title: Patterns of failure following high-dose chemotherapy and autologous bone marrow transplantation with involved field radiotherapy for relapsed/refractory Hodgkin's disease.
abstract: OBJECTIVE
  To evaluate the patterns of failure and outcome of patients undergoing high-dose chemotherapy and autologous bone marrow transplantation for relapsed/refractory Hodgkin's disease with emphasis on the impact of involved-field radiotherapy.
  
  
  METHODS
  Fifty-four adult patients with refractory (25) or relapsed (29) Hodgkin's disease underwent high-dose chemotherapy with either autologous bone marrow (32) or peripheral stem cell (23) transplantation. Twenty patients received involved-field radiotherapy either prior to (7) or following (13) high-dose chemotherapy. Patients treated prior to the high-dose chemotherapy received radiation to bulky or symptomatic sites, and those treated following the transplantation were treated to sites of disease persistence (10) or to consolidate a complete response (3). Twenty-six patients had purely nodal disease, 10 had lung involvement, 7 liver, 5 bone, and 3 bone marrow. A total of 147 sites were present prior to high-dose chemotherapy. Nineteen were bulky (> or = 5 cm), and 42 arose in a previous radiotherapy field.
  
  
  RESULTS
  Twenty-five of the 54 patients (46.3%) relapsed. Seventeen (68.0%) relapsed in sites of disease present prior to high-dose chemotherapy. Patients treated with involved-field radiotherapy had a lower rate of relapse in sites of prior disease involvement (26.3 vs. 42.8%) (p < 0.05) than those not treated with radiotherapy. Twenty-one patients had disease persistence following high-dose chemotherapy, of which 10 received involved-field radiotherapy and were converted to a complete response. Patients with disease persistence who received involved-field radiotherapy had a better progression-free survival (40.0 vs. 12.1%) (p = 0.04) than those who did not. Moreover, the patients converted to a complete response had similar progression-free and cause-specific survival as those patients achieving a complete response with high-dose chemotherapy alone. Of the initial 147 sites, 142 (97.3%) were amenable to involved-field radiation therapy. The addition of involved-field radiotherapy improved the 5-year local control of all sites (p = 0.008), nodal sites (p = 0.01), and sites of disease persistence (p = 0.0009).
  
  
  CONCLUSIONS
  Patients with relapsed/refractory Hodgkin's disease undergoing high-dose chemotherapy and autologous bone marrow rescue have a high rate of relapse in sites of prior disease involvement. Involved-field radiotherapy is capable of improving the control of these sites, the majority of which are amenable to radiotherapy. In addition, the use of radiotherapy to sites of disease persistence following high-dose chemotherapy may improve the outcome of these patients.
authors.affiliation: Department of Radiation and Cellular Oncology, Michael Reese/University of Chicago Center for Radiation Therapy, IL 60637, USA.
authors.forename: A J
authors.initials: AJ
authors.lastname: Mundt
authors.forename: G
authors.initials: G
authors.lastname: Sibley
authors.forename: S
authors.initials: S
authors.lastname: Williams
authors.forename: D
authors.initials: D
authors.lastname: Hallahan
authors.forename: J
authors.initials: J
authors.lastname: Nautiyal
authors.forename: R R
authors.initials: RR
authors.lastname: Weichselbaum
mesh_terms: D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D016026:Bone Marrow Transplantation; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006689:Hodgkin Disease / Q000188:drug therapy / Q000532:radiotherapy / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011879:Radiotherapy Dosage; D012008:Recurrence; D012074:Remission Induction; D017211:Treatment Failure