An analysis of prognostic factors in early stage Hodgkin's disease

Bystander cells and prognosis in Hodgkin lymphoma. Review based on a doctoral thesis

Hodgkin lymphoma (HL) is characterised histologically by a minority of malignant Hodgkin and Reed-Sternberg (HRS) cells surrounded by benign cells, and clinically by a relatively good prognosis. The treatment, however, leads to a risk of serious side effects. Knowledge about the biology of the disease, particularly the interaction between the HRS cells and the surrounding cells, is essential in order to improve diagnosis and treatment. HL patients with abundant eosinophils in the tumours have a poor prognosis, therefore the eosinophil derived protein eosinophil cationic protein (ECP) was studied. Serum-ECP (S-ECP) was elevated in most HL patients. It correlated to number of tumour eosinophils, nodular sclerosis (NS) histology, and the negative prognostic factors high erythrocyte sedimentation rate (ESR) and blood leukocyte count (WBC). A polymorphism in the ECP gene (434(G>C)) was identified and the 434GG genotype correlated to NS histology and high ESR. The poor prognosis in patients with abundant eosinophils in the tumours has been proposed to depend on HRS cell stimulation by the eosinophils via a CD30 ligand (CD30L)-CD30 interaction. However, CD30L mRNA and protein were detected in mast cells and the predominant CD30L expressing cell in HL is the mast cell. Mast cells were shown to stimulate HRS cell lines via CD30L-CD30 interaction. The number of mast cells in HL tumours correlated to worse relapse-free survival, NS histology, high WBC, and low blood haemoglobin. Survival in patients with early and intermediate stage HL, diagnosed between 1985 and 1992, was generally favourable and comparatively limited treatment was sufficient to produce acceptable results for most stages. The majority of relapses could be salvaged. Patients treated with a short course of chemotherapy and radiotherapy had an excellent outcome. In conclusion prognosis is favourable in early and intermediate stages and there are possibilities for further improvements based on the fact that mast cells and eosinophils affect the biology and prognosis of HL.

[Volume-effect in radiation therapy part one: volume-effect and tumour]

Volume is an important parameter of radiation therapy. Local control is inversely related to tumor size and the complication rate increases with the importance of the irradiated volume. Although the effect of irradiated volume has been widely reported since the beginning of radiotherapy, it has been less studied than other radiation parameters such as dose, fractionation, or treatment duration. One of the first organ system in which the adverse effect of increased volume was well defined is the skin. Over the last twenty years, numerous mathematical models have been developed for different organs. In this report we will discuss the relation between irradiated volume and tumor control. In a second article we will study the impact of irradiated volume on radiation adverse effects.

Risk-adapted therapy for clinical stage I-II Hodgkin's disease: 7-years results of radiotherapy alone for low-risk disease, and ABVD and radiotherapy for high-risk disease

Treatment outcomes were documented for 204 adult patients with clinical Stage I-II Hodgkin's disease who were treated with risk-adapted ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) and radiotherapy (RT) at the Toronto-Sunnybrook Regional Cancer Centre between 1984 and 1994. Forty-nine patients with clinical Stage I disease (excluding bulky mediastinal presentations) and 50 patients with a combination of clinical Stage IIA disease, age 50 years or less, and favourable pathology (lymphocyte predominant or nodular sclerosing histology) were identified as low risk and treated with RT alone to 35 Gy. One hundred and five high-risk patients were treated with chemotherapy (86 with ABVD) followed by RT to 25 Gy. The 7-year cause-specific, overall and disease-free survivals were 95%, 90% and 75% respectively for the low-risk cohort, and 91%, 90% and 88% respectively for the high-risk cohort. In-field relapses accounted for 50% of the failures in both groups. Sixteen of 24 (67%) patients with RT failure and 6/14 (43%) with combined modality therapy (CMT) failure were salvaged. Twenty-eight per cent of the patients treated with RT and 21% of those treated with CMT developed hypothyroidism by 7 years. Fatal complications were recorded in 6% of the low-risk patients managed with RT and 8% of high-risk patients managed with CMT. Septic death and second malignancy accounted for the majority of treatment-related fatalities. Risk-adapted therapy emphasizing RT alone for selected patients with favourable prognostic factors and CMT based on ABVD provides excellent long-term disease control. Further treatment refinements, including the wider application of CMT with lower doses of chemotherapy and RT, will be required to reduce the rate of fatal complications to more acceptable levels.

Prognostic factors affecting disease-free survival in patients with Hodgkin's disease stages IA and IIA treated initially with radiotherapy alone in a single centre during 1973 to 1992

One hundred forty-nine patients with either stage IA (90 patients) or stage IIA (59 patients) Hodgkin's disease (HD) received radiotherapy alone as their first line treatment. Only stage of the nine factors selected for Cox multivariate analysis was of prognostic significance. Patients with grade 1 nodular sclerosing HD did not have a significantly better disease-free survival than those with grade 2 disease.

Serum Levels of Soluble CD 30 and Their Relationship to Tumour Burden and Prognosis in Patients with Hodgkin's Disease

PURPOSE

The purpose of the present study was to examine the relationship between the serum levels of soluble CD 30 (S-sCD 30), the Hodgkin and Reed Sternberg (HRS) cell density and the macroscopic tumour burden in untreated patients with Hodgkin's disease (HD).

MATERIALS AND METHODS

In 126 untreated patients with HD diagnosed between 1979-1991, (79 males and 47 females, median age 33 years) S-sCD 30 was measured using frozen serum samples. The number of HRS cells (the HRS cell density) was counted in 10 high-power vision fields. The macroscopic tumour volume was estimated in 70 patients in stages I and II by counting the number of involved sites and scoring them according to size.

RESULTS

Soluble CD 30 was detected in the sera of all patients. The levels were significantly higher in patients with high HRS cell density, high macroscopic tumour burden, stages III-IV, B symptoms and bulky disease. Patients with high S-sCD 30 had a significantly poorer DFS (p < 0.05) and survival (p < 0.001). High HRS cell density correlated to large macroscopic tumour burden, stage IV disease and B-symptoms. Patients with the highest HRS cell density had a significantly poorer disease-free survival (DFS) (p < 0.01) and survival (p < 0.01). In a multivariate analysis, S-sCD 30 was more important as regards prognosis than HRS cell density.

CONCLUSIONS

Serum levels of sCD 30 are probably a measurement of tumour burden in HD and are also strongly related to the prognosis. A high number of HRS cells correlated to an extensive spread HD and also to prognosis.

Hodgkin's disease: historical perspective and clinical presentation

In conclusion, emphasis has shifted from a progressive increase in the weight of treatment to the reduction of management aggressiveness for some subsets of patients by taking advantage of clinical presentation and risk factors. The first period was based on the philosophy that extensive work-up can help to minimize treatment. The goal has become to avoid unnecessary invasive techniques. With better knowledge of the late effects and causes of death, there is now a consensus that management should be modulated according to the individual characteristics of the patient. The aim of further studies will be to progress in the identification of the various subsets of HD and to introduce new therapeutic modalities as effective but less toxic than the present ones. This approach requires for each subset of patients a rigorous assessment of the long-term cost and benefit of the various therapeutic modalities used for treatment of HD.

Radiation therapy for early stage Hodgkin's disease: Australasian patterns of care. Australasian Radiation Oncology Lymphoma Group

PURPOSE

Analysis of treatment outcome for Stage I-IIA supradiaphragmatic Hodgkin's disease treated solely by irradiation in Australia and New Zealand.

METHODS AND MATERIALS

Patients with supradiaphragmatic Hodgkin's disease only who were treated by irradiation alone with curative intent between 1969 to 1988 were retrospectively reviewed. Ten radiation oncology departments in Australia and New Zealand contributed patient data to the study. Patient, tumor, and treatment variables were recorded. Disease-free interval, survival, and complications were analyzed.

RESULTS

Eight hundred and twenty patients were reviewed. The median age was 29 years. There were 437 men and 383 women. The distribution of 310 clinically staged patients was 170 stage IA, 5 IB, and 135 IIA. Five hundred and ten patients received laparotomies, and pathologic staging was as follows: IA 214, IB 13, IIA 283. The 10-year actuarial disease-free rate was 69% and overall survival rate was 79%. Increasing age, male sex, higher number of involved sites, the use of involved field irradiation, no staging laparotomy, and earlier year of treatment were significantly associated with an increased risk of relapse and lower survival. Actuarial 10-year survival following recurrence was 48%. Acute complications requiring interruption to treatment occurred in 46 patients (6%), but < 1% had their treatment permanently suspended. Actuarial complication rates at 10 years were: cardiac 2%, pulmonary 3% and thyroid 5%. There were 44 second malignancies including 10 non-Hodgkin's lymphomas, 3 leukemias, 7 lung, and 6 breast cancers. Mean delay to the development of a second cancer was 6 years. The 10-year actuarial rate of second malignancy was 5%.

CONCLUSIONS

The Australasian experience of early stage Hodgkin's disease is consistent with the results in the published literature and confirms that irradiation produces a high cure rate with minimal toxicity.

Radiotherapy alone for early stage Hodgkin's disease: a 16 year experience at the Royal Adelaide hospital

The records of all patients with stage I and II Hodgkin's disease treated with radiotherapy alone at the Royal Adelaide Hospital between 1970 and 1986 were reviewed. The aim was to ensure the results were equivalent to the best reported series, particularly as treating such patients with chemotherapy alone has been shown to produce equivalent overall survival figures with improved relapse-free survival. There were 104 patients of whom 67 had undergone staging laparotomy. Fifty-seven patients were stage I and 47 stage II. Nine patients had B symptoms. Overall survival at 10 years was 83% with disease-specific survival being 86% and relapse-free survival 68%. These results compare favourably with those in the world literature. Multivariate analysis only revealed stage as an independent predictor of improved relapse-free survival. The use of radiotherapy for most patients with early stage Hodgkin's disease is continued at Royal Adelaide Hospital. However, careful selection criteria need to be applied to minimize the incidence of relapse after radiotherapy.

Hodgkins disease: clinical and radiological prognostic factors in a laparotomy series

From July 1979 to June 1988, 62 patients managed at Westmead Hospital underwent a staging laparotomy (LAP) for Hodgkins disease. Fifty-four patients were clinical stage (CS) I or II and eight were CS III. The sensitivities of the imaging modalities of computed tomography (CT), Gallium and bipedal lymphangiogram (LAG) were assessed for their predictive value for abdominal disease in patients who underwent a LAP. The most sensitive combination for predicting a negative laparotomy (78%) was a negative abdominal CT and a negative Gallium scan. Upstaging occurred in two of 16 Stage I patients (13%) and nine of 38 Stage II patients (24%). Of the 11 patients upstaged, the spleen was involved in 10 (91%). Factors which predicted for upstaging in a univariate analysis were: age greater than 40 years (P = 0.02), mixed cellularity or lymphocyte depleted histology (P = 0.02), and more than three sites involved above the diaphragm (P = 0.008). In a multivariate analysis, the only significant predictor was the number of sites of involvement (P = 0.007). Two subgroups who had a low probability of upstaging were favourable histology patients with up to two sites of involvement (0%) and females with up to two sites of involvement (0%). We conclude that abdominal imaging is associated with a high false-negative rate, particularly for CS II disease.

Hodgkin's disease: a case of late relapse

A case of Stage 1 nodular lymphocytic predominant Hodgkin's Disease relapsing after 32 years is described. Recent immunophenotyping suggests that this is a low grade B-cell lymphoma.

Salvage radiotherapy in recurrent Hodgkin's disease

Forty-four patients with Hodgkin's disease (HD) which relapsed after chemotherapy were treated with salvage radiotherapy (S-RT) with curative intent. Patients were aged 7 to 80 years (median 32 years) at the time of S-RT and the median follow-up from S-RT was 5 years (1-15). Nine patients had recurrent HD following first-line chemotherapy and thirty five patients had refractory HD. Salvage therapy consisted of radiotherapy alone in 25 and combined chemotherapy and radiotherapy in 19 patients. The overall CR rate of salvage therapy was 66%. The overall median survival of 44 patients was 4.6 years from S-RT with 46% 5 year and 40% 10 year survivals. Age (greater than 40 years) and progression free interval (less than or equal to 1 year) were adverse independent prognostic factors for survival on multivariate analysis. The 5 and 10 year progression free survivals were 38% and 23% respectively. Adverse independent prognostic factors for progression-free survival were extranodal site of recurrence and short progression free interval (less than or equal to 1 year). We conclude that radiotherapy with or without chemotherapy has a role in the salvage of patients failing chemotherapy, particularly in those with nodal disease and progression-free interval greater than 1 year.

Radiation therapy in clinical stage I and II Hodgkin's disease. The Princess Margaret Hospital Lymphoma Group

A review of the Princess Margaret Hospital experience over the last 20 years in treating clinically staged patients with stage I and II Hodgkin's disease was performed to analyse the impact of patient selection and extended field radiation on relapse and survival. Of the 878 patients with stage I and II Hodgkin's disease, 521 with clinical stages I and II received radiation alone as the initial treatment. The actuarial survival for all stage I and II patients was 85.1% at 5 years and 76.2% at 10 years, and for clinically staged patients treated with radiation alone, 87.2 and 77.6%, respectively. The relapse-free rate (RFR) for all clinical stage I and II patients treated with radiotherapy (RT) alone was 70.1% at 5 years and 65.8% at 10 years. Significant prognostic factors for RFR and survival included age, stage and histology. In addition, the extent of radiation was identified as an independent prognostic factor for survival as well as for relapse. The RFR for those treated with involved field RT was 58.4% at 5 years and 50.5% at 10 years; for patients treated with mantle RT, 69.9 and 65.6%, and those treated with extended field RT 77.4 and 75.8%, respectively. In a highly selected group of patients with no adverse features, i.e. with stages IA-IIA, lymphocyte predominant or nodular sclerosis histology, erythrocyte sedimentation rate < 40, age < 50, no large mediastinal mass, and no E-lesions--the policy of mantle RT (M) and extended field RT (EF) produced comparable 5-year relapse-free rates (M, 84.9%; EF, 87.1%; P = 0.53). We conclude that a policy of treatment selection based upon clinicopathological prognostic factors and the use of extended field RT confers excellent results in the treatment of clinical stage I and II Hodgkin's disease.

The relevance of a staging laparotomy for Hodgkin's disease in India

A retrospective analysis of 328 cases of Hodgkin's Disease (HD) subjected to a staging laparotomy at the Tata Memorial Hospital, Bombay, India, from 1974 to 1986 was undertaken to assess its relevance to our setup. Eighty percent of the patients were from clinical stages (CS) I and II, 38% with lymphocyte predominance (LP), and 41% with mixed cellularity (MC) histologies. Staging laparotomy was positive in 60% cases overall, including 50% from CS IA and IIA, 68% from CS IB and IIB, and 53% and 67%, respectively, from LP and MC histologies. Splenic involvement was seen in 54% cases. Operative complications were encountered in 2% of cases and deaths in two cases only. In view of the high propensity for abdominal spread, only selected CS IA and IIA cases would merit a staging laparotomy within which, nearly 50% cases with a negative yield could be offered radical segmental irradiation alone for cure. The majority of our patients would, however, require combination therapy.

Cure of early-stage Hodgkin's disease with subtotal nodal irradiation

Ninety-four consecutive patients with Stage I or II Hodgkin's disease who presented supradiaphragmatically were treated with radiation therapy alone at the Mallinckrodt Institute of Radiology from January 1978 through December 1986. Fifty-two patients (55%) were staged pathologically, and 42 (45%) were staged clinically. The latter included lymphangiography and/or abdominal computed tomographic scan. Most patients with B symptoms and/or bulky disease were excluded from this series. Seventy-four patients were treated with subtotal nodal irradiation (mantle and periaortic fields). The spleen was treated if the patient had not undergone splenectomy. Twenty patients received mantle irradiation only. No patient received total nodal irradiation. All patients had an initial complete response. With a minimum follow-up of 7 months (median, 7.7 years; seven patients died before 3 years of follow-up, but all other patients had at least 3 years of follow-up), 81 patients (86%) remained disease-free. Six of 52 (12%) of the pathologically staged group had a relapse, as did seven of 42 (17%) of the clinically staged group (P = 0.68). Eight of 57 Stage I patients versus five of 37 Stage II patients had a relapse (P greater than 0.99). Analysis of disease-free survival by age, histologic findings, sex, and sites of involvement did not predict relapse. The pelvis was the most common site of failure (nine patients, 10%). However, only three patients (3%) failed in the pelvis alone. These results indicate that patients who, after adequate clinical staging with selective use of staging laparotomy, are found to have Stage I and II Hodgkin's disease may be treated with subtotal nodal irradiation with a high rate of cure.

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. 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.

The management of early Hodgkin's disease

Hodgkin's disease has provided a focus of academic attention for haematologists, radiotherapists and oncologists over the last 20 years but nevertheless there is considerable controversy over the management especially of early presentations. Options include performing a staging laparotomy and splenectomy with radiotherapy for pathological stage I and II disease, clinical staging with combined chemotherapy and radiotherapy, clinical staging with either extensive radiotherapy or with limited radiotherapy and close surveillance, or finally, clinical staging and treatment with chemotherapy alone. An appropriate management decision depends upon an assessment of the disease and also on the impact of treatment side-effects on the individual patient.

A risk factor for relapse in Hodgkin's disease: female gender?

A retrospective study of 163 patients with Hodgkin's disease treated between 1969 and 1987 was performed to identify adverse prognostic factors. One hundred and thirty-five patients (83 per cent) attained a complete remission and 42 (31 per cent) of these have relapsed (median follow-up--43 months). Using multivariate analysis, no independent factors predicted for the event of relapse. However, analysis of disease-free survival revealed that females fared significantly worse than males (p less than 0.05) and this was independent of other prognostic variables. Female sex has not been recognized as an independent prognostic factor predictive of inferior survival and inferior disease-free survival.

Changing patterns of relapse in Hodgkin's disease

The patterns of early and late relapses (those occurring later than 3 years after diagnosis) in 432 patients achieving complete remission after treatment for stage I and II Hodgkin's disease at the Royal Marsden Hospital between 1964 and 1983 were studied to identify factors predicting for late relapse. The incidence of early relapse has fallen progressively in recent treatment eras as staging procedures and management have improved but in contrast there has been no decrease in the risk of late relapse. The incidence of late relapse was greater in patients treated with radiotherapy rather than combined modality therapy (P less than 0.05). However, patients who were clinically staged and treated with combined modality therapy retained as high a risk of relapse between 3 and 6 years as in years 2 and 3. The risk of late relapse was also greater in patients with stage II disease and in those without B symptoms at presentation. Patients falling into the higher risk categories for late relapse require continued close follow-up beyond 3 years to monitor for possible relapse.

Stage III Hodgkin's disease--long-term results following chemotherapy, radiotherapy and combined modality therapy

215 patients with stage III Hodgkin's disease (HD) were treated at the Royal Marsden Hospital between 1963 and 1985 (median follow-up 9 years). The actuarial 5- and 10-year survival was 77 and 65%, respectively with 55 and 48% 5 and 10 year disease-free survival. Of 13 variables tested, age was the only independent prognostic indicator for survival on multivariate analysis. Patients aged under 40, 40-59 and over 60 years had a 10-year survival of 76, 41 and 8%, respectively (p much less than 0.001). Ninety-one patients were initially treated with combined chemotherapy and radiotherapy (combined modality therapy, CMT), 73 patients with radiotherapy (RT) and 51 patients with chemotherapy (CT) alone. Patients under 40 years treated with CMT achieved the best disease-free survival (10 year disease-free survival: CMT 68%; RT 38%; CT 45%). The observed survival advantage for CMT was not statistically significant. In patients aged greater than 40 there was no survival or disease-free survival advantage following CMT. Analysis of recurrence pattern confirmed that CMT improves initial disease control both at previously involved and uninvolved sites. Recurrences at previously uninvolved sites continued up to 6 years following CT, up to 8 years following CMT and up to 14 years after RT alone. These results indicate that only long-term follow-up gives the true picture of stage III HD.

Radiotherapy results in laparotomy-staged Hodgkin's disease

Between 1970 and 1978, 131 patients with laparotomy-staged, supradiaphragmatic Hodgkin's disease were treated at the Royal Marsden Hospital with mantle radiotherapy, reserving chemotherapy for relapse. Forty-four patients relapsed at a total of 64 sites, the majority of which were infradiaphragmatic. Analysis of the factors predicting relapse showed that bulky mediastinal disease, and three or more sites of involvement at presentation significantly decreased disease-free survival in this group. Age above 60 years, high erythrocyte sedimentation rate (ESR) and adverse histology were of borderline significance. Although the majority (75%) of relapsed patients were salvaged with subsequent chemotherapy, it is suggested that patients with three or more sites of nodal involvement and bulky mediastinal disease would be managed best with initial combined modality therapy.

Second malignancies and Hodgkin's disease--the Royal Marsden Hospital experience

The frequency of secondary malignant neoplasms occurring in patients treated for Hodgkin's disease at the Royal Marsden Hospital between 1963 and 1978 is reported and the literature is reviewed. 730 patients were reviewed and 583 patients permanently resident in the United Kingdom were included in the analysis. The frequency of leukaemia and solid tumors was determined from age- and sex-corrected data from the South Thames Cancer Registry. Thirty-seven malignancies were recorded in 36 patients including 9 leukaemias, 10 lung cancers, 6 skin cancers and 2 non-Hodgkin's lymphoma, all of which were observed in significant excess. When all remaining sites are combined, there was a slight excess but no one site is individually significant.