Radiotherapy in the treatment of Hodgkin's disease

[Hematological pathologies: the most successful model of de-escalation in radiotherapy]

The proportion of patients irradiated in the context of malignant hematological pathologies decreased over the last decades. The main causes are the late side effects of the historical series and the new therapeutic strategies aiming to relay radiotherapy to the rank of option. At the same time, radiotherapy has been modernised, target volumes and total doses have been drastically reduced. Hodgkin's lymphomas, indolent follicular lymphomas and primary cerebral lymphomas are the main witnesses of this therapeutic deflation.

Extended-field radiotherapy in favorable stage IA-IIA Hodgkin's disease (prognostic role of stage)

PURPOSE

The study was undertaken to evaluate the long-term results in a favorable subset of patients with pathological Stage IA-IIA treated with irradiation alone.

METHODS AND MATERIALS

One hundred and forty-seven adults with laparotomy- Staged IA-IIA "favorable" Hodgkin's disease were treated with primary subtotal nodal irradiation. Patients with infradiaphragmatic presentation were irradiated through paraortic and inguino-iliac node chains (inverted Y field) followed by prophylactic mediastinal and supraclavicular fields.

RESULTS

Actuarial overall survival (OS) at 7 years (median follow-up 77 months) was: 93% for the whole series, 94% for Stage I, and 92% for Stage II. The freedom from first progression (FFP) (80% for the whole series) showed a statistically significant difference (p = 0.008) between Stage I (88%) and Stage II (71%). By univariate analysis, stage alone had an independent prognostic significance for OS and FFP. Of the 29 relapsed patients, 8 were previously classified as Stage I and 21 as Stage II; 16 of 29 (55%) of the relapses occurred in the pelvis and 9 in extranodal sites. After salvage treatment with chemotherapy all patients achieved a second complete remission. Seven second malignancies (two acute nonlymphocytic leukemias, one preleukemic syndrome, and four solid tumors) have been detected so far. Hypothyroidism was observed in 16% of patients and a reversible pulmonary restrictive syndrome in 14% of cases, respectively.

CONCLUSIONS

Within 7 years from radiation therapy, about one-quarter of the patients with Stage II disease will experience a relapse and need intensive salvage chemotherapy. This is not invariably successful and safe, for it may be complicated by either acute or potentially fatal long-term adverse effects, such as second malignancies and cardiac or pulmonary sequelae, in about 5% of patients. The high frequency of relapse in Stage IIA patients suggests a combined modality approach with relatively short-term chemotherapy not including alkylating agents.

Management of stage II Hodgkin's disease: 15 years experience at St. Bartholomew's Hospital

One hundred seventy-seven consecutive patients with newly diagnosed stage II Hodgkin's disease (HD) (supradragmatic 157; infra diaphragmatic 20) were treated at St. Bartholomew's Hospital on the basis of pathologic stage (PS) in 84 (IIA 69; IIB 15) and clinical stage (CS) in 93 (IIA 33, IIB 60) between January 1968 and December 1984. The median follow up is 13 years. Overall, complete remission (CR) was achieved in 143 patients (75%) of whom 53 have had a recurrence. One hundred twenty-seven patients remain alive, the cumulative predicted survival at 15 yrs being 70%. Mantle radiotherapy was prescribed to 88 patients with supradiaphragmatic HD, of whom 75 entered CR and 9 achieved good partial remission (GPR) (95%). The duration of remission correlated strongly with ESR (greater than 50 mm/h) and mediastinal thoracic ratio (less than 33% vs. greater than 33%) in a multivariate analysis (p = 0.05 and 0.02, respectively). 46/88 patients remain in continuous first remission, the median duration of remission having not reached at 15 years. Combined modality therapy or chemotherapy alone was prescribed to 69 patients with supradiaphragmatic HD, CR being achieved in 51 patients and GPR in 8 at the completion of all therapy. 48/59 patients continue in first remission. The duration of remission of patients receiving combined modality therapy or CT alone was significantly longer (p = 0.002) than that of patients receiving RT alone, in spite of the fact that the former group comprised predominantly of patients with unfavourable features.(ABSTRACT TRUNCATED AT 250 WORDS)

Three-dimensional photon treatment planning for Hodgkin's disease

A multi-institutional study was undertaken using computerized planning systems to develop three-dimensional (3-D) radiotherapy plans for Hodgkin's disease (H.D.). Two patients, the first afflicted with bulky stage II disease and another one with early stage I H.D., were studied. Three main categories of plan were produced for each patient: a) a traditional plan which modelled a conventional mantle treatment on the 3-D system, b) a 3-D standard plan where anterior and posterior fields were designed to cover 3-D target volumes, and c) a 3-D unconstrained plan where innovational techniques were employed. Three-dimensional planning provides information about the dose distribution throughout the large volume irradiated in patients with H.D. that is not available with conventional mantle planning. The use of 3-D techniques resulted in improved tumor coverage, but by allowing for uncertainties such as motion, the doses to normal tissues tended to be higher. The use of unorthodox beam arrangements introduced added complexities, and further increased the lung doses. The most even dose distributions were obtained by incorporating compensating filters into anterior fields. Clinicians showed wide variations in their assessment of the plans, possible reasons for which are addressed in this paper. In addition, calculated probabilities from models of tumor control and normal tissue damage are also presented.

Chemotherapy of Hodgkin's disease

An overall perspective of chemotherapy for Hodgkin's disease has been presented with particular emphasis on the treatment options to be considered at each stage of the disease. In 1950, M. Vera Peters ended her paper on the 'radiological' treatment of Hodgkin's disease thus: 'In the light of present knowledge the diagnosis of Hodgkin's disease should not be regarded with despair and the patient treated as incurable.... If a single ray of hope emerges from this analysis, the treatment of the individual concerned is a challenge to the combined efforts of the radiotherapist, the physician and the surgeon' (Peters, 1950). Over the ensuing 40 years, substantial progress has been made, but any further improvement must begin with an increase in the proportion of patients for whom complete remission is achieved. Prospective comparisons of hybrid regimens against standard chemotherapy are in progress and the results of these trials will hopefully answer the question as to which is the optimal regimen in the primary treatment of advanced Hodgkin's disease. The advent of growth factors may allow for an increase in dose intensity, possibly improving the results further. The role of very intensive therapy with autologous bone marrow support remains to be defined and is currently being evaluated in different trial settings. Meanwhile, the quest for alternative, less toxic compounds goes on. The challenge continues.

Radiotherapy for stage I Hodgkin's disease: 20 years experience at St Bartholomew's Hospital

One hundred and one consecutive patients with newly diagnosed stage I Hodgkin's disease (HD) received treatment at St Bartholomew's Hospital, between 1968 and 1987, with a median follow-up of 12 years. Eleven patients have been excluded from detailed analysis because they either received involved field radiotherapy (RT) or radiotherapy with chemotherapy or were lost to follow-up. Actuarial analysis predicts 78% to be alive and without relapse of Hodgkin's disease at 15 years. Ninety evaluable patients (clinical stage (CS) 24; pathological stage (PS) 66) received either mantle or inverted 'Y' RT and form the basis of this analysis. The median age was 33 years (63 men, 27 women). Histology at presentation was nodular sclerosing (39), lymphocytic predominant (27) or mixed cellularity (24). The presenting site was neck (78), axilla (6) groin (4) and mediastinum (2). Complete remission was achieved in all evaluable patients, the actuarial proportion in remission being 75% at 15 years. Factors predictive of a prolonged remission were pathological staging versus clinical staging (P = 0.02) and lymph node size less than 3 cm (P = 0.04). Actuarial overall survival in these 90 patients was 75% at 15 years and none of the above factors correlated with survival. Relapse of HD has occurred in 18 patients (5 within RT field, 10 without and 3 in both). Second remission was achieved in 15/18. The actuarial rate of second remission and survival was 40% at 10 years. Sixteen patients have died, 7 of Hodgkin's disease, 7 of unrelated causes and 2 of second malignancy. A further 3 patients who developed second malignancy are still alive. At 15 years the actuarial mortality related to HD was 12%. These results confirm the importance of long follow up to assess the efficacy of primary therapy.

Thyroid function in survivors of cancer

Thyroid function was assessed in three selected groups of children who had survived cancer. Children in group 1 had received radiotherapy to the thyroid area, group 2 had radiotherapy to the thyroid area and adjuvant chemotherapy, and group 3 had chemotherapy with or without radiotherapy away from the thyroid area. There were 75 survivors and 63 (40 boys, 23 girls) were available for study. Eighteen (29%) were found to have thyroid dysfunction, and these included all those who had had lymphangiograms or received a radiation dose greater than 40 Gy to the thyroid area. Only nine of the 18 children were already known to have thyroid dysfunction, and only 15 of 44 children who had had irradiation to the thyroid area had had their thyroid function examined. This study shows that children who have received radiotherapy to the thyroid area should have their thyroid function assessed regularly. Chemotherapy does not appear to be a risk factor but longer follow up of these children is necessary.

Hodgkin's disease: a reassessment of prognostic factors following modification of radiotherapy

Between 1970 and 1982, 175 patients with Stage IA, B, IIA, B, or IIIA Hodgkin's disease were treated with curative radiotherapy following surgical staging. The patients treated prior to 1975 received either regular extended or total nodal field treatments (Treatment Group 1, N = 65). Unsatisfactory results from this treatment program led to treatment modification in 1975. The modified protocols consisted of low-dose lung irradiation in patients having large mediastinal masses and/or hilar disease, and low-dose liver irradiation for Stage IIIAS+ patients (Treatment Group 2, N = 110). Recurrence-free survival rates improved significantly for various risk groups. Univariate analysis indicated that age, stage, symptoms, mediastinal mass size, number of sites involved, hilar disease, stage, and symptoms were significant risk factors in Treatment Group 1. In Treatment Group 2, only sex was a statistically significant risk factor. Stepwise Cox regression analysis for risk factors selected mediastinal mass size and stage as the most significant prognostic factors in Treatment Group 1. In Treatment Group 2, number of initial disease sites and sex were the most significant risk factors. The results of the study show significant improvement in recurrence-free survival rates in Treatment Group 2. It is concluded that these improvements are due to the modification in treatment.

Second primary malignant neoplasms in patients treated for Hodgkin's disease at St Bartholomew's Hospital

The incidence of second malignant neoplasms (SMN's) was investigated in a group of 529 patients with Hodgkin's Disease (HD) treated at St Bartholomew's Hospital (SBH). SMN's were seen in 27 of these patients giving an incidence rate three and a half times that expected in an age and sex matched normal population (p = much less than 0.001). The incidence rate was higher in those receiving multiple chemotherapy and radiotherapy for relapsed HD compared with those receiving primary radiotherapy, chemotherapy or chemotherapy with adjuvant radiotherapy (p = 0.02). However, the increased incidence rate in those patients treated with chemotherapy on relapse, may reflect in part a delayed effect of their primary therapy, since the incidence rate in the primary treatment group only becomes significantly raised after six years. When allowance was made for this delay the difference between the two groups was no longer significant. The incidence rates for Non-Hodgkin's Lymphoma (NHL) and myelogenous leukaemia were 32 and 57 times those expected, compared with only two and a half times the expected rate for non-haematological SMN's (p = much less than 0.001). The four acute myeloid leukaemias (AML) all occurred within five years of treatment compared to wide-ranging intervals between treatment and occurrence of SMN in the other groups. The increased incidence of NHL may be an alternative expression of lymphoid abnormality rather than a treatment-related occurrence. Multiple SMN's were diagnosed in three patients. This represented a highly significant (p = much less than 0.001) increase over the expected incidence of multiple neoplasia in the general population. Several factors may contribute to the development of SMN's in HD, including an inherent disposition of HD itself. The time-dependent incidence pattern of SMN's with a delay followed by an increased incidence rate, suggests that treatment plays a key role. It is not yet clear whether more intensive, or multiple treatments add to the risk accrued for the initial treatment.

The management of stage II supradiaphragmatic Hodgkin's disease at St. Bartholomew's Hospital. A retrospective review of 114 previously untreated patients over 14 years

Between January, 1968 and July, 1981, 114 consecutive patients with newly diagnosed supradiaphragmatic stage II Hodgkin's disease were treated at St. Bartholomew's Hospital on the basis of pathologic staging (PS) in 56 (47 IIA, 9 IIB) and clinical staging (CS) in 58 (23 IIA, 35 IIB). Complete remission (CR) was achieved in 104 (91%) patients, of whom 27 have relapsed. Ninety-three patients remain alive, the cumulative predicted survival at 10 years being 81%, with a minimum follow-up of 2 years and a maximum of 15 years. Mantle radiotherapy (RT) was prescribed for 76 patients, of whom 67 (88%) entered CR. The duration of CR correlated inversely with the presence of intrathoracic lymphadenopathy. No patient with PS IIA and a normal chest radiograph has yet relapsed, whereas in contrast, a rising probability of relapse is related to increasing volume of intrathoracic lymphadenopathy. Combination chemotherapy (CT) with mustine, vinblastine, procarbazine, and prednisone (MVPP) was prescribed to 38 patients, 27 with "B" symptoms and 11 stage IIA patients with "unfavorable" features. CR was attained in 32 (84%) patients, of whom 24 subsequently proceeded to mantle irradiation. Only one of these has relapsed, compared to two of eight patients who did not receive adjuvant RT (P = NS). The duration of remission of patients receiving combined modality therapy (CT + RT) or CT alone was significantly longer (P less than 0.05) than that of patients receiving RT alone, in spite of the fact that the CT + RT group comprised predominantly patients with unfavorable features.

Combined modality therapy for mediastinal Hodgkin's disease. Prognostic significance of constitutional symptoms and size of disease

Combined modality therapy was used in an attempt to increase the complete remission rate and survival of previously untreated patients with Hodgkin's disease. MOPP (nitrogen mustard, vincristine, procabazine, prednisone) chemotherapy was followed by radiotherapy. The median duration of follow-up exceeded 5 years. Complete remissions were achieved in 63 of 71 patients (89%) with mediastinal masses. The actuarial survival of 10 years was 72% for patients with small mediastinal masses (mediastinal mass ratio less than 0.35) and 46% for patients with large mediastinal masses (P less than 0.05). The corresponding disease-free survival figures were 69% and 46%, respectively (P less than 0.05). A small mediastinal mass did not affect prognosis. Systemic symptoms especially affected the prognosis in patients with a large mediastinal mass, since in symptomatic patients the actuarial survival and freedom from relapse were 19%, whereas all asymptomatic patients survived without relapse. In patients with a small mediastinal mass, systemic symptoms had no significant effect on the actuarial survival or disease free survival. Age and stage did not affect the prognosis in patients with large mediastinal masses. It was concluded that MOPP chemotherapy followed by radiotherapy was an adequate treatment for asymptomatic patients with large mediastinal disease. However, in symptomatic patients with large mediastinal masses, this treatment was clearly inadequate.

The management of localized, infradiaphragmatic Hodgkin's disease: experience of a rare clinical presentation at St Bartholomew's Hospital

Between 1969 and 1982, 23 previously untreated patients with Hodgkin's disease (HD) confined to infradiaphragmatic sites were treated at St Bartholomew's Hospital. The distinguishing clinical characteristics of the patient population were a male: female ratio of 20:3. The mean age was 39 years, which was significantly older (P less than 0.05) than the mean age of patients with supradiaphragmatic HD (32 years) referred during the same period. Sixteen patients underwent formal pathological staging while one additional patient underwent a diagnostic laparotomy without splenectomy. The final pre-treatment stages were PS IA: 5; PS IIA: 11; CS IIA: 1; PS IIB: 1; CS IIB 5. Splenic involvement correlated closely with the number of nodal sites involved, being detected in 1/7 patients with one site only compared with 8/9 with more (P less than 0.001). Complete remission (CR) was achieved in 21 (91 per cent) patients: 12/12 following 'inverted Y' radiotherapy (RT) and 9/11 following combination chemotherapy. Twenty patients remain alive and 18 continue without recurrence of HD between 15 months and 12 years. All patients who failed to enter CR or who relapsed had presented with three or more sites of involvement or with constitutional ('B') symptoms. These results confirm the generally good prognosis of this uncommon presentation of HD and also suggest that prognosis is determined by the bulk of disease rather than its precise anatomical localization, provided that appropriate therapy is administered.

The place of staging laparotomy in the management of Hodgkin's disease

The results of laparotomy and splenectomy in 225 patients with Hodgkin's disease are presented. The investigation changed the staging of the disease in 35% of patients. It carried no mortality and a low morbidity. It is concluded that the procedure provides information unobtainable accurately by other means and that it should be carried out in adult patients of both sexes and all histological subgroups who have clinical Stage I and II disease.

A randomised study of adjuvant chemotherapy after mantle radiotherapy in supradiaphragmatic Hodgkin's disease PS IA-IIB: a report from the Manchester lymphoma group

One hundred and fourteen untreated patients with pathological stage (PS) IA-IIB supradiaphragmatic Hodgkin's Disease were randomised to mantle radiotherapy alone (55) or mantle radiotherapy followed by 6 courses of adjuvant chemotherapy with mustine, vinblastine, prednisolone and procarbazine- MVPP (59). Patients excluded were those outside the age range 16-65 years and those with massive mediastinal disease precluding laparotomy. Bulk disease was defined as a mass of lymph nodes measuring five centimetres or more in any axis. Mediastinal bulk was present if the ratio of the maximum width of mediastinal disease to the maximal chest diameter was more than one third. All patients achieved a complete remission. Median duration of follow-up was 62 months (range 16-97). The relapse free survival (RFS) was 81%; 69% for radiotherapy alone and 93% for adjuvant chemotherapy (P = 0.002). RFS was also shown to be adversely affected by B symptoms (P = 0.0003), bulk disease (P = 0.018), abnormal CXR (P = 0.037), and increasing stage (P = 0.039). Age, sex, histology, and number of sites involved had no significant effect upon RFS. A Cox multivariate analysis showed that only three variables had a significant adverse effect on RFS - radiotherapy alone, the presence of bulk disease, and B symptoms. The overall 5 year survival was 93% with no statistically significant difference between the two treatment groups (P = 0.54). Survival was adversely affected by three variables - B symptoms (P = 0.02), the presence of bulk disease (P = 0.002), and pathological stage (P = 0.05). High risk groups for relapse are those with bulk and B symptoms. This analysis has shown that RFS was significantly improved by adjuvant chemotherapy, but that overall survival was not.

The effects of conventionally fractionated, extended portal radiotherapy on the human peripheral blood count

Conventionally fractionated, extended portal radiotherapy (CFEPRT) has been used to treat two diseases in which there was no marrow infiltration (viz. Hodgkin's disease and medulloblastoma). Blood count indices have been monitored during therapy and in the recovery phase. The lymphocytes were the most sensitive and the monocytes the most refractory leucocytes to change; the monocyte count tended to recover during CFEPRT. The platelet count fell gradually and soon after the neutrophil count. The nadir counts for white cells and platelets occurred early or toward the middle of CFEPRT, after which levels were maintained. The hemoglobin slightly and progressively declined. The patterns of change were similar for the two portals analyzed. Absolute eosinophilia occurred in 9 of the 53 CFEPRT patients, often in the recovery period. All patients who maintained their early nadir levels throughout the rest of the CFEPRT demonstrated fast recovery of all indices following completion of radiotherapy; the lymphocyte count recovered fastest. Recent prior CFEPRT or standard MVPP (nitrogen mustard, vinblastine, procarbazine, prednisolone) chemotherapy rendered the blood count more liable to radiation induced cytopenia. A lapse of more than 3 months between MVPP and CFEPRT allowed greater tolerance to the radiotherapy. Recent MVPP may be less myelosuppressive than recent mantle radiotherapy with respect to subsequent tolerance to CFEPRT.

Five years' experience with ChlVPP: effective low-toxicity combination chemotherapy for Hodgkin's disease

Since 1975, 191 patients with Hodgkin's disease have been treated with a combination of chlorambucil, vinblastine, procarbazine and prednisolone (ChlVPP). Complete remission rates were 73% for previously untreated patients, 91% for patients previously treated with radiotherapy and 55% for patients previously treated with chemotherapy. In 59 patients with advanced disease who received no other treatment, a 5-year survival rate of 66% was comparable with that achieved by more toxic mustine-containing combinations. ChlVPP has few side effects, is easily given to outpatients, and can be combined with elective radiotherapy in selected patients.

The changing role of staging laparotomy in Hodgkin's disease: a personal series of 310 patients

A series of 310 patients with Hodgkin's disease having a staging laparotomy under the care of one surgeon (J-C. G.) between October 1969 and June 1980 is presented. A total of 51 per cent had positive laparotomy findings, and 30 per cent had their staging altered, but there was a low incidence of positive laparotomy findings when performed within 2 months of initial treatment by chemotherapy. None of the investigations used to determine possible splenic or hepatic involvement preoperatively was found to be of any value, and their routine use is not recommended. Bipedal lymphography was found to give an accurate assessment of iliac and lower para-aortic nodal involvement, and so the laparotomy protocol since 1975 has not included biopsy of these nodes. The incidence of minor complications was 31 per cent and of major complications 4 per cent. One patient died.

Staging laparotomy has played an important part in the management of Hodgkin's disease over the past decade, but it is likely to assume a less prominent role in the 1980s as the role of chemotherapy in early Hodgkin's disease expands. In non-bulky clinical stage I and II Hodgkin's disease, when radiotherapy alone is curative, then a staging laparotomy is justifiable because it will detect occult abdominal disease, especially in the lymphogram-negative patient, which may require the addition of chemotherapy or more extensive radiotherapy. Laparotomy is essentially an operation to remove the spleen and to obtain adequate liver biopsy specimens in order to ascertain possible involvement of these two organs. Non-opacified nodes at the porta hepatis and coeliac axis should also be sampled, as should a node from the poorly opacified upper paraaortic area. Routine oophoropexy is not recommended.

The effects of cancer and cancer therapy on male fertility

Multimodality treatments have increased the survival of cancer patients in recent years. With cure the quality of life also should be taken into consideration. Maintenance of the reproductive capacity is of great concern to many young patients. Until now the cause of sterility was attributed to the long-term side effects of treatment when recovery could not be predicted. Pre-treatment sperm banking is advised routinely for many of these patients. Our own observation as well as a few other reports show that cancer itself seems to have an adverse effect on fertility before any form of treatment. As assessed by semen quality the majority of our patients were subfertile when first seen. Hence, sperm banking may be a poor guarantee for future reproduction in these patients.

[Treatment results of Hodgkin's disease, stages I and II (author's transl)]

The results obtained in the treatment of Hodgkin's disease, stages I and II, are discussed comparing survival data of the literature after various radiotherapy programs and after combined modality using additional chemotherapy. In stage IA 90 to 97% and in stage IIA 75 to 80% of patients are not prone to relapse after extended-field irradiation. In stage IIB 0 to 80% long-lasting remissions are reported after radiotherapy. Additional chemotherapy improved relapse-free survival, but not overall survival in stages I and II. Subgroups are discussed which bear a high risk of relapsing disease (big mediastinal masses, E-lesions of the lungs, histological findings with lymphocyte depletion).

Hodgkin's disease irradiated with the inverted-Y technique

Thirty-four patients with Hodgkin's disease were treated with the inverted-Y technique. Target absorbed dose was 40 Gy given in a split-course schedule to all but one patient. Only one recurrence occurred. Seventeen patients remained symptom-free after treatment and another 9 were rescued by further therapy. Eight patients died. All 7 patients in stages I and II are alive. In stage III A more patients with upper abdominal disease remained symptom-free after treatment than patients with lower abdominal disease. Of 7 patients in stage III B, 5 died. Actuarial survival at 10 years was significantly better for patients without systemic symptoms. Radiation side effects were mild. One serious complication occurred, acute gastrointestinal ulceration in the patient given the total dose in one series. No permanent symptom-producing side effects from liver, kidneys, spinal cord or bone marrow occurred.

Cyclical combination chemotherapy and thyroid function in patients with advanced Hodgkin's disease

Clinical and biochemical assessment of thyroid function was undertaken in patients with Hodgkin's disease at designated points following diagnosis. At diagnosis, two of 20 patients had either abnormally low routine thyroid indices, or elevated thyroid stimulating hormone (TSH) levels that were not due to iodine-based investigations. Following lymphography, 76.5% of patients had TSH levels that remained elevated for a median period of 3 months. No detectable thyroid dysfunction was induced during chemotherapy. Fifty-four patients were studied at a median time of 35 months after chemotherapy. One euthyroid patient had a nodular goitre, and one had abnormal thyroid indices. Tsh levels were elevated in 44% of patients, although the median TSH level for the group was normal. Half the patients had abnormal TRH stimulation tests. Sixty patients were studied after irradiation and chemotherapy. Four patients had clinical thyroid dysfunction, and 10% of routine thyroid indices were abnormal. TSH levels were abnormal in 80%, with a markedly elevated median level. All thyroid releasing hormone stimulation tests were abnormal.

Chemotherapy--radiotherapy association in Hodgkin's disease, clinical stages IA, II2A: results of a prospective clinical trial with 166 patients

One hundred sixty-six patients with clinical stages IA, II2A Hodgkin's disease were treated between April 1972 and December 1976 with three courses of multiagent chemotherapy (methylchlorethamine, vincristine, procarbazine, prednisone) followed by mantle irradiation--excluding mediastinum for those with initial upper cervical presentation and absence of mediastinal involvement--or inverted Y radiotherapy. None had staging laparotomy. With a follow-up of 12--84 months, median 40 months, the overall survival is 93.5% and the overall relapse-free survival 89.9%. Eight patients died, three of them with evident disease. Ten patients relapsed; four are now free of disease after retreatment. With chemotherapy-radiotherapy sequence, staging laparotomy is not indicated. Results and side effects of this treatment strategy are compared with those of other treatment policies.

Is staging laparotomy of therapeutic value in patients with supradiaphragmatic Hodgkins's disease, clinical stage IA-IIA?

Between 1968 and 1972, 123 patients with clinical stage (CS) IA and IIA Hodgkin's disease were seen. Staging laparotomy was introduced in June 1970. The impact of staging laparotomy on the prognosis has been evaluated by comparing the treatment results before and after the introduction of this procedure. The patients were treated only on the basis of CS before staging laparotomy, and mainly on the basis of pathological stage (PS) after the introduction of this procedure. Patients with stage IA to IIIA disease received radiotherapy alone with the extended field techniques, while patients with stage IVA disease had combination chemotherapy. After an observation time of 7 years there was no difference in survival between the two groups. The relapses occurred earlier in the patients treated after the introduction of staging laparotomy. It is known that the survival is unaffected by staging laparotomy in the patients with Hodgkin's disease CS IA and IIA.

Increasing frequency of acute myeloid leukemia complicating Hodgkin's disease: a review

Between the years 1911 and 1969, there were 16 reported cases of Hodgkin's disease terminating in acute myeloid leukemia. During the period from 1970 to 1978, the number reported was 161. Other severe complications of Hodgkin's disease (second malignancies and infections) also seem to appear with increased frequency after the introduction of modern aggressive high-energy radiation therapy and combination chemotherapy. It is thus desirable to search for alternative methods of treatment of Hodgkin's disease.

Computerised tomographic (CT) abdominal scanning in Hodgkin's disease

Thirty-nine patients with Hodgkin's disease (HD) with little or no clinical evidence of abdominal disease were investigated by abdominal CT scanning. The results were compared with those of bipedal lymphography and laparotomy and splenectomy. In the assessment of para-aortic lymph nodes, CT scanning and lymphography were of equal efficacy in determining the presence or absence of disease (87 and 79% respectively). Although CT scan could occasionally demonstrate disease in nodes in areas other than the retroperitoneum, its value was limited by its inability to detect involvement of nodes which were not significantly enlarged. CT assessment of splenic HD was unreliable, focal deposits being detected in only one of the 11 spleens involved. In this selected group of patients, CT scan had little advantage over lymphography in the description of disease extent. However, CT scan would appear to be the investigation of choice in patients with suspected abdominal relapse because of the more frequent presence of disease in sites not seen on lymphography. When treatment decisions are dependent on accurate knowledge of distribution of disease, CT scanning cannot yet effectively replace staging laparotomy and splenectomy as the means of achieving this information.

Combined modality treatment of Hodgkin's disease confined to lymph nodes. Results eight years later

Eighty-seven patients with newly diagnosed Hodgkin's disease, pathologic stages IA, IIA, IIB and IIIA, were assigned at random to receive either extended field radiotherapy alone or that therapy followed by six cycles of MOPP (nitrogen mustard, Oncovin, procarbazine, prednisone) chemotherapy. Patients were entered into the study from January 1970 to January 1974. Patients were followed for a median of 69 + months from the end of all treatments. Patients whose disease was less than stage IIIA had a 31 per cent relapse rate with radiotherapy alone compared to a 6 per cent relapse rate with combined modality treatment (P = 0.04). No deaths from Hodgkin's disease have occurred in patients who received combined modality therapy, whereas 24 per cent of the patients who received radiotherapy alone have died with active disease. However, three patients with stage IIIA disease who were treated with both modalities have died from other causes (myocardial infarction, adenocarcinoma of lung, acute leukemia). Combined modality therapy of patients with early Hodgkin's disease may be superior to radiotherapy alone, especially for certain subgroups of patients discussed in detail.

Cyclical combination chemotherapy and gonadal function. Retrospective study in males

The effect of cyclical chemotherapy on fertility and gonadal function was investigated in seventy-four male patients who had been treated for advanced Hodgkin's disease. All patients were azoospermic after therapy, and, with a median follow-up period of 27 months (range 1--62 months), only four patients have regained spermatogenesis. Testicular biopsy showed an absence of germinal epithelium without other gross architectural changes. Despite this high degree of infertility, 60% of patients were practising contraception. A decline in libido and sexual performance with frequent long periods of sexual inactivity was noted by most men during therapy. Although some recovery was apparent once therapy was stopped, this was incomplete in approximately half of the patients. Follicle-stimulating-hormone levels were consistently raised after therapy at all periods of study. Median luteinising-hormone levels were at, or just above, the upper limit of normal, and median testosterone levels were normal. Increased prolactin levels were noted in 42% of patients, of whom about a half had an identifiable cause for hyperprolactinaemia. Return of spermatogenesis could not be predicted by serial hormone assessment. Because of the guaranteed infertility and the low frequency and unpredictability of recovery of spermatogenesis, sperm storage should be available for male patients undergoing cytotoxic therapy, since most of these patients may enjoy prolonged survival. Hormone-replacement therapy will usually be unnecessary. However, the probability of major changes in libido and sexual performance should be discussed with patients so that additional stress can be avoided. Contraceptive advice should be available to those who require it.

Post-treatment laparotomy in the management of Hodgkin's disease

Tissues obtained by laparotomy and splenectomy from patients with Hodgkin's disease who had received either supradiaphragmatic irradiation for localised disease or combination chemotherapy for advanced disease were examined histologically. 4 of 19 patients considered to be free of abdominal disease after chemotherapy showed residual active Hodgkin's disease; the spleen was the commonest site showing active disease. 2 patients thought to have intra-abdominal disease showed no histological evidence of active disease in the tissue excised. The finding of residual active abdominal disease in patients considered to be in "clinical" remission indicates that the interpretation of the result of treatment depends on the definition of response. A proportion of "relapses" may, in fact, be patients who never achieve genuine remission of disease, whereas the prognosis for those who do achieve complete remission may be even better than currently accepted, and may even amount to "cure". This study shows that histological changes of lymphoreticular tissue can be defined after treatment and may help in determining more accurately the need for further therapy.