Mantle irradiation alone for selected patients with laparotomy-staged IA to IIA Hodgkin's disease: preliminary results of a prospective trial

ACR Appropriateness Criteria on Hodgkin's lymphoma: favorable prognosis stage I and II

The treatment for favorable-prognosis stage I and II Hodgkin's lymphoma has evolved over the past several years. Studies have attempted to reduce long-term treatment-related side effects, such as second malignancies and cardiac toxicity, through reduced chemotherapy or reduced radiotherapy. Randomized trials have compared radiation therapy alone with combined-modality therapy (chemotherapy followed by involved-field radiotherapy). Recent and ongoing trials have evaluated the optimal regimen and number of cycles of chemotherapy and the optimal radiotherapy dose and field size as part of combined-modality therapy, as well as the elimination of radiation therapy. Combined-modality therapy represents the current standard of care for most patients with favorable-prognosis early-stage Hodgkin's lymphoma. Chemotherapy alone could also be an option for selected patients who are at low risk for relapse and high risk for late effects from radiotherapy. This article reviews recent and ongoing studies on treatment for favorable-prognosis early stage Hodgkin's lymphoma. Representative clinical cases are presented, with treatment recommendations from an expert panel of radiation oncologists and medical oncologists.

Site of relapse after chemotherapy alone for stage I and II Hodgkin's disease

BACKGROUND

Short course chemotherapy followed by radiotherapy is a standard treatment for early Hodgkin's disease. There is yet no consensus regarding the appropriate radiotherapy portal following chemotherapy. A good guide to the adjuvant radiotherapy field is the site of relapse in patients treated with chemotherapy alone.

PATIENTS AND METHODS

From 1980 to 1996, 61 patients with stage I and II supradiaphragmatic Hodgkin's disease were treated with chemotherapy alone at the Royal Marsden Hospital. We undertook a retrospective review and failure analysis to define the pattern of recurrence.

RESULTS

After a median follow-up of 6.5 years, 24 patients had relapsed giving a 5-year relapse rate of 40%. The 5 and 10-year actuarial survival rates were 94 and 89%, respectively with cause-specific survival being 94% at 5 and 10 years. Two-thirds of the relapses were nodal and supradiaphragmatic. Twenty patients (83%) relapsed in the initially involved sites of disease and this was the sole site of recurrence in 11 (45%) of patients. In retrospect, it appeared that at least 12 recurrences could have been prevented by involved field radiotherapy. Review of detailed imaging data (available in 9 out of 11 patients with recurrences in initial sites of disease) showed that the relapses were always in the initially involved nodes.

CONCLUSION

After chemotherapy alone in early stage HD most initial recurrences are nodal. Loco-regional recurrences are in the originally involved nodes. Based on limited data it appears that involved nodal RT is equivalent to involved field radiotherapy and may halve the risk of recurrence.

Radiotherapy alone in the treatment of clinical stage I-IIA, nonbulky, Hodgkin's disease: single-institution experience on 73 patients staged with lymphangiography and laparoscopy

From 1985 to 1998, at the Regional Cancer Center of Padua, patients with Hodgkin's disease (HD) routinely underwent a clinical staging procedure including lymphangiography and laparoscopy with multiple liver and spleen biopsies. Patients with IA and IIA nonbulky HD were treated with radiotherapy alone. The aim of this study is to analyze the efficacy of radiotherapy as radical treatment in this group of patients, and the role of lymphangiography and laparoscopy in the selection of patients with abdominal disease located to the spleen, liver, or the pelvic lymphatic chains. From January 1985 to January 1998, 94 previously untreated patients with biopsy-proven HD underwent clinical staging procedures consisting of history, physical examination, routine laboratory tests, chest radiography, total-body computed tomography scan, and bone marrow biopsy and were considered in stage I-IIA nonbulky. In addition, all patients underwent bipedal lymphangiography, which was positive in 12 (12.8%). Of the 82 patients with negative lymphangiography, 9 (11%) showed disease below the diaphragm at laparoscopy with multiple random spleen and liver biopsies. Of the remaining 73 patients, 32 were male and 41 were female with a median age of 29 years (range: 14-72 years).

Stage I-III Hodgkin's disease: outcome and pattern of failure following treatment with radiation therapy and chemotherapy in a modern era

PURPOSE

To analyse the long term outcome, pattern of failure and treatment related complications after radiation therapy (RT) with or without chemotherapy for stage I-III Hodgkin's disease (HD).

MATERIAL AND METHODS

Detailed records from 86 patients with stage I-III HD treated between 1989 and 1998, were retrospectively reviewed. Seventeen patients with favourable stage I-IIA were treated with RT alone, and the remaining 69 patients with combined modality treatment (CMT). Patients treated with RT received extended-field or subtotal nodal irradiation (STNI) to a total dose of 36-54 Gy, and patients with CMT, received involved-field irradiation to a lower doses, 26-40 Gy. The median follow-up time was 50 months (range 16-180).

RESULTS

The 10-year overall survival (OS) for the whole group was 96% (SE 2%), 100% for stage I, 95% for stage II and 100% for stage III patients. Of potential prognostic factors analysed for statistical significance, only the response to chemotherapy (p=0.0393) was found to influence significantly OS rates. Twelve patients (13.9%) relapsed. Salvage treatment was effective in 10 of the 12 relapsed patients. The 10-year freedom from treatment failure (FFTF) was 79% (SE 6%). Although 8 (9.6%) of the 83 surviving patients developed late effects that could represent toxicity from the treatment, no patient died of late complications.

CONCLUSIONS

RT alone for favourable early stage HD attains good survival rates with a modest treatment related morbidity. For patients with unfavourable stage II and stage III HD, CMT with limited RT provides a good to excellent prognosis.

Mantle irradiation alone for pathologic stage I and II Hodgkin's disease: long-term follow-up and patterns of failure

PURPOSE

We performed a retrospective study to determine the long-term outcome, patterns of failure, and prognostic factors for patients with pathologic Stage I or II Hodgkin's disease (HD) who were treated with mantle irradiation alone.

METHODS AND MATERIALS

The medical records of 145 patients with pathologic Stage I or II supradiaphragmatic Hodgkin's disease treated with mantle irradiation alone between June 1967 and June 1991 were reviewed. Patterns of failure, overall survival (OS) rate, and progression-free survival (PFS) rate were determined. Univariate and multivariate analyses were performed to identify adverse prognostic factors for OS and PFS. The number of adverse prognostic factors per patient was counted, and a prognostic score was assigned to each patient. The log-rank test was used to compare the OS or PFS rates among patients with prognostic scores 0, 1, and 2.

RESULTS

The median patient age was 27 years (range 10-66), with almost even male to female distribution. Every patient had splenectomy and negative laparotomy (LAP). Fifty-one patients had Stage I disease (IA-49, IB-2) and 94 Stage II (IIA-89, IIB-5). The histologic subtypes were nodular sclerosing in 110, mixed cellularity in 28, lymphocyte predominance in 5, lymphocyte depleted in 1, and unclassified in 1. Twelve patients with Stage II disease had >/= 3 sites of nodal involvement. Fifty-four patients had a prognostic score of 0, 70 of 1, and 21 of 2. The median follow-up time for the 109 surviving patients was 146 months (range 25-381). The 10- and 20-year actuarial OS rates for the whole group were 87.6% and 65.3%, respectively. The corresponding actuarial PFS rates were 75.3% and 74.2%, respectively. Thirty-six patients (9 Stage I, 27 Stage II) had relapses in a total of 41 sites. Failures by histology were 29 patients with nodular sclerosing, 6 with mixed cellularity, and 1 with lymphocyte predominance. Failures by sites were: trans-diaphragmatic, 22 (para-aortic nodes, 15; as the only site of progression in 12; visceral, 7; as the only site of progression in 5); within radiation field, 8; marginal miss, 8 (as the only site of failure in 2); and unknown, 3. The majority of the failures occurred within 5 years of diagnosis. Long-term side effects of radiation included cardiac complications in 30 patients, with 10- and 20-year actuarial cardiac complication rates of 12.6% and 35.1%, respectively; secondary solid tumors in 14, with 10- and 20-year actuarial rates of 2.3% and 25.7%, respectively; leukemia in 4; non- Hodgkin's lymphoma in 4, with the 10- and 20-year actuarial rates for leukemia and non-Hodgkin's lymphoma of 4.0% and 13.9%; and hypothyroidism in 38. Four adverse prognostic factors were identified for PFS: age > or = 40 years, > or = 3 sites of involvement, male sex, and constitutional symptoms. The prognostic score correlated with patients' outcome as indicated by PFS and OS rates. Patients with a prognostic score of 0 did significantly better than those with a score of 1 or 2.

CONCLUSION

In this select group of patients with pathologic Stage I and II Hodgkin's disease treated with mantle irradiation alone, the OS and PFS rates at 10 and 20 years were comparable to those reported in the literature. The major pattern of disease progression was relapse below the diaphragm, therefore close surveillance of the abdomen is warranted. The prognostic score used in our series may predict the patient's outcome, and might be worth testing in a prospective trial. In our series, patients with a prognostic score of 0 had excellent long-term survival, indicating adequate treatment with mantle irradiation alone. Late complications of the treatment pose a significant threat for the patient's survival with long-term follow-up.

Results of a prospective trial of mantle irradiation alone for selected patients with early-stage Hodgkin's disease

PURPOSE

To determine the efficacy of mantle radiation therapy alone in selected patients with early-stage Hodgkin's disease.

PATIENTS AND METHODS

Between October 1988 and June 2000, 87 selected patients with pathologic stage (PS) IA to IIA or clinical stage (CS) IA Hodgkin's disease were entered onto a single-arm prospective trial of treatment with mantle irradiation alone. Eighty-three of 87 patients had > or = 1 year of follow-up after completion of mantle irradiation and were included for analysis in this study. Thirty-seven patients had PS IA, 40 had PS IIA, and six had CS IA disease. Histologic distribution was as follows: nodular sclerosis (n = 64), lymphocyte predominant (n = 15), mixed cellularity (n = 3), and unclassified (n = 1). Median follow-up time was 61 months.

RESULTS

The 5-year actuarial rates of freedom from treatment failure (FFTF) and overall survival were 86% and 100%, respectively. Eleven of 83 patients relapsed at a median time of 27 months. Nine of the 11 relapses contained at least a component below the diaphragm. All 11 patients who developed recurrent disease were alive without evidence of Hodgkin's disease at the time of last follow-up. The 5-year FFTF in the 43 stage I patients was 92% compared with 78% in the 40 stage II patients (P =.04). Significant differences in FFTF were not seen by histology (P =.26) or by European Organization for Research and Treatment of Cancer H-5F eligibility (P =.25).

CONCLUSION

Mantle irradiation alone in selected patients with early-stage Hodgkin's disease is associated with disease control rates comparable to those seen with extended field irradiation. The FFTF is especially favorable among stage I patients.

Treatment of nonlaparotomized (clinical) stage I and II Hodgkin's disease patients by extended field and splenic irradiation

PURPOSE

At the New York Presbyterian Hospital-Cornell Medical Center, patients with unequivocal clinical stage I and IIA Hodgkin's disease (HD) have been treated with mantle, splenic, and extended field radiation therapy (EFRT) (without surgical staging). A 24-year retrospective review was conducted to determine the effectiveness of our patient selection on the outcome of patients treated with this modality.

METHODS AND MATERIALS

During the period 1971 to 1994, 94 patients with clinically staged HD, with favorable prognostic factors, were retrospectively reviewed. Patients with pathological or equivocal staging, "B" symptoms, bulk disease, history of previous chemotherapy, and/or Stage III or IV disease were excluded from our analysis. There were 27 Stage IA and 67 Stage IIA patients. All patients were treated to 3600 cGy with a 400 cGy boost to the involved field. The median follow-up was 52 months, mean of 62.1 months.

RESULTS

Ten of 94 patients (10.5%) relapsed. Seven of the relapses were in the pelvis, one submandibularily, one in the tonsil, and one in the axilla. Nine of the relapses had nodular sclerosis histology, one had lymphocyte predominance, and none had mixed cellularity. The median time to relapse was 38 months; mean time 42. 3 months. All patients are alive, well and free of disease, including nine who received subsequent chemotherapy and one who underwent autotransplantation.

CONCLUSIONS

Careful clinical staging of early, asymptomatic HD patients treated with mantle, splenic, and EFRT may obviate the need for exploratory laparotomy.

Mantle irradiation alone for clinical stage I-II Hodgkin's disease: long-term follow-up and analysis of prognostic factors in 261 patients

PURPOSE

To evaluate mantle radiotherapy (MRT) alone as the initial therapy of patients with clinical stage (CS) I-II Hodgkin's disease (HD).

PATIENTS AND METHODS

We performed a retrospective study of patients treated with MRT alone for CS I-II supradiaphragmatic HD between 1969 and 1994. Prognostic factor analysis was performed for progression-free survival (PFS) and overall survival (OS). Outcome was also assessed in favorable cohorts defined in the literature.

RESULTS

There were 261 eligible patients. The median follow-up period for surviving patients was 8.4 years (range, 1.8 to 27.4 years). The 10-year OS rate was 73%. Multifactor analysis for OS showed that age was the only important prognostic factor. The 10-year PFS rate was 58%. On multifactor analysis for PFS, the most important prognostic factors were clinical stage, B symptoms, histology, number of sites, and tumor bulk. The 10-year PFS rate for lymphocyte-predominant disease was 81% for stage I and 78% for stage II. In favorable patient cohorts defined in the literature, the 10-year PFS rate ranged from 70% to 73% for the whole group and from 71% to 90% in patients with favorable stage I disease, but only from 48% to 57% in patients with favorable stage II disease. On competing-risks analysis, the cumulative 10-year incidence of first site of failure in the para-aortic/splenic region alone was 10.5%. Sixty percent of relapsed patients remain progression-free at 10 years after chemotherapy salvage.

CONCLUSION

These results support the use of MRT alone in patients with favorable CS I HD and CS I-II HD with lymphocyte-predominant histology. The remainder of patients with CS I-II HD require more intensive treatment.

Long-term outcome of treatment for Ann Arbor stage 1 Hodgkin's disease: patterns of failure, late toxicity and second malignancies

PURPOSE

Radiation therapy results in excellent short-term survival in patients with early-stage Hodgkin's disease. However, the optimal therapeutic scheme that achieves the highest disease-free survival with the minimum long-term toxicity is yet to be determined. An analysis of the patterns of failure and late complications after radiation therapy was conducted to address this question.

METHODS AND MATERIALS

A retrospective study was conducted of 145 patients with Stage I Hodgkin's disease treated at M. D. Anderson Cancer Center from 1967 through 1987. Follow-up extended from a minimum of 30 to 339 months, with a median period of observation of 16.5 years. All the patients were treated with radiation therapy and, and 16 received combination MOPP-based chemotherapy as part of their initial treatment. The radiotherapy technique, was involved/regional in 71 (49%), extended in 62 (43%), and subtotal nodal irradiation in 12 patients. The median total dose was 40 Gy.

RESULTS

The actuarial freedom from progression at 10 and 20 years was 76% and 69%, respectively. Forty of 145 patients relapsed (27.6%). The site of primary disease was cervical adenopathy in 30 (75%), axillary in 7 (17.5%), mediastinal in 2 patients and subdiaphragmatic in one patient. Twenty-two patients were treated with involved/regional technique (55%), 17 with extended (42.5%), and 1 with subtotal nodal irradiation technique. There were three in field and four marginal recurrences. Six relapses occurred in non-irradiated nodal regions at the same side of the diaphragm and 17 in non-irradiated transdiaphragmatic lymph nodes (57.5%). Nine patients (22.5%) relapsed with visceral disease. Nineteen patients (47.5%) relapsed within the first 2 years, 15 (37.5%) 3 to 10 years after diagnosis and the remaining 6 (15%) after 10 years. Eleven of 40 patients died of disease after the first or subsequent relapses (27.5%). Three of six patients with late relapses had progression in viscera but only two died with disease. Thirty-eight of 145 patients developed late toxicity from the treatment (26.2%). Twenty-three patients experienced ischemic heart disease (15.9%), only 13 of whom received mediastinal irradiation (9%). Fifteen patients developed secondary malignant solid tumors (10.3%). Nine of those (6.2%) occurred within the irradiation field (two were also treated with chemotherapy). Two additional patients, one of whom received chemotherapy as part of the initial treatment, died of acute myelogenous leukemia. Non-Hodgkin's lymphoma and lung cancer were the most common second malignancies.

CONCLUSIONS

Limited field radiotherapy results in a significant number of relapses in non-irradiated, especially transdiaphragmatic lymph nodes. Subtotal nodal irradiation can prevent some relapses and therefore improve freedom from progression. Careful design of the treatment fields may decrease the risk of morbidity and mortality from coronary artery disease and second malignancies in early-stage Hodgkin's disease. Careful long-term surveillance may permit early detection and management of late relapses and treatment complications.

Long-term outcome of treatment for Ann Arbor Stage I Hodgkin's disease: prognostic factors for survival and freedom from progression

PURPOSE

The earliest stages of Hodgkin's disease are associated with excellent short-term survival with radiation therapy. This has led to controversies regarding pretreatment evaluation, the extent of irradiation, the role of chemotherapy, and the relative importance of prognostic factors. Long-term results were sought to address these controversies.

METHODS AND MATERIALS

A retrospective study was conducted of patients with Stage I Hodgkin's disease treated at the M. D. Anderson Cancer Center from 1967 through 1987. The median age at presentation of 145 patients was 31 years, and the male-to-female ratio was 1.8. Pretreatment evaluation included lymphangiography and bone marrow aspiration and biopsy in all patients. Laparotomy was performed in 101 of the 145 patients (70%). There were 133 patients with supradiaphragmatic presentations; 12 patients had infradiaphragmatic adenopathy. Only five patients had B symptoms (3.5%). Histologic subtypes of the disease included lymphocyte predominance 17.9%, nodular sclerosis 40.7%, mixed cellularity 40.7%, and one unclassified Hodgkin's disease with primary splenic involvement. All patients were treated with radiotherapy, and 16 (11%) also received combination chemotherapy as part of their initial treatment. Radiotherapy techniques included involved/regional field in 49%, extended field in 42.7% (mantle or inverted Y), and subtotal nodal irradiation in 8.3%. Follow-up extended from a minimum of 30-339 months, with a median period of observation of 16.5 years.

RESULTS

The median survival was 13.7 years. The 10- and 20-year survival rates were 83% and 66%, respectively. The only factor important for decreased survival was age >40 years at diagnosis (p < 0.0001). Out of 43 deaths, 11 were the result of Hodgkin's disease and the remaining 32 resulted from intercurrent disease, including treatment-related causes. Median freedom from progression was 10.5 years, and the 10- and 20-year freedom from progression were 76% and 69%, respectively. Out of 39 relapses, 5 (13%) occurred beyond 10 years. Women had higher freedom from progression (p = 0.0534) than men. Age, histology, bulk of disease, site of involvement including the mediastinal presentations, and the addition of chemotherapy did not influence the freedom of progression. Although very few patients (12 of 145) received subtotal nodal irradiation, the freedom from progression at 10 years was 91.7% for this group versus 64.7% for the group of patients who were treated with more limited techniques.

CONCLUSION

Treatment with radiation therapy for patients with Stage I Hodgkin's disease leads to an excellent outcome, but patients require long-term surveillance as late relapses are not rare. Age is the only factor that affects survival, and gender marginally affects freedom from progression. Subtotal nodal irradiation may improve freedom from progression; further investigation of this treatment is justified.

Management of early stage Hodgkin's disease: the role of radiation therapy and/or chemotherapy

The treatment of early stage HD has become more complicated over the past 10 years. The development of standards for both radiation therapy and chemotherapy have made it more feasible to treat HD in community practice settings. Yet initial treatment decisions may have profound long-term effects on patients who are young and likely to have a long survival. Whenever possible, routine cases should be treated along guidelines of standard accepted practice, and physicians should refer patients to major centres for the management of more complicated cases. There is hope that less toxic chemotherapy will be effective in curing occult microscopic disease, perhaps eventually obviating the need for staging laparotomy and splenectomy. Yet for now, there are little long-term data defining specifics of treatment, or the long-term efficacy or toxicity of modified regimens. Thus at present, the management of patients with HD in ways that do not adhere to standard practice, such as modifying standard RT or chemotherapy, should be strongly discouraged outside controlled clinical trials. In parts of the USA there is still a general acceptance of staging laparotomy and splenectomy as a means to aggressively stage patients in order to minimize treatment. By utilizing diagnostic laparotomy and splenectomy, the majority of patients with PS IA-IIA HD will be cured with RT alone thus sparing them the toxicity of combined chemotherapy and RT, and preserving the effectiveness of chemotherapy in case of relapse. Using this approach, patients who are likely to need chemotherapy due to a high risk of relapse (LMA, or extensive B symptoms), or high risk for having abdominal involvement (more than one positive abdominal radiographical test) should not undergo a staging laparotomy. In addition, chemotherapy and limited field irradiation may be preferred under special circumstances (i.e. for paediatric patients). Diagnostic staging laparotomy and splenectomy is not routinely performed outside the continental USA. Academic centres in Canada, Europe and South America have identified prognostic factors to aid in determining treatment for clinically staged patients. Patients with the most favourable characteristics receive RT alone with CMT used for the remainder of patients. On average, without the information obtained at staging laparotomy, patients require more treatment, either with larger radiation fields, or with the more frequent use of chemotherapy.

Management of early stage Hodgkin's disease: the role of radiation therapy and/or chemotherapy

Clinical trials in early stage Hodgkin's disease comparing radiation therapy (RT) alone versus chemotherapy (CMT) have indicated fewer relapses in the CMT groups. However, none of the trials have demonstrated an overall survival difference. Risk factors for relapse in early stages include large mediastinal adenopathy, fevers, and weight loss. Ongoing clinical trials might prove less toxic CMT effective in curing occult microscopic disease, perhaps eventually obviating the need for staging laparotomy and splenectomy.