PELVIC RELAPSE FOLLOWING SUBTOTAL LYMPHOID IRRADIATION IN EARLY-STAGEHODGKINS-DISEASE - AN ANALYSIS OF RISK, MANAGEMENT, AND OUTCOME

Purpose: To evaluate the time of onset, method of identification, mana gement, and outcome of pelvic relapse following subtotal lymphoid irra diation (STLI) alone (mantle and paraaortic/spleen or splenic pedicle fields, excluding the pelvis) in supradiaphragmatic Stage I-II Hodgkin 's disease. Methods and Materials: A retrospective analysis was perfor med of the initial, relapse, and regular followup evaluations of patie nts with pelvic relapse following STLI alone from 1968 to the present for supradiaphragmatic Stage I-II Hodgkin's disease after pathologic s taging (PS-laparotomy staging) and clinical staging (CS-no laparotomy staging). Results: Following staging, which included bipedal lymphangi ography, 482 patients (408 PS and 74 CS), were treated with STLI alone for supradiaphragmatic Stage I-II Hodgkin's disease. The actuarial fr eedom from relapse at 20 years was 75% in PS patients and 81% in CS pa tients. The actuarial pelvic failure at 20 years was 7% for PS patient s and 3% for CS patients. Of the 29 patients with pelvic relapse, 97% (28 of 29) occurred within 5 years of treatment, including 1 patient w ho progressed during initial treatment. Pelvic relapse was most common ly initially identified by abnormalities involving patient symptoms'(6 2%), physical examination (55%), erythrocyte sedimentation rate (48%), and bipedal lymphangiogram and/or abdominal radiograph (38%). Relapse was limited to previously unirradiated sites in 17 patients (58%). In addition to pelvic lymph node disease, 3 patients (10%) had involveme nt of bone, and 4 patients (14%) had bone marrow involvement. Followin g relapse, all patients were treated with chemotherapy (MOP[P], MOP[P] /ABV[D], ABVD, or PAVe) and 19 of 29 patients received involved field consolidative irradiation. Twenty-one of 29 (72%) remained relapse fre e at the time of last follow-up evaluation, including 15 of 19 (79%) t reated with combined therapy. Eight patients experienced a second rela pse despite salvage therapy, and all eight expired with recurrent Hodg kin's disease. Two patients died of complications related to prior tre atment. Therefore, the actuarial risk of death at 20 years associated with pelvic failure in the entire cohort of 482 patients was 2%. Concl usion: Pelvic relapse occurred in 7% of patients following STLI alone and was effectively diagnosed by regular follow-up, which included a c ombination of patient history, physical examination, and radiographic laboratory evaluation. Seventy-two percent of patients remained relaps e free following salvage treatment, which included chemotherapy, resul ting in an overall survival rate associated with pelvic control of 98% . This approach, therefore, spared the majority of patients the long-t erm risks associated with pelvic irradiation and/or chemotherapy, such as infertility, but maintained an excellent prognosis.