The management of stage II Hodgkin's disease with a large mediastinal mass: a prospective program emphasizing irradiation.

Between October 1980 and July 1983, 13 patients with clinical Stage II Hodgkin's disease who had a large mediastinal mass (mediastinal mass ratio, MMR greater than 1/3) were entered into a prospective treatment program emphasizing irradiation. Careful clinical staging, including CT scanning, was completed in order to define precisely the extent of disease in the chest. All patients had a negative lymphogram. The range of MMR was .34 to .56 (median .39). By the time mantle irradiation was completed the MMR ranged from .21 to .35. One patient had such extensive pulmonary parenchymal extension that treatment with combined modality therapy was necessary. Twelve patients underwent laparotomy after adequate reduction of the mediastinal mass size, but only two had subdiaphragmatic disease detected. One patient had disease extension into the lung during mantle irradiation and one patient failed in a rib six months after completion of irradiation. Both have been treated successfully with salvage chemotherapy. All the remaining patients received prophylactic irradiation below the diaphragm and all are doing well with a median follow up of 21 months. The 2 year actuarial freedom from relapse of the entire group of 13 patients is 83%. These early results are very encouraging for this unfavorable group of patients with large mediastinal masses. This may be due to the routine use of CT scans to determine tumor volume and aggressive mantle irradiation, which often includes prophylactic treatment to the lungs. Careful monitoring of tumor response and use of a shrinking field technique has helped to keep complications to a minimum.