International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationRelapse Analysis of Irradiated Patients Within the HD15 Trial of the German Hodgkin Study Group
Introduction
The combination of multiagent chemotherapy (CTX) and radiation therapy (RT) has improved survival rates of patients with Hodgkin lymphoma (HL), and the combined-modality approach has become the standard of care for patients in early favorable and early unfavorable stages 1, 2, 3. Today HL is one of the most favorable cancers in terms of cure. The role of consolidative RT after intense CTX for patients in advanced stages is discussed controversially. Results of randomized trials challenged the benefit of adjuvant RT 4, 5, 6, 7, 8, 9, and therefore the European Organization for Research and Treatment of Cancer (EORTC) conducted a trial to determine the role of consolidative RT after CTX. The data of this analysis showed no improvement in outcome when adding consolidative involved-field RT (IF-RT) for patients in complete remission after CTX (10). However, patients in partial remission treated with IF-RT had the same outcome as patients in complete remission (10).
In addition, the German Hodgkin Study Group (GHSG) HD12 trial for patients in advanced stages also evaluated the value of consolidative local RT to initial bulky regions and/or sites of residual disease after BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) CTX. The final analysis of the HD12 trial demonstrated that patients with residual disease show improved progression-free survival (PFS) due to consolidative RT (11).
The following GHSG HD15 trial for advanced HL investigated the value of fluorodeoxyglucose positron emission tomography (FDG-PET) for treatment stratification in patients with advanced stages. After completion of CTX, all patients with residual disease of ≥2.5 cm underwent PET, and those with PET-positive results were irradiated with 30 Gy local RT to the site of residual disease; for bone lesions RT was also recommended (12).
The aim of the present analysis was to determine whether relapses occur in the irradiated planning target volume (PTV) and whether the definition of local RT used by the GHSG is adequate, because there is no harmonization of field and volume definitions among the large cooperative groups in the treatment of advanced-stage HL. In addition, we analyzed the correlation between quality of RT and risk of relapse.
Section snippets
Study design
The HD15 trial (recruitment 2003-2008) was an open, multicenter, randomized trial. Included were patients with de novo HL in advanced stages (ie, Ann Arbor stage IIB having a large mediastinal mass [one-third or more of the maximal thoracic diameter] or extra nodal lesions, and all patients in stages III and IV). Patients were randomly assigned to receive either 8 cycles BEACOPP escalated (Besc), or 6 cycles Besc, or 8 cycles BEACOPP14 (B14). After completion of CTX patients were restaged, and
HD15 trial
A total of 2126 patients were eligible in the final analysis. Five-year freedom from treatment failure was 84.4% for the 8×Besc group, 89.3% for the 6×Besc group, and 85.4% for the B14 group. Overall survival in the 3 groups was 91.9%, 95.3%, and 94.5%, respectively, and significantly better in the 6×Besc group compared with the 8×Besc group. The 8×Besc group showed a higher mortality.
After CTX, 822 patients with residual disease were evaluated using FDG-PET. Of those, 739 patients were
Discussion
The aim of the present analysis was to evaluate whether relapses occur in the irradiated sites and whether the definition of local RT used by the GHSG is adequate, because the international study groups are using different RT strategies in the treatment of patients with advanced-stage HL. In addition we analysed the correlation between quality of RT and patterns of relapse.
This study produced the following results: (1) Local RT with 30 Gy to PET-positive residuals after 6 cycles BEACOPP
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Conflict of interest: none.