title: Definition of bulky disease in early stage Hodgkin lymphoma in computed tomography era: prognostic significance of measurements in the coronal and transverse planes.
abstract: Disease bulk is an important prognostic factor in early stage Hodgkin lymphoma, but its definition is unclear in the computed tomography era. This retrospective analysis investigated the prognostic significance of bulky disease measured in transverse and coronal planes on computed tomography imaging. Early stage Hodgkin lymphoma patients (n=185) treated with chemotherapy with or without radiotherapy from 2000-2010 were included. The longest diameter of the largest lymph node mass was measured in transverse and coronal axes on pre-treatment imaging. The optimal cut off for disease bulk was maximal diameter greater than 7 cm measured in either the transverse or coronal plane. Thirty patients with maximal transverse diameter of 7 cm or under were found to have bulk in coronal axis. The 4-year overall survival was 96.5% (CI: 93.3%, 100%) and 4-year relapse-free survival was 86.8% (CI: 81.9%, 92.1%) for all patients. Relapse-free survival at four years for bulky patients was 80.5% (CI: 73%, 88.9%) compared to 94.4% (CI: 89.1%, 100%) for non-bulky; Cox HR 4.21 (CI: 1.43, 12.38) (P=0.004). In bulky patients, relapse-free survival was not impacted in patients treated with chemoradiotherapy; however, it was significantly lower in patients treated with chemotherapy alone. In an independent validation cohort of 38 patients treated with chemotherapy alone, patients with bulky disease had an inferior relapse-free survival [at 4 years, 71.1% (CI: 52.1%, 97%) vs 94.1% (CI: 83.6%, 100%), Cox HR 5.27 (CI: 0.62, 45.16); P=0.09]. Presence of bulky disease on multidimensional computed tomography imaging is a significant prognostic factor in early stage Hodgkin lymphoma. Coronal reformations may be included for routine Hodgkin lymphoma staging evaluation. In future, our definition of disease bulk may be useful in identifying patients who are most appropriate for chemotherapy alone.
authors.affiliation: Lymphoma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA kumara2@mskcc.org.
authors.forename: Anita
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Department Medical Radiology, University Hospital Zurich, Switzerland.
authors.forename: Irene A
authors.initials: IA
authors.lastname: Burger
authors.affiliation: Biostatistics and Epidemiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: Zhigang
authors.initials: Z
authors.lastname: Zhang
authors.affiliation: Biostatistics and Epidemiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: Esther N
authors.initials: EN
authors.lastname: Drill
authors.affiliation: Lymphoma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: Jocelyn C
authors.initials: JC
authors.lastname: Migliacci
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ng
authors.affiliation: Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
authors.forename: Ann
authors.initials: A
authors.lastname: LaCasce
authors.affiliation: Department of Hematology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Darci
authors.initials: D
authors.lastname: Wall
authors.affiliation: Department of Hematology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Witzig
authors.affiliation: Department of Hematology, Mayo Clinic, Rochester, MN, USA.
authors.forename: Kay
authors.initials: K
authors.lastname: Ristow
authors.affiliation: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: Joachim
authors.initials: J
authors.lastname: Yahalom
authors.affiliation: Lymphoma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: Craig H
authors.initials: CH
authors.lastname: Moskowitz
authors.affiliation: Lymphoma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Zelenetz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002648:Child; D015331:Cohort Studies; D003131:Combined Modality Therapy / Q000379:methods / Q000401:mortality; D018572:Disease-Free Survival; D005260:Female; D006689:Hodgkin Disease / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011878:Radiotherapy; D012189:Retrospective Studies; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult