title: Dose-response relationship of complementary radiotherapy following four cycles of combination chemotherapy in intermediate-stage Hodgkin's disease.
abstract: OBJECTIVE
  To determine the appropriate irradiation dose after four cycles of modern combination chemotherapy in nonbulky involved field (IF/BF) and noninvolved extended-field (EF/IF) sites in patients with intermediate-stage Hodgkin's disease (HD).
  
  
  METHODS
  HD patients in stage I to IIIA with a large mediastinal mass, E stage, or massive spleen involvement were treated with two double cycles of alternating cyclophosphamide, vincristine, procarbazine, and prednisone (COPP) plus doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by EF irradiation in two successive trials (HD1 and HD5). In the HD1 trial (1983 to 1988), 146 patients who responded to chemotherapy were randomized to receive 20 Gy (70 patients) or 40 Gy (76 patients) of EF irradiation in all fields outside bulky disease sites. A cohort of 111 patients who fulfilled the same inclusion criteria in the subsequent trial HD5 (1988 to 1993) were treated with 30 Gy. Bulky disease always received 40 Gy.
  
  
  RESULTS
  Freedom-from-treatment-failure (FFTF) and survival (SV) curves showed no differences between the 20-, 30-, and 40-Gy groups. However, acute toxicities were more frequent in the 40-Gy arm. Analysis of relapse patterns showed that 18 of 26 relapsing patients either failed to respond in initial bulky sites (n = 5) or had an extranodal relapse (n = 9) or both (n = 4). After 5 years, the cumulative risk for relapse in bulky sites is 10%, despite 40 Gy of radiation.
  
  
  CONCLUSIONS
  Our results strongly suggest that there is no relevant radiotherapy dose effect in the range between 20 Gy and 40 Gy in IF/BF and EF/IF after 4 months of modern polychemotherapy in patients with intermediate-stage HD. Relapse patterns indicate that patients destined to relapse need more systemic, rather than local, treatment. Based on our data, we conclude that 20 Gy is sufficient in EF/IF of intermediate-stage HD following four cycles of modern polychemotherapy.
authors.affiliation: German Hodgkin Lymphoma Study Group, Cologne. loeffler@imisc.uni_leipzig.de
authors.forename: M
authors.initials: M
authors.lastname: Loeffler
authors.forename: V
authors.initials: V
authors.lastname: Diehl
authors.forename: M
authors.initials: M
authors.lastname: Pfreundschuh
authors.forename: U
authors.initials: U
authors.lastname: Rühl
authors.forename: D
authors.initials: D
authors.lastname: Hasenclever
authors.forename: H
authors.initials: H
authors.lastname: Nisters-Backes
authors.forename: M
authors.initials: M
authors.lastname: Sieber
authors.forename: H
authors.initials: H
authors.lastname: Tesch
authors.forename: J
authors.initials: J
authors.lastname: Franklin
authors.forename: W
authors.initials: W
authors.lastname: Geilen
authors.forename: H
authors.initials: H
authors.lastname: Bartels
authors.forename: C
authors.initials: C
authors.lastname: Cartoni
authors.forename: G
authors.initials: G
authors.lastname: Dölken
authors.forename: J
authors.initials: J
authors.lastname: Enzian
authors.forename: R
authors.initials: R
authors.lastname: Fuchs
authors.forename: W
authors.initials: W
authors.lastname: Gassmann
authors.forename: H
authors.initials: H
authors.lastname: Gerhartz
authors.forename: U
authors.initials: U
authors.lastname: Hagen-Aukamp
authors.forename: E
authors.initials: E
authors.lastname: Hiller
authors.forename: H
authors.initials: H
authors.lastname: Hinkelbein
authors.forename: W
authors.initials: W
authors.lastname: Hinterberger
authors.forename: H
authors.initials: H
authors.lastname: Kirchner
authors.forename: P
authors.initials: P
authors.lastname: Koch
authors.forename: B
authors.initials: B
authors.lastname: Krüger
authors.forename: E W
authors.initials: EW
authors.lastname: Schwarze
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001761:Bleomycin / Q000008:administration & dosage; D003131:Combined Modality Therapy; D003520:Cyclophosphamide / Q000008:administration & dosage; D003606:Dacarbazine / Q000008:administration & dosage; D004307:Dose-Response Relationship, Radiation; D004317:Doxorubicin / Q000008:administration & dosage; D005260:Female; D006689:Hodgkin Disease / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011241:Prednisone / Q000008:administration & dosage; D011344:Procarbazine / Q000008:administration & dosage; D016016:Proportional Hazards Models; D012008:Recurrence; D016019:Survival Analysis; D016896:Treatment Outcome; D014747:Vinblastine / Q000008:administration & dosage; D014750:Vincristine / Q000008:administration & dosage
chemical_list: D001761:Bleomycin; D011344:Procarbazine; D014750:Vincristine; D014747:Vinblastine; D003606:Dacarbazine; D004317:Doxorubicin; D003520:Cyclophosphamide; D011241:Prednisone