137 Stage I and II follicular lymphoma: Longterm outcome and pattern of failure following treatment with involved field radiation therapy alone

Proceedings

136 Kim Joint

HK,

HODGKIN’S TREATMENT Silver

Center,for

DISEASE IN THE STRATEGIES

B, Mauch

P

Radiation

Therapy,

Harvard

of the 41st Annual

ELDERLY

Medical

ASTRO

PATIENTS

School,

Meeting

(60 OR OLDER):

Boston,

MA,

217

CLINICAL

OUTCOME

AND

USA

Purpose: Older age is a major adverse prognostic factor for survival for patients with Hodgkin’s disease. Data suggests that patients 40-60 years old, when treated similarly to younger patients, have a higher mortality both from Hodgkin’s disease and from treatment related causes. In addition, patients over age 60 may not tolerate the aggressive diagnostic and treatment approaches used for younger patients further compromising their outcome. This study assesses the outcome of elderly patients (60 or older) with Hodgkin’s disease treated with radical intent, in attempt to provide optimal treatment strategies for this group of patients. Materials and Methods: Eighty-six patients, 60 to 93 years of age at the time of diagnosis, were treated for Hodgkin’s disease with radical intent between 1969 and 1995. Patients who had been previously treated for Hodgkin’s disease or who were treated with palliative intent were excluded from the analysis. All patients underwent radiographic staging of the chest, abdomen and pelvis and seventeen patients underwent staging laparotomy. Histologic subtypes included 29 patients with nodular sclerosis histology, 33 patients with mixed cellularity histology, and 16 patients with lymphocyte predominance or lymphocyte depletion histology. Eight patients did not have subclassification of their Hodgkin’s disease. Fifty-one patients had early stage disease (stage IAIIA) and 35 patients had stage III-IV Hodgkin’s disease. Stage IA-IIA patients were treated with radical radiation therapy alone (RT) (37), chemotherapy alone (CT) (9) or combined chemotherapy and radiotherapy (CMT) (5). Treatment for stage II&IV patients included RT alone (6), CT alone (19), or CMT (10). Of patients treated with CT or CMT, 10 received single agent CT; the remainder multiagent CT. Median follow-up time was 42.5 months for all patients and 74.5 months for surviving patients. Results: The 5-year and lo-year freedom from recurrence for all patients was 52% and 48%, respectively. The 5year freedom from recurrence for patients with stage IA-IIA and stage IIB-IV disease was 58% and 43%, respectively (p=O.14). The 5-year and lo-year survival rates (all causes) for all patients were 48% and 30%, respectively. The 5-year survival rates for patients with stage IA-IIA and stage IIB-IV disease were 56% and 36%, respectively (p=NS). Of 63 patients who died, 28 died of Hodgkin’s disease, 11 of second malignancies, 7 or cardio-pulmonary causes, 6 of infections, 2 of CVA’s and 9 of miscellaneous causes. We analyzed the outcome of patients who developed a first recurrence after initial treatment. Five-year survival was only 20% following recurrence of Hodgkin’s disease. Five-year survival by stage and initial treatment after recurrence was 40% for stage IA-IIA patients initially treated with RT, 25% for stage IA-IIA patients initially treated with CT or CMT, and 5% for stage IIB-IV patients initially treated with CT or CMT. Conclusion: This is one of the largest single institution studies of patients 60 or older treated radically for Hodgkin’s disease. Although the extent of disease, staging, and the type of treatment varied considerably, all patients received aggressive CT and/or RT. Although more patients succumbed from non-Hodgkin’s disease causes than Hodgkin’s disease, recurrence of Hodgkin’s disease had a significant impact on survivals the median survival following recurrence was less than one year and only 20% were alive at 5-years. Thus, we favor the use of CMT in early stage patients over the age of 60 to minimize the risk of relapse. Moditications in the number of cycles of chemotherapy and in the radiation field size may allow for control of the Hodgkin’s disease while minimizing the treatment risks. To what extent the CMT can be limited will depend on the results of ongoing clinical trials in younger patients,

137

STAGE FAILURE

Gospodarowica Princess

Margaret

I AND II FOLLICULAR LYMPHOMA: FOLLOWING TREATMENT WITH MK’,‘,

Lippuner

Hospital,

Tt,‘,

Toronto,

Pintilie

Ml,‘,

ON, Canada’;

Patterson University

LONGTERM INVOLVED B’.*,

Bezjak

qf Toronto,

Introduction: Localized follicular lymphoma has an indolent course purpose of this review is to assess the ability of involved field radiation disease control and failure-free survival.

OUTCOME AND FIELD RADIATION A’,‘,

Tsang

Toronto,

RW’,‘,

PATTERN THERAPY Wells

OF ALONE

W’.’

ON, Canada’

with prolonged median therapy (RT) to control

survival disease

of lo-20 years. The in terms of both local

Methods: We analyzed the records of 596 adult patients (pts) with stage I and II follicular lymphoma treated at the Princess Margaret Hospital between 1967 and 1996. Median age was 58.9 yrs (range 17-86 yrs), with median follow-up duration 10.3 yrs (range 0.7-28.3 yrs). The clinical anatomic extent of disease was: stage IA - 379 pts, stage IIA 199 pts, IB 4 pts and IIB - 14 pts. Histology was: follicular small cell (FSC) in 197 pts, follicular mixed (FM) in 189 pts, and follicular large cell (FLC) lymphoma in 210 pts. The majority presented with nodal disease (462 pts, 77.5%), while the remaining 134 pts (22.5%) presented with disease in extranodal sites. Most patients (71%) were treated with involved field RT alone to a median dose of 35 Gy. Results: The median overall survival (OS) and median disease-free survival (DFS) were 15.3 yrs and 6.8 yrs respectively. At the time of analysis, 336 pts were alive and 152 died of lymphoma. In the RT alone cohort OS and DFS were 15.7 yrs and 6.6 yrs respectively. Local control was excellent, and 93% of all relapses occurred in sites outside of radiation fields, RT dose of 30-35 Gy was sufficient to achieve local disease control. Adverse prognostic factors for relapse identified in univariate analysis included age > 50 yrs, FLC histology (cytologic grade III), pre-treatment tumor bulk > 2 cm. and extensive stage IL4 disease (more than 2 contiguous disease sites or non-contiguous disease). In a multivariable analysis, the following 3 factors predicted for high risk of relapse and poorer cause-specific survival (CSS): age (> 50 yrs), pre-treatment tumor bulk (> 2 cm), and extensive clinical stage IIA disease. Time to relapse following RT alone was predictive for long term survival: the median CSS for patients who relapsed early (5 2 years from diagnosis) was 6.1 yrs, while it was 13.5 yrs for those who relapsed more than 2 yrs from diagnosis. Conclusions: Younger patients with small bulk (< 2 cm) disease, stage IA or localized IIA, and follicular lymphoma grade I and II: are at a lower risk for relapse or death of lymphoma. No significant survival differences were observed between the three grades of follicular lymphoma, i.e., follicular small cleaved, follicular mixed and follicular large cell lymphoma. Involved field radiation therapy provides long-term clinical disease control in stage I and II follicular lymphomas in over 40% of pts.