The Radical Radiotherapy of Regionally Localized Hodgkin's Disease

Abstract

Hodgkin's disease has long been a subject of controversy focused variously on its essential nature (neoplasia vs. infection), its site of origin (unifocal vs. multicentric or systemic), its histologic classification, and its optimal treatment (14) . It is therefore ironic that one of the few aspects concerning which there has been rather wide agreement is its prognosis. The concept of Hodgkin's disease as an inexorably fatal condition has taken firm hold, so much so that it is actually defined in one recent textbook on the pathology of lymphoid tumors (21) as a “progressive condition leading inevitably to death.” If one were to accept such a definition at its face value, the advent of a curative form of therapy would presumably require a change in the diagnosis! This hopeless attitude, which seems philosophically linked to the view that the disease makes its first appearance in multicentric or disseminated foci, is responsible for the fact that the established approach to treatment has been palliative (23), even in the relatively infrequent cases in which the diagnosis can be made while the condition is still apparently localized. When x-irradiation is the first therapeutic modality employed, tumor doses during the first course are conventionally in the range of a few hundred roentgens, and fields are confined to the areas of palpable or roentgenologically demonstrable involvement. Moreover, although roentgen therapy is still generally accepted as the initial treatment of choice in localized cases, the widespread availability of the nitrogen mustards and other alkylating agents, coupled with their acknowledged palliative benefit in the later stages of the disease and the tacit assumption of a hopeless outlook, has led many physicians to employ these cytotoxic agents as the first treatment, even for localized involvement. Yet, the literature is not without serious challenges to this point of view. As early as 1922, the late Swiss radiotherapist, René Gilbert, proceeding from the diametrically opposite point of departure, that Hodgkin's disease was a neoplasm of unicentric origin, began to administer sharply increased tumor doses, which, with the equipment available in his day, were indeed radical. Moreover, he advocated enlargement of fields to cover entire lymph-node chains beyond those clearly involved by the disease. This form of treatment, to which Gilbert gave the name “segmental radiation therapy,” appears to have been notably successful, if one is to judge by the voluminous report of his work which was published in the United States in 1939 (8). Unfortunately, there was then no generally established classification of the extent of disease, and the Jackson-Parker histologic classification (16–18) had been presented only in preliminary form. The concept of a controlled clinical radiotherapeutic trial did not exist in Gilbert's day, and has been fully developed only during the past decade.