1~. f. Radiarion Oncology Bid Phys.. Vol. 18, p. 493 Printed in 1heU.S.A. Allrights reserved.
0360-3016/90 $3.00 +.OO Copyright0 1990Pergamon Press plc
??Correspondence
RESPONSE TO “DILEMMAS
AND DECISIONS”
7’0 the Editor: Carefully designed prospective studies are important in clinical trials. However, there are no prospective or randomized trials to evaluate the role of whole lung irradiation (WLI) in Hodgkin’s disease. The only studies which address the possible benefit of WLI are retrospective studies and thus, Leviu’s warning regarding potential bias applies to all the studies mentioned. The Stanford study (1) demonstrated no decrease in the pulmonary relapse rate in patients who received WLI. They conclude however, that whole lung irradiation is of benefit since patients treated with WLI were felt to be at higher risk of pulmonary relapse. Despite their conclusion, no direct benefit was demonstrated. Dr. Levitt’s papers have de:monstrated an improvement in overall survival of Stage I-III patients receiving WLI. Their radiotherapy technique and diagnostic evaluation have improved in these sequential, nonrandomized retrospective studies and these refinements could account for their improvement in disease-free survival and could be unrelated to the use of WLI. Our retrospective study selected patients for WLI because of presumed increase risk due to large mediastinal disease and/or hilar involvement (5). However, it is the largest single institution study attempting to address the potential benefit of prophylactic whole lung irradiation in a selected group. Our data do not support a benefit. There are a number of inaccuracies in Levitt’s editorial (4) which also deserve comment:
2. Our treatment indications are explained. The indications for whole lung irradiation were large mediastinal disease and/or hilar involvement (5). 3. Our standard fraction size of 150 cGy/day was based on the original Stanford data demonstrating that the risk of pneumonitis was increased with large fraction sizes (greater than 200 &y/day) (1). Only one patient in the early 1970’swas treated with 200 cGy/day fractionation. Although this fraction size is larger than that given with the thin lung block technique, our pneumonitis rate is nearly identical to that reported by Stanford: 3% and 41, respectively (3, 5). The risk of pneumonitis in a large group of patients treated with WLI and/or MOPP chemotherapy has not been reported by Stanford since the use of the thin lung block technique. However, Castellino (2) did report an increase in the occurrence of pneumonitis in association with the use of Prednisone in MOPP. 4. Our risk of second neoplasms will be reported separately. Since the risk appears related primarily to the use of radiation, the risk of lung cancer will not be reduced with the use of whole lung irradiation. 5. The use of WLI is an empiric technique based on theoretical considerations and retrospective clinical observations. The potential benefit of WLI in selected patients has not been clearly demonstrated. NANCY J. TARBELL, M.D. PETERMAUCH, M.D.
Joint Center for Radiation Therapy Harvard Medical School 50 Binney Street Boston, MA 02 I I5
1. We have never previously reported our Stage IA-IIIB results using WLI.
REFERENCES 1. Carmel, R. J. and Kaplan, H. J. Mantle irradiation in Hodgkin’s disease. An analysis of technique, tumor eradication and complications. Cancer 37:28 13-2825; 1976. 2. Castellino, R. A.; Glatstem, E; Turbow, M; Rosenberg, J; Kaplan, H. J. Patent radiation injury of lungs or heart activated by steriod withdrawal. Ann Int Med 80:593-599. 3. Kaplan, H. S. Complication of radiation therapy: respiratory system.
Hodgkin’s Disease, Cambridge, MA: Harvard University Press; Cambridge, MA, 1980: 421-427. 4. Levitt, S. H.; Lee, C. K. K. Dilemmas and Decisions. Int J Radiat Oncol Biol Phys 18:485-488; 1990. 5. Tarbell, N. J.; Thompson, L.; Mauch, P. Thoracic irradiation in Hodgkin’s disease: Disease control and long-term complications. Int J Radiat Oncol Biol Phys l&275-281; 1990.
0360-3016/90 $3.00 +.OO Copyright0 1990Pergamon Press plc
??Correspondence
RESPONSE TO “DILEMMAS
AND DECISIONS”
7’0 the Editor: Carefully designed prospective studies are important in clinical trials. However, there are no prospective or randomized trials to evaluate the role of whole lung irradiation (WLI) in Hodgkin’s disease. The only studies which address the possible benefit of WLI are retrospective studies and thus, Leviu’s warning regarding potential bias applies to all the studies mentioned. The Stanford study (1) demonstrated no decrease in the pulmonary relapse rate in patients who received WLI. They conclude however, that whole lung irradiation is of benefit since patients treated with WLI were felt to be at higher risk of pulmonary relapse. Despite their conclusion, no direct benefit was demonstrated. Dr. Levitt’s papers have de:monstrated an improvement in overall survival of Stage I-III patients receiving WLI. Their radiotherapy technique and diagnostic evaluation have improved in these sequential, nonrandomized retrospective studies and these refinements could account for their improvement in disease-free survival and could be unrelated to the use of WLI. Our retrospective study selected patients for WLI because of presumed increase risk due to large mediastinal disease and/or hilar involvement (5). However, it is the largest single institution study attempting to address the potential benefit of prophylactic whole lung irradiation in a selected group. Our data do not support a benefit. There are a number of inaccuracies in Levitt’s editorial (4) which also deserve comment:
2. Our treatment indications are explained. The indications for whole lung irradiation were large mediastinal disease and/or hilar involvement (5). 3. Our standard fraction size of 150 cGy/day was based on the original Stanford data demonstrating that the risk of pneumonitis was increased with large fraction sizes (greater than 200 &y/day) (1). Only one patient in the early 1970’swas treated with 200 cGy/day fractionation. Although this fraction size is larger than that given with the thin lung block technique, our pneumonitis rate is nearly identical to that reported by Stanford: 3% and 41, respectively (3, 5). The risk of pneumonitis in a large group of patients treated with WLI and/or MOPP chemotherapy has not been reported by Stanford since the use of the thin lung block technique. However, Castellino (2) did report an increase in the occurrence of pneumonitis in association with the use of Prednisone in MOPP. 4. Our risk of second neoplasms will be reported separately. Since the risk appears related primarily to the use of radiation, the risk of lung cancer will not be reduced with the use of whole lung irradiation. 5. The use of WLI is an empiric technique based on theoretical considerations and retrospective clinical observations. The potential benefit of WLI in selected patients has not been clearly demonstrated. NANCY J. TARBELL, M.D. PETERMAUCH, M.D.
Joint Center for Radiation Therapy Harvard Medical School 50 Binney Street Boston, MA 02 I I5
1. We have never previously reported our Stage IA-IIIB results using WLI.
REFERENCES 1. Carmel, R. J. and Kaplan, H. J. Mantle irradiation in Hodgkin’s disease. An analysis of technique, tumor eradication and complications. Cancer 37:28 13-2825; 1976. 2. Castellino, R. A.; Glatstem, E; Turbow, M; Rosenberg, J; Kaplan, H. J. Patent radiation injury of lungs or heart activated by steriod withdrawal. Ann Int Med 80:593-599. 3. Kaplan, H. S. Complication of radiation therapy: respiratory system.
Hodgkin’s Disease, Cambridge, MA: Harvard University Press; Cambridge, MA, 1980: 421-427. 4. Levitt, S. H.; Lee, C. K. K. Dilemmas and Decisions. Int J Radiat Oncol Biol Phys 18:485-488; 1990. 5. Tarbell, N. J.; Thompson, L.; Mauch, P. Thoracic irradiation in Hodgkin’s disease: Disease control and long-term complications. Int J Radiat Oncol Biol Phys l&275-281; 1990.
