- Email: [email protected]
Reply to the editorial by Dr. Lee and Dr. Levitt
Int. J. Radiation Oncology Biol. Phys., Vol. 30, No. 4. p. 1007. 1994 Coovriaht 0 1994 Elsevier Science Ltd P&ted in the USA. All rights reserved
Pergamon
0360-30 16194 $6.00 + .OO
0360-3016(94)00504-4
??Correspondence
REPLY
TO THE EDITORIAL BY DR. LEE AND DR. LEVITT
dose chemotherapy was administered to patients relapsed after extensive radiotherapy. We obviously agree with Dr. Lee and Dr. Levitt that more patients and a longer observation are required before drawing firm conclusions on this different treatment modality.
To he Editor: With pathological staging (PS) and extended field radiotherapy (EFRT) followed in relapsing patients by salvage chemotherapy, overall survival in earlystage Hodgkin’s disease is over 90% and it is difficult to think to substantially improve these results. However, this treatment modal ,ty requires an invasive diagnostic procedure, such as staging laparotomy, which is associated with some acute and long-term, morbidity, and delays the beginning of treatment by 23 weeks. Moreover, even surgical staging does not permit us to prevent pelvic recurrences that represent 40-50% of relapses, as reported by Lee and Levitt in their editorial (2). On the other hand, pelvic recurrences alone occur in only 4-10% of patients treated with EFRT. In our opinion, extending the fields of radiotherapy to the pelvis (total nodal irradiation), as suggested by Mendenhall et 01. (4) based on the results of a retrospective nonrandomized study, could only slightly improve the relapse-free survival, while exposing patients to sterility and bone marrow myelosuppression. With these preliminary remarks, the option of a combined treatment including short-term chemotherapy, without alkylating agents, and limited radiotherapy, possibly reduced in doses and extension, seems to us worthy of careful evaluation. Since 1990, we have started a mndomized trial comparing four cycles of ABVD followed by subtotal nodal irradiation vs. involved field radiotherapy (1). With a median follow-up of 24 months, in 73 evaluable patients, overall survival and disease-free survival are 100% in both groups, So far, no severe toxic sequelae were observed, as reported when full-
M. ZANINI, M.D. Division of Radiation Therapy lstituto Nazionale Tumori Via Venezian, I 20133 Milano, Italy 1. Bonfante, V.; Santoro, A.; Viviani, S.; Devizzi, L.; Zanini, M.; Soncini, F.: Gasparini, M.; Valagussa, P.; Bonadonna, G. ABVD plus Radiotherapy (subtotal nodal vs. involved field) in early-stage Hodgkin’s disease (HD). Proc. Am. Sot. Clin. Oncol. 13:373(Abstr. 1262); 1994. 2. Lee, C. K. K.; Levitt, S. H. Curative radiotherapy is the best single treatment modality for the favorable early stage Hodgkin’s disease. Int. J. Rad. One. Bio. Phys. 3O:IOO5-XXXX; 1994. 3. Mauch, P.; Somers, R. Controversies in the use of diagnostic staging laparotomy and splenectomy in the management of Hodgkin’s disease. Ann. One. 3(Suppl. 4): S4l-S43; 1992. 4. Mendenhall, P. N.; Taylor, B. W.; Marcus, R. B.; Million, R. R. The impact of pelvic recurrence and elective pelvic irradiation on survival and treatment morbidity in early-stage Hodgkin’s disease. Int. J. Rad. One. Bio. Phys. 21:1157-l 165; 1991. 5. Valagussa, P. Second neoplasms following treatment of Hodgkin’s Disease. Curr. Opin. Oncol. 5:805-L? I I; 1993.
1007
Pergamon
0360-30 16194 $6.00 + .OO
0360-3016(94)00504-4
??Correspondence
REPLY
TO THE EDITORIAL BY DR. LEE AND DR. LEVITT
dose chemotherapy was administered to patients relapsed after extensive radiotherapy. We obviously agree with Dr. Lee and Dr. Levitt that more patients and a longer observation are required before drawing firm conclusions on this different treatment modality.
To he Editor: With pathological staging (PS) and extended field radiotherapy (EFRT) followed in relapsing patients by salvage chemotherapy, overall survival in earlystage Hodgkin’s disease is over 90% and it is difficult to think to substantially improve these results. However, this treatment modal ,ty requires an invasive diagnostic procedure, such as staging laparotomy, which is associated with some acute and long-term, morbidity, and delays the beginning of treatment by 23 weeks. Moreover, even surgical staging does not permit us to prevent pelvic recurrences that represent 40-50% of relapses, as reported by Lee and Levitt in their editorial (2). On the other hand, pelvic recurrences alone occur in only 4-10% of patients treated with EFRT. In our opinion, extending the fields of radiotherapy to the pelvis (total nodal irradiation), as suggested by Mendenhall et 01. (4) based on the results of a retrospective nonrandomized study, could only slightly improve the relapse-free survival, while exposing patients to sterility and bone marrow myelosuppression. With these preliminary remarks, the option of a combined treatment including short-term chemotherapy, without alkylating agents, and limited radiotherapy, possibly reduced in doses and extension, seems to us worthy of careful evaluation. Since 1990, we have started a mndomized trial comparing four cycles of ABVD followed by subtotal nodal irradiation vs. involved field radiotherapy (1). With a median follow-up of 24 months, in 73 evaluable patients, overall survival and disease-free survival are 100% in both groups, So far, no severe toxic sequelae were observed, as reported when full-
M. ZANINI, M.D. Division of Radiation Therapy lstituto Nazionale Tumori Via Venezian, I 20133 Milano, Italy 1. Bonfante, V.; Santoro, A.; Viviani, S.; Devizzi, L.; Zanini, M.; Soncini, F.: Gasparini, M.; Valagussa, P.; Bonadonna, G. ABVD plus Radiotherapy (subtotal nodal vs. involved field) in early-stage Hodgkin’s disease (HD). Proc. Am. Sot. Clin. Oncol. 13:373(Abstr. 1262); 1994. 2. Lee, C. K. K.; Levitt, S. H. Curative radiotherapy is the best single treatment modality for the favorable early stage Hodgkin’s disease. Int. J. Rad. One. Bio. Phys. 3O:IOO5-XXXX; 1994. 3. Mauch, P.; Somers, R. Controversies in the use of diagnostic staging laparotomy and splenectomy in the management of Hodgkin’s disease. Ann. One. 3(Suppl. 4): S4l-S43; 1992. 4. Mendenhall, P. N.; Taylor, B. W.; Marcus, R. B.; Million, R. R. The impact of pelvic recurrence and elective pelvic irradiation on survival and treatment morbidity in early-stage Hodgkin’s disease. Int. J. Rad. One. Bio. Phys. 21:1157-l 165; 1991. 5. Valagussa, P. Second neoplasms following treatment of Hodgkin’s Disease. Curr. Opin. Oncol. 5:805-L? I I; 1993.
1007