Reappraisal of the role of radiation therapy in lymphoma treatment

Risk of Cardiovascular Disease in Patients With Classical Hodgkin Lymphoma: A Danish Nationwide Register-Based Cohort Study

Risk of cardiovascular disease (CVD) in patients with classical Hodgkin lymphoma (cHL) undergoing contemporary treatment is unclear. cHL patients ≥ 18 years at diagnosis treated with doxorubicin-containing chemotherapy between 2000 and 2022 were matched 1:5 with comparators on birth year, sex, and Charlson Comorbidity Index at time of matching (score of 0 or ≥ 1). Cause-specific cumulative incidence of a composite of CVDs with corresponding 95% confidence intervals (CIs) were computed with death and lymphoma relapse as competing events (i.e., by censoring individuals at such occurrences) using the Aalen-Johansen estimator. A total of 1905 patients and 9525 comparators with a median follow-up of 10 years (interquartile range, [IQR]: 5.9-17.4). Median age was 39 years (IQR: 27-56), median cumulative doxorubicin dose was 250 mg/m2 (IQR: 200-300). The CVD cumulative incidences were 4.7% (95% CI: 3.6-5.7) for patients versus 2.6% (95% CI: 2.3-2.9) for comparators at 5 years, 8.9% (95% CI: 7.2-10.5) versus 5.5% (95% CI: 4.9-6.0) at 10 years, and 17.0% (95% CI: 14.1-19.9) versus 8.2% (95% CI: 7.4-9.0) at 15 years. CVD remains a substantial effect after contemporary treatment for cHL, suggesting that awareness of symptoms and a low threshold for referral to diagnostic examination are still important measures during survivorship.

Role of Radiotherapy in the Management of Elderly Patients With Lymphoma

Lymphoma in elderly patients has unique treatment challenges due to baseline co-morbidities, nutrition status, impairment in functional capacities and fitness. While geriatric-specific assessment can be used to tailor treatment decisions, lack of adequate representation of elderly patients in lymphoma clinical trials impairs generalizability. Radiation treatment has traditionally been associated with high response and local control for lymphomas. The volume and dose of radiation in lymphomas has gradually decreased over the decades, which has led to improved compliance and lower toxicities. The use of radiation in Hodgkin and aggressive B-cell non-Hodgkin lymphomas has allowed for reduction in the number systemic therapy cycles, which is important in elderly patients who may be at high risk for treatment-related adverse events. Current strategies include a risk-adapted approach with minimal chemo-immunotherapy followed by radiation treatment, with dose adapted by response. Here, we provide a review of the literature regarding the role of radiation in the management of elderly patients with lymphoma, especially in follicular lymphoma, diffuse large cell lymphoma and Hodgkin lymphoma.

Ulcerating skin lesions from blastic plasmacytoid dendritic cell neoplasm responding to low-dose radiotherapy-a case report and literature review

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematologic malignancy that can manifest with skin nodules and erythematous plaques. In most cases BPDCN progresses rapidly, causing multiple skin lesions and also affecting internal organs and bone marrow, warranting initiation of systemic therapies or hematopoietic stem cell transplantation (HCT). Although not curative, radiotherapy for isolated lesions might be indicated in case of (imminent) ulceration and large or symptomatic lesions. To this end, doses of 27.0-51.0 Gy have been reported. Here, we present the case of an 80-year-old male with BPDCN with multiple large, nodular, and ulcerating lesions of the thorax, abdomen, and face. Low-dose radiotherapy of 2 × 4.0 Gy was administered to several lesions, which resolved completely within 1 week with only light residual hyperpigmentation of the skin in affected areas and reliably prevented further ulceration. Radiotoxicity was not reported. Therefore, low-dose radiotherapy can be an effective and low-key treatment in selected cases of BPDCN, especially in a palliative setting, with a favorable toxicity profile.

Bone Marrow Biopsies: Is CT, Fluoroscopy, or no Imaging Guidance the Most Cost-Effective Strategy?

RATIONALE AND OBJECTIVES

To determine the most cost-effective strategy for pelvic bone marrow biopsies.

MATERIALS AND METHODS

A decision analytic model from the health care system perspective for patients with high clinical concern for multiple myeloma (MM) was used to evaluate the incremental cost-effectiveness of three bone marrow core biopsy techniques: computed tomography (CT) guided, and fluoroscopy guided, no-imaging (landmark-based). Model input data on utilities, costs, and probabilities were obtained from comprehensive literature review and expert opinion. Costs were estimated in 2023 U.S. dollars. Primary effectiveness outcome was quality adjusted life years (QALY). Willingness to pay threshold was $100,000 per QALY gained.

RESULTS

No-imaging based biopsy was the most cost-effective strategy as it had the highest net monetary benefit ($4218) and lowest overall cost ($92.17). Fluoroscopy guided was excluded secondary to extended dominance. CT guided biopsies were less preferred as it had an incremental cost-effectiveness ratio ($334,043) greater than the willingness to pay threshold. Probabilistic sensitivity analysis found non-imaging based biopsy to be the most cost-effective in 100% of simulations and at all willingness to pay thresholds up to $200,000.

CONCLUSION

No-imaging based biopsy appears to be the most cost-effective strategy for bone marrow core biopsy in patients suspected of MM.

CLINICAL RELEVANCE

No imaging guidance is the preferred strategy, although image-guidance may be required for challenging anatomy. CT image interpretation may be helpful for planning biopsies. Establishing a non-imaging guided biopsy service with greater patient anxiety and pain support may be warranted.

Stable use of radiotherapy in lymphoma patients over time - A comprehensive national overview of radiotherapy use in Sweden with focus on older patients

Background and purpose

The role of radiotherapy (RT) in lymphoma is constantly refined with the advent of novel treatments. However, RT is still an effective treatment and tolerability is high. Therefore, we aimed to describe the use of RT in primary treatment of lymphoma over calendar time, with a specific focus on older patients (age ≥ 70 years) with non-Hodgkin lymphoma (NHL) subtypes.

Materials & Methods

All adult patients diagnosed with lymphoma from 2007 to 2018 in Sweden were included and followed for survival until end of 2020. Patient characteristics and relative survival (RS) were described for patients with NHL by subtype and RT use.

Results

In the cohort of lymphoma patients aged ≥ 70 years (n = 12,698) 11 % received RT as part of primary treatment. No decline in use of RT over calendar period was seen. Use of RT as monotherapy was associated with stage I-II disease and older age among patients with stage III-IV disease. Patients with indolent lymphomas aged ≥ 70 years who were selected for treatment with RT as monotherapy with a dose of ≥ 20 Gy had 2-year RS rate of 100 % which remained similar at five years. For patients with DLBCL, RT as monotherapy with a dose of ≥ 20 Gy was mostly administered to patients aged ≥ 85 years with a 2-year RS rate of 68 %.

Conclusion

The use of RT in first-line lymphoma treatment was stable over calendar time. RT monotherapy is associated with encouraging outcomes among patients with NHL aged ≥ 70 years who were selected to receive this.