The management of stage I--II Hodgkin's disease with irradiation alone or combined modality therapy: the Stanford experience

Abstract

At Stanford University, between 1968 and 1978, 230 patients with pathologic stage I--II Hodgkin's disease were treated on prospective clinical trials with either irradiation alone or irradiation followed by 6 cycles of adjuvant combination chemotherapy. The actuarial survival at 10 yr was 84% for patients in either treatment group. Freedom from relapse at 10 yr was 77% among patients treated with irradiation alone and 84% after treatment with combined modality therapy [p(Gehan) = 0.09]. Freedom from second relapse at 10 yr was 89% and 94%, respectively [p(Gehan) = 0.56]. Several prognostic factors were evaluated in order to identify patients at high risk for relapse or with poor ultimate survival after initial treatment with irradiation alone. Systemic symptoms, histologic subtype, age, and limited extranodal involvement (E-lesions) did not affect the prognosis of patients and failed to identify patients whose survival could be improved by the routine use of combined modality therapy. Patients with large mediastinal masses (mediastinal mass ratio greater than or equal to 1/3) had a significantly poorer freedom from relapse when treated with irradiation alone than when treated initially with combined modality therapy [45% versus 81% at 10 yr, p(Gehan) = 0.03). The 10-yr survival of these patients, however, was not significantly different (84% versus 74%). The implications of these observations on the management of patient with early stage Hodgkin's disease are discussed.

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

“…Multivariate statistical methods have shown that mediastinal involvement is not an independent poor prognostic factor in most series (Cosset et al, 1984;Pillai et al, 1985;Sutcliffe et al, 1984;Tubiana et al, 1985;Horwich et al, 1986). In contrast, Hoppe et al (1982) report mediastinal bulk as a predictor of shorter disease-free survival but this did not account for the inferior outcome for females in our series.…”

“…Factors which predict the length of CR include B symptoms (Cosset et al, 1984;Tubiana et al, 1985;Longo et al, 1986), stage (Haybittle et al, 1985;Sutcliffe et al, 1984;Horwich et al, 1986), histology (Haybittle et al, 1985;Sutcliffe et al, 1984;Specht et al, 1987), number of disease sites (Cosset et al, 1984;Tubiana et al, 1985;Horwich et al, 1986), age (Sutcliffe et al, 1984;Tubiana et al, 1985;Longo et al, 1986), male sex (Tubiana et al, 1985;Specht et al, 1987), erythrocyte sedimentation rate (ESR) (Haybittle et al, 1985;Tubiana et al, 1985), tumour burden (Specht et al, 1987), number of extranodal sites (Longo et al, 1986), the presence of bulky mediastinal disease (Hoppe et al, 1982), time to achieve CR (Longo et al, 1986) and drug dose intensity (Pillai et al, 1985).…”

Staging Laparotomy in the Management of Hodgkin's Disease: Is it Still Necessary?

“…To distinguish these patients from the 60% or more of patients who will have some degree of mediastinal involvement at presentation [5,64], many discriminant functions were developed, but the one used most commonly is the mediastinal-thoracic (MT) Multani, Grossbard 43 ratio, a ratio between the largest transverse diameter of the mediastinal mass and the transverse diameter of the thorax at T5-6 on a standard standing postero-anterior chest radiograph [65]. Those patients with a ratio greater than 0.35, comprising 15%-20% of pathologic early stage patients [63,[65][66][67], have DFS rates ranging from 39%-55%, compared to 72%-92% for patients with smaller or no mediastinal involvement when treated with extended field (mantle and para-aortic fields) radiotherapy alone [38,[64][65][66][67][68][69][70][71][72][73][74][75]. Of note, most relapses in these patients are intrathoracic failures [38,[63][64][65][66][67][68]70].…”

“…Those patients with a ratio greater than 0.35, comprising 15%-20% of pathologic early stage patients [63,[65][66][67], have DFS rates ranging from 39%-55%, compared to 72%-92% for patients with smaller or no mediastinal involvement when treated with extended field (mantle and para-aortic fields) radiotherapy alone [38,[64][65][66][67][68][69][70][71][72][73][74][75]. Of note, most relapses in these patients are intrathoracic failures [38,[63][64][65][66][67][68]70]. The addition of chemotherapy to the initial treatment regimen significantly decreases relapse risk, increasing the DFS rate from 73% to 92%.…”

Stage IA to IIB supradiaphragmatic Hodgkin's disease. Long-Term survival and relapse frequency

“…More recently, a separate group of 19 Stage I to I1 patients with large mediastinal disease received careful clinical staging followed by MOPP chemotherapy if there was no evidence of disease below the diaphragm. Mantle irradiation was given after the chemotherapy in all patients.…”