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Changing patterns of relapse in Hodgkin's disease
ABSTRACTS RADIOTHERAPY
AND
ONCOLOGY
685
PSEUDOLYMPHOMA - A PSEUDODIAGNOSIS
P. PRICE, J. M. HENK, E. M. BESSELL, R. A. F. WHITELOCKE and J. E. WRIGHT* CHANGING PATTERNS OF RELAPSE IN HODGKIN'S DISEASE
G. DUCHESNE, J. CROW, M. B R A D A and A. HORWICH
Royal Marsden Hospital, Sutton, Surrey A study of 419 patients with Stage I and II Hodgkin's disease was undertaken to determine the incidence and timing of relapse with changing management policies. Between 1964 and 1969, 91 patients were treated with radiotherapy (RT) and 13 had additional chemotherapy (CMT). In 1970-1974 80/138 patients had staging laparotomies (PS), 122 patients had RT and 16 patients CMT. In 19751980 108/126 patients had PS and 46/126 received CMT. Recognising adverse prognostic factors, 28/51 patients in 1981-1983 received CMT without PS, while 14 PS and nine CS patients received RT alone. Early relapses (ER, <3 years) fell over the study period (1964-1969 42.3%, 1981-1983 8.8%) but late relapses (LR, >3 years) stayed constant (8.3+3.4%). The risk of LR corrected for length of follow-up increased from 1:57.8 person-years at risk (PYAR) in 1964-1969 to 1:20.1 PYAR in 1981-1983. Patients receiving RT alone were at greater risk of LR than those receiving CMT (log-rank analysis, X2=7.8, P<0.01) and particularly PS RT patients (X~=8.42, P<0.01). Other factors predicting for LR were age >60 (P<0.05), and absence of B symptoms (P<0.05). The increasing risk of LR has implications for the.long-term follow-up of these patients.
The Royal Marsden Hospital and *Moorfields Eye Hospital, London One hundred and thirty-three patients with primary orbital or conjunctival lymphoma were treated at the Royal Marsden Hospital between 1970 and 1987. Twenty-two were classified histologically as high grade lymphoma and 47 as low grade lymphoma. The larger group (64) consisted histologically mainly of mature lymphocytes with no definite histological features of neoplasia and were termed 'indeterminate lymphocytic lesions' (ILL). The term 'pseudolymphoma' is often applied to the group; similar lesions occur in the gut, lung and skin. All tumours were locally controlled by radiotherapy. Results of staging, survival rates and sites of dissemination will be presented. The natural history ot tumours classified as low grade lymphoma and ILL were similar. It was not possible to identify on clinical, histological or immunocytochemical grounds a group of tumours which had no potential for dissemination. We consider that so called pseudolymphoma presents the earliest stage of a neoplastic process and the term should be discarded. UPPER LIMB MORBIDITY AFTER LOCAL THERAPY FOR EARLY BREAST CANCER
A. RODGER, W. J. JACK, M. N. G A Z E , R. J. AITKEN and U. CHETTY
Western General Hospital and Royal Infirmary, Edinburgh HODGKIN'S DISEASE - A H O N G KONG EXPERIENCE
P. CHOX, R. LIANG, D. CHOY and D. TODD
Queen Mary Hospital, Hong Kong Ninety-three patients with histologically proven Hodgkin's disease (HD) were seen between 1963 and 1987. There were 54 males and 39 females. The median age was 37 years (range 7-75). Stage of disease was I in 18, II in 24, III in 18 and IV in 33. Nine patients had LP, 10 LD, 33 NS, 29 MC and 12 unclassified HD; 40 patients had B symptoms. Twenty-five patients had laparotomy and splenectomy. Thirty-four patients received radiotherapy (RT) only, 39 patients received chemotherapy (CT) only and 20 received combined CT and RT. Sixty-five patients (69%) achieved complete remission (CR) with first line therapy, 24 (37%) eventually relapsed. Seven patients attained a second remission but six of these relapsed. The median duration of second remission was 19 months (range 7-163 months). Eight patients were eventually lost to follow-up. The relapse free survival (RFS) of CR patients at 5 years was 73% for stage IA, 93% for IIA, 27% for IIB, 54% for IIIA, 44% for IVA and 51% for IVB. The overall survival of all patients at 5 years was 90% for stage IA, 100% IIA, 46% for IIB, 57% for IIIA, 0% for IIIB, 56% for IVA and 50% for IBV. Only one patient had stage IB disease, surviving only 2 months. The RFS of the IIIB patients did not reach 5 years and their 2 years DFS was 60%. The relapse free and overall survival rates according to histology were LP 86% 100%, LD 0% 41%, NS 70% 68%, MC 39% 64% respectively.
COMPUTED T O M O G R A P H Y IN THE DIAGNOSIS AND MANAGEMENT OF PRIMARY ORBITAL L Y M P H O M A
P. MILLS and C. A. PARSONS
The Royal Marsden Hospital, London Primary orbital lymphoma is a rare form of extranodal lymphoma and accounts for 1% of all orbital tumours. A proportion of patients subsequently develop systemic lymphoma. The prognosis depends on the histology and the stage of disease. Five-year survival varies between over 90% for patients with low grade lymphoma and Stage I disease, and 45% for patients with high grade lymphoma and more advanced disease (Bessell et al. in press). We have studied 18 patients presenting with lymphoma in the orbit. The CT appearances of orbital lymphoma will be presented together with the results of other radiological staging investigations. Factors affecting the development of disseminated lymphoma will also be discussed. REFERENCE
Bessel, EM, Henk, JM, Wright, JE & Whitelock, RAF (1988). Orbital and conjunctival lymphoma: treatment and prognosis. Radiotherapy and Onocology. (in press).
The local management of early breast cancer is highly variable in extent of surgery and in the indications for postoperative X-ray therapy. Local therapy seldom affects survival but may have a major impact on both local control and local morbidity. The Departments of Clinical Oncology and Surgery in Edinburgh analysed, from patients treated both electively and within randomised trials, the effects of variations of axillary management on arm morbidity. Wherever possible, morbidity assessments have been both objective and subjective. It has not been the policy to prescribe radiotherapy to the axillary area after axillary clearance. We have shown that after mastectomy, shoulder joint mobility is significantly reduced if axillary treatment is by axillary sample and radiotherapy compared with axillary clearance or sample alone. Arm oedema and power are not different. A separate retrospective analysis of late post-radiation changes in mastectomised patients has shown that subcutaneous fibrosis and upper limb oedema are related to radiation fraction dose with significantly worse changes in patients receiving tractions of 4 Gy compared with fractions of 2 Gy. In patients undergoing breast conserving therapy including radiotherapy to the axillary area a lower axillary dissection (level I and II) produces significantly more severe and more persistent arm oedema (and a significantly higher incidence of temporary breast oedema), than axillary sampling (level I). A randomised trial of axillary sampling plus X-ray therapy versus clearance in breast conservation patients is underway. Objective measurement of upper limb treatment-related morbidity in breast cancer patients is as essential as analysis of local control in determining optimal and minimal therapy. BREAST CONSERVATION IN E D I N B U R G H 1981-1985: A REVIEW
A. R O D G E R , W. J. JACK, and U. CHETTY*
Western General Hospital and *Longmore Hospital, Edinburgh Between 1981 and 1985, 218 patients underwent breast conserving treatment for early breast cancer with local excision and radiotherapy (the latter supervised by the first author). The local relapse rate in breast is 3.6% and in regional nodes 4.2%. To date, age remains the most significant prognostic factor with highest risk of locoregional recurrence seen in those less than 40 years of age (10%) compared with those 40 or over (5.9%). Histological parameters are being reviewed. Generally, when histological margins were considered positive, re-excision was recommended. Of 44 patients with positive margins, 24 accepted re-excision, but only four (16.7%) showed residual tumour in the re-excision specimen, two of whom later recurred, one in breast, one in nodes, i.e. 1 in 24 (4.1%) re-excised patients recurred in breast. In 194 who did not undergo re-excision, six (3.1%) recurred in breast, but none of these were in the 20 patients with positive margins not undergoing re-excision. Cosmesis deteriorated with time but remained acceptable or excellent in over 80% of patients. The indications for safe breast conservation and the place of re-excision will be discussed.
AND
ONCOLOGY
685
PSEUDOLYMPHOMA - A PSEUDODIAGNOSIS
P. PRICE, J. M. HENK, E. M. BESSELL, R. A. F. WHITELOCKE and J. E. WRIGHT* CHANGING PATTERNS OF RELAPSE IN HODGKIN'S DISEASE
G. DUCHESNE, J. CROW, M. B R A D A and A. HORWICH
Royal Marsden Hospital, Sutton, Surrey A study of 419 patients with Stage I and II Hodgkin's disease was undertaken to determine the incidence and timing of relapse with changing management policies. Between 1964 and 1969, 91 patients were treated with radiotherapy (RT) and 13 had additional chemotherapy (CMT). In 1970-1974 80/138 patients had staging laparotomies (PS), 122 patients had RT and 16 patients CMT. In 19751980 108/126 patients had PS and 46/126 received CMT. Recognising adverse prognostic factors, 28/51 patients in 1981-1983 received CMT without PS, while 14 PS and nine CS patients received RT alone. Early relapses (ER, <3 years) fell over the study period (1964-1969 42.3%, 1981-1983 8.8%) but late relapses (LR, >3 years) stayed constant (8.3+3.4%). The risk of LR corrected for length of follow-up increased from 1:57.8 person-years at risk (PYAR) in 1964-1969 to 1:20.1 PYAR in 1981-1983. Patients receiving RT alone were at greater risk of LR than those receiving CMT (log-rank analysis, X2=7.8, P<0.01) and particularly PS RT patients (X~=8.42, P<0.01). Other factors predicting for LR were age >60 (P<0.05), and absence of B symptoms (P<0.05). The increasing risk of LR has implications for the.long-term follow-up of these patients.
The Royal Marsden Hospital and *Moorfields Eye Hospital, London One hundred and thirty-three patients with primary orbital or conjunctival lymphoma were treated at the Royal Marsden Hospital between 1970 and 1987. Twenty-two were classified histologically as high grade lymphoma and 47 as low grade lymphoma. The larger group (64) consisted histologically mainly of mature lymphocytes with no definite histological features of neoplasia and were termed 'indeterminate lymphocytic lesions' (ILL). The term 'pseudolymphoma' is often applied to the group; similar lesions occur in the gut, lung and skin. All tumours were locally controlled by radiotherapy. Results of staging, survival rates and sites of dissemination will be presented. The natural history ot tumours classified as low grade lymphoma and ILL were similar. It was not possible to identify on clinical, histological or immunocytochemical grounds a group of tumours which had no potential for dissemination. We consider that so called pseudolymphoma presents the earliest stage of a neoplastic process and the term should be discarded. UPPER LIMB MORBIDITY AFTER LOCAL THERAPY FOR EARLY BREAST CANCER
A. RODGER, W. J. JACK, M. N. G A Z E , R. J. AITKEN and U. CHETTY
Western General Hospital and Royal Infirmary, Edinburgh HODGKIN'S DISEASE - A H O N G KONG EXPERIENCE
P. CHOX, R. LIANG, D. CHOY and D. TODD
Queen Mary Hospital, Hong Kong Ninety-three patients with histologically proven Hodgkin's disease (HD) were seen between 1963 and 1987. There were 54 males and 39 females. The median age was 37 years (range 7-75). Stage of disease was I in 18, II in 24, III in 18 and IV in 33. Nine patients had LP, 10 LD, 33 NS, 29 MC and 12 unclassified HD; 40 patients had B symptoms. Twenty-five patients had laparotomy and splenectomy. Thirty-four patients received radiotherapy (RT) only, 39 patients received chemotherapy (CT) only and 20 received combined CT and RT. Sixty-five patients (69%) achieved complete remission (CR) with first line therapy, 24 (37%) eventually relapsed. Seven patients attained a second remission but six of these relapsed. The median duration of second remission was 19 months (range 7-163 months). Eight patients were eventually lost to follow-up. The relapse free survival (RFS) of CR patients at 5 years was 73% for stage IA, 93% for IIA, 27% for IIB, 54% for IIIA, 44% for IVA and 51% for IVB. The overall survival of all patients at 5 years was 90% for stage IA, 100% IIA, 46% for IIB, 57% for IIIA, 0% for IIIB, 56% for IVA and 50% for IBV. Only one patient had stage IB disease, surviving only 2 months. The RFS of the IIIB patients did not reach 5 years and their 2 years DFS was 60%. The relapse free and overall survival rates according to histology were LP 86% 100%, LD 0% 41%, NS 70% 68%, MC 39% 64% respectively.
COMPUTED T O M O G R A P H Y IN THE DIAGNOSIS AND MANAGEMENT OF PRIMARY ORBITAL L Y M P H O M A
P. MILLS and C. A. PARSONS
The Royal Marsden Hospital, London Primary orbital lymphoma is a rare form of extranodal lymphoma and accounts for 1% of all orbital tumours. A proportion of patients subsequently develop systemic lymphoma. The prognosis depends on the histology and the stage of disease. Five-year survival varies between over 90% for patients with low grade lymphoma and Stage I disease, and 45% for patients with high grade lymphoma and more advanced disease (Bessell et al. in press). We have studied 18 patients presenting with lymphoma in the orbit. The CT appearances of orbital lymphoma will be presented together with the results of other radiological staging investigations. Factors affecting the development of disseminated lymphoma will also be discussed. REFERENCE
Bessel, EM, Henk, JM, Wright, JE & Whitelock, RAF (1988). Orbital and conjunctival lymphoma: treatment and prognosis. Radiotherapy and Onocology. (in press).
The local management of early breast cancer is highly variable in extent of surgery and in the indications for postoperative X-ray therapy. Local therapy seldom affects survival but may have a major impact on both local control and local morbidity. The Departments of Clinical Oncology and Surgery in Edinburgh analysed, from patients treated both electively and within randomised trials, the effects of variations of axillary management on arm morbidity. Wherever possible, morbidity assessments have been both objective and subjective. It has not been the policy to prescribe radiotherapy to the axillary area after axillary clearance. We have shown that after mastectomy, shoulder joint mobility is significantly reduced if axillary treatment is by axillary sample and radiotherapy compared with axillary clearance or sample alone. Arm oedema and power are not different. A separate retrospective analysis of late post-radiation changes in mastectomised patients has shown that subcutaneous fibrosis and upper limb oedema are related to radiation fraction dose with significantly worse changes in patients receiving tractions of 4 Gy compared with fractions of 2 Gy. In patients undergoing breast conserving therapy including radiotherapy to the axillary area a lower axillary dissection (level I and II) produces significantly more severe and more persistent arm oedema (and a significantly higher incidence of temporary breast oedema), than axillary sampling (level I). A randomised trial of axillary sampling plus X-ray therapy versus clearance in breast conservation patients is underway. Objective measurement of upper limb treatment-related morbidity in breast cancer patients is as essential as analysis of local control in determining optimal and minimal therapy. BREAST CONSERVATION IN E D I N B U R G H 1981-1985: A REVIEW
A. R O D G E R , W. J. JACK, and U. CHETTY*
Western General Hospital and *Longmore Hospital, Edinburgh Between 1981 and 1985, 218 patients underwent breast conserving treatment for early breast cancer with local excision and radiotherapy (the latter supervised by the first author). The local relapse rate in breast is 3.6% and in regional nodes 4.2%. To date, age remains the most significant prognostic factor with highest risk of locoregional recurrence seen in those less than 40 years of age (10%) compared with those 40 or over (5.9%). Histological parameters are being reviewed. Generally, when histological margins were considered positive, re-excision was recommended. Of 44 patients with positive margins, 24 accepted re-excision, but only four (16.7%) showed residual tumour in the re-excision specimen, two of whom later recurred, one in breast, one in nodes, i.e. 1 in 24 (4.1%) re-excised patients recurred in breast. In 194 who did not undergo re-excision, six (3.1%) recurred in breast, but none of these were in the 20 patients with positive margins not undergoing re-excision. Cosmesis deteriorated with time but remained acceptable or excellent in over 80% of patients. The indications for safe breast conservation and the place of re-excision will be discussed.