The prognostic significance of large mediastinal masses in the treatment of Hodgkin's disease. The experience of the institut gustave‐roussy

Abstract

At the Institut Gustave‐Roussy we undertook a study of 154 patients with clinical stages I and II Hodgkin's disease treated by irradiation to evaluate the prognostic significance of the mediastinal mass size. The population under study included those patients treated at our institute and entered into the H₂ and H₅ E.O.R.T.C. trials between 1972 and 1981. Patients were divided into three groups for purposes of analysis; large mediastinal masses (MT ratio ≥ 0·35) were noted in 20 cases (13 per cent), moderate mediastinal invasion (MT ratio < 0·35) was observed in 60 cases (39 per cent), and 74 patients (48 per cent) had no mediastinal involvement on presentation. Intrathoracic relapses were more frequent in those patients with mediastinal involvement at presentation (p < 0·001) but there was no statistically significant difference between those patients with ‘large’ masses and patients with ‘small’ masses. Additionally multivariate analyses showed that neither the presence nor the size of mediastinal disease adversely affected relapse free survival or overall survival. These results can perhaps be linked to the technique of radiotherapy where a ‘split course’ technique was habitually used for large masses and the radiation fields were routinely modified during treatment according to the tumour response. Consequently we do not advocate the routine use of extensive primary treatment such as combined modality therapy utilizing MOPP chemotherapy for all patients presenting with bulky mediastinal masses. Rather chemotherapy should be reserved for those tumours which are particularly voluminous (MT ratio > 0·50) where primary radiotherapy may potentially result in unsatisfactory late pulmonary complications. We also advise the use of combined modality therapy for those patients who may additionally have certain unfavourable prognostic factors which we have previously identified.