 (1.1%) and unclassified histology in 1 (1.1%). Of the patients, 32 (36.8%) underwent laparotomy for diagnosis or staging purpose, 74 (85.1%) had lymphangiography, and 35 (40.2%) had computerized tomography of the abdomen and pelvis. Among the patients, 22 (25%) had more than three sites of nodal involvement at presentation, 56 (64.4%) had pelvic or abdominal disease, and 14 (18.4%) had bulky disease that was defined as disease with the largest dimension > or = 7 cm. Stage distribution was IA in 33.3%, IIA in 39.1%, and IIB in 27.6%. Treatment was radiotherapy alone in 60 (69%) patients, chemotherapy and radiation in 23 (26.4%), and chemotherapy alone in 4 (4.6%).

RESULTS

The 10- and 20-year actuarial overall survival rates for all patients were 74.6% and 55.3%, and the corresponding disease-free survival rates were 72.4% and 67.5%, respectively. On univariate analysis, age > 40 years, B symptoms, nodular sclerosis or mixed cellularity histology, and decreased albumin or hemoglobin levels were statistically significant adverse pretreatment factors for overall survival. B symptoms, decreased albumin level, more than 3 sites of disease at presentation, and Stage II were statistically significant negative pretreatment prognostic factors for disease-free survival. Only B symptoms and decreased albumin level predicted worse outcome in both overall and disease-free survivals. On multivariate analysis, age > 40 years, nodular sclerosis and mixed cellularity histology, and decreased hemoglobin levels were three independent risk factors for overall survival. An analysis of the pattern of failure revealed that the majority of the patients with central Stage II disease who did not receive mantle radiation failed in the supradiaphragmatic area. Late complications of radiation were infrequent.

CONCLUSIONS

Long-term follow-up of this group of patients revealed similar overall and disease-free long-term survival, as would be expected from supradiaphragmatic Hodgkin's disease. For patients with central Stage II disease, it is anticipated that supradiaphragmatic radiation therapy would improve the disease-free survival.

Radiotherapy for early infradiaphragmatic Hodgkin's disease: the Australasian experience

PURPOSE

To review the Australasian results of Stage I and IIA Infradiaphragmatic Hodgkin's Disease (IHD) treated solely by irradiation.

METHODS AND MATERIALS

Eligible patients had IHD only and were treated by irradiation with curative intent over the period of 1969 to 1988. Ten radiation oncology centres from within Australia and New Zealand were surveyed for patient, tumour and treatment variables. Disease free rates, survival and complications were analysed.

RESULTS

106 patients with IHD were studied. The average potential follow up was 9.4 years. The male to female ratio was 3.3:1. The median age was 37.5 years. Histological subgroups were as follows; lymphocyte predominant 43%, mixed cellularity 21%, lymphocyte depleted 5%, nodular sclerosing 27% and unclassifiable 4%. Fifty nine patients had laparotomy of which 22 (37%) were positive for tumour. Nine laparotomies were performed for diagnosis and the remainder for staging. One patient was up-staged by laparotomy and three were down-staged. Sixty-eight patients presented with inguinal disease alone, five with abdominal disease alone, 19 with two sites of involvement and 12 with inguinal, pelvic and abdominal disease. In two patients the site was unknown. There was no correlation between site of involvement, age, sex or histological subtype. Forty seven cases were clinically staged (CS) as follows: CS IA-23, CS IIA-24. The other 59 were pathologically staged (PS) as follows: PS IA-37, PS IB-1, PS IIA-21. Treatment consisted of involved field alone (16), inverted Y (68), inverted Y and spleen (13), para-aortic irradiation only (3), or total nodal irradiation (6). Mean dose was 37 Gy. There were 30 recurrences to give an acturial 10-year disease-free rate of 70%. In multivariate analysis lower number of tumour sites, lymphocyte predominant histology and higher dose were all significantly correlated with higher disease free rates. Eight patients died of Hodgkin's disease and 19 of other causes. The 10-year overall survival rate was 71%. Older age and higher number of disease sites were significantly correlated with shorter survival. Fourteen of 30 relapses may have been avoidable by the use of total nodal irradiation. In particular ten of 21 patients with abdominal disease relapsed in nodal sites which would have been covered by total nodal irradiation.

CONCLUSIONS

The rate of control in IHD could perhaps be improved by avoiding involved field irradiation or by aggressive therapy with total nodal irradiation or combined modality chemo-irradiation in Stage II disease. Staging laparotomy does not appear to be indicated.

Infradiaphragmatic Hodgkin's disease: long term results of combined modality therapy

Hodgkin's disease (HD) confined below the diaphragm accounts for less than 5% of all patients with HD. Although the major characteristics of this presentation appear established, optimal modalities of treatment still remain difficult to define. From April 1972 to October 1988, 28 patients with newly diagnosed infra-diaphragmatic HD, clinical stages I or II have been treated with 3 successive prospective protocols combining initial chemotherapy and radiotherapy (40 gy). This series of patients accounted for 4,3% of patients with HD limited to clinical stages (CS) I and II. Overall survival and freedom from relapse at 15 years were 74,4% and 73% respectively, without significant differences between clinical stages I and II, presence or absence of B symptoms or histologic subtype. There is only a trend (p < 0,10) in favour of patients younger than 40 years. In all 7 clinically staged IA patients no relapses were seen and combined treatment does not appear to be better than inverted Y irradiation alone. On the other hand initial chemotherapy seems necessary in patients with CS II A and B since 15 of our 21 patients are alive in first CR whereas the crude rate of transdiaphragmatic nodal relapses may reach up to 53% following radiotherapy alone.

Treatment of subdiaphragmatic Hodgkin's disease: is radiotherapy alone appropriate only for inguino-femoral presentations?

PURPOSE

Evaluate the role of staging laparotomy, and the impact of disease subsites on treatment outcome, for sub-diaphragmatic Hodgkin's Disease.

METHODS AND MATERIALS

Between 1966 and 1989, 23 patients with Hodgkin's disease limited to sites below the diaphragm were treated at the Royal Adelaide Hospital. The high male:female ratio (2:8), low proportion of nodular sclerosis subtype (26%), and older age (mean = 40) relative to supra-diaphragmatic Hodgkin's disease is consistent with most other series. Thirteen patients underwent staging laparotomy. Initial treatment consisted of radiation therapy alone in 11, chemotherapy alone in 7, and combined modality therapy in 4 patients. This data was then combined with other published series over the last decade, to analyse relapse patterns and treatment results in relation to initial site(s) of disease.

RESULTS

The overall, disease specific, and progression free 5 (and 10) year survival rates were 69%, 81%, and 58% respectively. There was no statistically significant effect of staging laparotomy on any of these parameters. Combining these results with those in the literature revealed an unacceptable relapse rate for patients with disease outside of the inguino-femoral region treated with inverted-Y radiation therapy alone.

CONCLUSIONS

For the majority of patients with sub-diaphragmatic Hodgkin's disease, staging laparotomy can be avoided. Inverted-Y radiation therapy should only be used for inguino-femoral presentations.

Stage I and II subdiaphragmatic Hodgkin's disease

From January 1971 to December 1986, 521 patients with Hodgkin's disease were evaluated and treated at the Yale University School of Medicine or one of its close affiliates. A total of 258 patients had pathologic stage (PS) I or II disease, with 239 patients having Hodgkin's disease above the diaphragm (ADHD) and 19 patients having Hodgkin's disease below the diaphragm (BDHD). A comparison of patients with BDHD versus patients with ADHD showed that patients with BDHD were older (mean age, 42 versus 28 years of age, P = 0.005), were initially seen less often with nodular sclerosis subtype (32% versus 77%, P = 0.00001), and had a higher male: female ratio (2.8 versus 1.2, P = 0.12). Ten patients with BDHD (53%) had positive findings at staging laparotomy (0 of 4 clinical stage [CS] IA patients and 10 of 15 (67%) CS II patients). Radiation therapy alone was the initial treatment of choice for 74% of patients with BDHD versus 94% of the patients with ADHD. There was no statistical difference in the overall survival or relapse-free survival rates for patients with BDHD versus ADHD (10-year survival rates, BDHD = 73% and ADHD = 81%). However, patients with BDHD who initially had intra-abdominal disease had a statistically significant increase in death rate (60%) due to Hodgkin's disease compared with patients with BDHD who initially had only peripheral nodal disease (0%). Treatment recommendations for patients with BDHD should be tailored to the specific clinical presentation of each patient. For most PS IA/IIA patients initially seen with peripheral nodal disease, radiation therapy alone is a successful treatment program. However, combined modality therapy should be the treatment of choice for patients with BDHD initially seen with intra-abdominal disease.

Clinical features and response to treatment of infradiaphragmatic Hodgkin's disease

Among 247 patients with Hodgkin's disease, initial disease presentation was restricted to infradiaphragmatic sites in 17 (6.9%). Advanced age, B symptoms, increased ESR, low lymphocyte and platelet counts, as well as advanced pathological stage and lymphocyte depletion histology were common presenting features of these patients. 7 patients with infradiaphragmatic disease had isolated involvement of inguinofemoral nodes ("peripheral" group) and 10 had only intraabdominal disease ("central" group). Clinical characteristics of patients with "central" forms were different from those with supradiaphragmatic disease, but no differences were observed between "peripheral" infradiaphragmatic and supradiaphragmatic groups. Complete remission was achieved in the 82.2% of patients with infradiaphragmatic disease. Overall survival was 68% at 5 years, and disease-free survival was 74%. No statistically significant differences were observed in complete remission rates, survival, and disease-free survival when supradiaphragmatic, "central" infradiaphragmatic and "peripheral" infradiaphragmatic forms were compared.

Treatment of lower torso stages I and II Hodgkin's disease with radiation with or without adjuvant mechlorethamine, vincristine, procarbazine, and prednisone

From 1956 to 1987, 60 patients with either lymphangiogram-staged or laparotomy-staged I-II lower torso presentations of Hodgkin's disease were treated with radiation with or without Mustargen (mechlorethamine), vincristine, procarbazine, and prednisone (MOPP). In 22 with inguinal/femoral or pelvic disease and 24 with abdominal disease, treatment consisted of radiation only. Fourteen other patients with abdominal disease received MOPP chemotherapy before radiotherapy. In 11, the chemotherapy was limited to two cycles. At 10 years, the determinate survival and freedom from progression rates for all patients were 82% and 72%, respectively. For patients with inguinal/femoral or pelvic disease who were treated with radiation only, the corresponding rates were 90% and 86%. For patients with abdominal disease who received radiation only, the determinate survival and the freedom from progression rates were only 66% and 50%, respectively. However, corresponding results for 14 patients with abdominal disease who were treated with MOPP and radiation were 100% and 92% (P = 0.033 and P = 0.009, respectively.

Management of subdiaphragmatic early-stage Hodgkin's disease

Twenty-six patients with Stage IA-IIB Hodgkin's disease confined below the diaphragm were treated at the Mayo Clinic over a 9-year period (1974-1982). Ten of the twenty-six patients presented with intra-abdominal disease alone, and the remaining 16 patients presented with palpable inguinal-femoral adenopathy. One hundred thirty patients with pathologically staged supradiaphragmatic disease were treated over the same period and serve as a comparison group. The median age of 52 years among patients with subdiaphragmatic disease was significantly higher than the median age of 27 years in supradiaphragmatic group. There was no difference in sex distribution between the two groups. One-fifth of the subdiaphragmatic patients presented with B symptoms compared to one-tenth in the supradiaphragmatic group. No significant histological differences were seen. The majority of patients were treated with radiation therapy alone. The overall failure rate was 42% in the subdiaphragmatic group versus 22% in patients with supradiaphragmatic disease. All of the failures occurred in patients treated with radiotherapy alone. Stage and the presence of B symptoms were the most important prognostic factors. The type of subdiaphragmatic presentation (intra-abdominal versus inguinal-femoral) did not influence the outcome. Despite decreased 5-year recurrence-free survival (57% subdiaphragmatic vs. 79% supradiaphragmatic, p = 0.03), the overall 5-year survival rate of 85% is comparable to that of patients with supradiaphragmatic disease. It appears that inverted Y irradiation alone is sufficient for patients with Stage IA disease, but that patients with B symptoms or Stage II disease require more aggressive initial therapy if recurrence-free survival is to be improved.

Hodgkin's disease stages I and II with infradiaphragmatic presentation: a rare and prognostically unfavourable combination

Out of 323 patients with Hodgkin's disease CS I or II treated during the period 1969 to 1983 at Denmark's Finsen Institute, 35 presented with infradiaphragmatic disease. Patients with infradiaphragmatic presentation were older than patients with supradiaphragmatic presentation and were more often in stage II as opposed to stage I. NS histology was less prevalent among infradiaphragmatic than among supradiaphragmatic patients. Disease-free survival and overall survival was poorer in infradiaphragmatic patients. When other factors of prognostic importance were taken into account in a multivariate analysis, infradiaphragmatic presentation turned out to be an adverse prognostic factor with regard to disease-free survival, whereas it was not of significant independent prognostic value with regard to overall survival. Staging laparotomy in 11/35 infradiaphragmatic patients revealed 1 stage-IV case. The 34 remaining early stage patients were treated by irradiation plus combination chemotherapy (21 patients), irradiation only (9 patients), or combination chemotherapy only (4 patients). They were followed until death or from 4 to 171 months after initiation of therapy. With regard to disease-free survival, combined modality treatment (as opposed to radiotherapy only) was found to be of prognostic significance.