Abstract: Disease bulk is an important prognostic factor in early stage Hodgkin lymphoma, but its definition is unclear in the computed tomography-era. This retrospective analysis investigated the prognostic significance of bulky disease measured in transverse and coronal planes on computed tomography imaging. Early stage Hodgkin lymphoma patients (n=185) treated with chemotherapy with or without radiotherapy from 2000-2010 were included. The longest diameter of the largest lymph node mass was measured in transverse and coronal axes on pre-treatment imaging. The optimal cutoff for disease bulk was maximal diameter greater than 7 cm measured in either the transverse or coronal plane. Thirty patients with maximal transverse diameter ≤7 cm were found to have bulk in coronal axis. The 4-year overall survival was 96.5% (CI 93.3%, 100%) and 4-year relapse-free survival was 86.8% (CI 81.9%, 92.1%) for all patients. Relapse free survival at 4-years for bulky patients was 80.5% (CI 73%, 88.9%) compared to 94.4% (CI 89.1%, 100%) for non-bulky, Cox HR 4.21 (CI 1.43, 12.38), P = 0.004. In bulky patients, relapse free survival was not impacted in patients treated with chemoradiotherapy; however, was significantly inferior in patients treated with chemotherapy alone. In an independent validation cohort of 38 patients treated with chemotherapy alone, patients with bulky disease had an inferior relapse-free survival (at 4-years, 71.1% (CI 52.1%, 97%) versus 94.1% (CI 83.6%, 100%), Cox HR 5.27 (CI 0.62, 45.16), P = 0.09). Presence of bulky disease on multidimensional computed tomography imaging is a significant prognostic factor in early stage Hodgkin lymphoma. Coronal reformations may be included for routine Hodgkin lymphoma staging evaluation. In future, our definition of disease bulk may have utility in identifying patients who are most appropriate for chemotherapy-alone.
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