The risk of second malignant tumors and its consequences for the overall survival of Hodgkin's disease patients and for the choice of their treatmentat presentation: Analysis of a series of 1524 cases consecutively treated at the Florence University Hospital

Purpose: To quantify the incidence of second malignant tumors (SMT) as a wh ole and that of second "solid" tumors (SST) and leukemia (L) in a large ser ies of 1524 Hodgkin's disease (HD) patients (pts) treated at the Florence U niversity Hospital (UFH); to define the clinical and therapeutic features p ossibly related with SMT occurrence; to evaluate the consequences of SMT fo r the overall survival of the series studied and for the choice of the trea tment of HD at presentation. Methods and Materials: From 1960 to 1991, 1524 pts,vith HD, Clinical Stage (CS) I-IV have been treated at the UFH. Overall treatment consisted of radi ation alone (RT, 36%), chemotherapy alone (CHT, 21%), or both (RT + CHT, 43 %). The cumulative probability (CP) of SMT, SST, and L was calculated for t he whole series and for the different clinical and therapeutic subgroups, a nd the results compared with uni- and multivariate analysis ("internal" com parison, IC). Standardized incidence ratios (SIR) for different SMT types ( estimated on the basis of gender, age, period specific incidence rates of t he general population) have been also calculated ("external" comparison, EC ). The impact of the SMT-related mortality on the survival of the entire se ries has been estimated. Results: A 14.9% 20-year CP of SMT was registered, along with a SIR of 2.04 (95% confidence interval [CI]: 1.2-2.5). Both IC and EC showed a statistic ally significant relationship between L incidence and treatment with CHT, a lone or in combination with RT. A significant excess of breast cancers has been observed in RT-treated patients with longer follow-up (SIR, 2.9); an e xcess of other common SST (lung, non-Hodgkin's lymphomas) is evident in pts treated with either RT, RT + CHT, or CHT. The actuarial long-term survival of the series would have been better of about 3%, in absence of the SMT mo rtality possibly due to HD treatment, which is almost equally divided betwe en patients treated with RT alone, CHT alone, and RT + CHT. Conclusions: SMT represent an important late event in HD long-term survivor s. The relationship between L and treatment with CHT seems to be the mast c learly defined. The effect of SMT on the survival of the entire series, alt hough not negligible, does not seem to justify by itself substantial altera tions in the current standards for the treatment of HD at presentation. (C) 2001 Elsevier Science Inc.