1
|
Pepper NB, Oertel M, Rehn S, Kobe C, Eich HT. Modern PET-Guided Radiotherapy Planning and Treatment for Malignant Lymphoma. Semin Nucl Med 2023; 53:389-399. [PMID: 36241473 DOI: 10.1053/j.semnuclmed.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/16/2022] [Indexed: 12/24/2022]
Abstract
Malignant lymphoma comprises a broad spectrum of diverse entities originating from different types of lymphocytes. In the last century, successive improvements of treatment possibilities have led to an continuous amelioration of patient prognosis from lethal outcome to high rates of disease control and long-term survivors. PET/CT-based imaging plays a key role in stratification of stage and treatment response. Especially for radiotherapy, an essential treatment modality for lymphoma patients, functional imaging and the reevaluation of disease activity after frontline chemotherapy has led to major improvements regarding size of treatment fields and toxicity. International expert groups like the International Lymphoma Radiation Oncology Group (ILROG) develop guidelines for the optimal use of imaging for treatment planning. The shift from uniform large-field treatment volumes to complex individual setups taking into account biological response-assessments based on functional imaging resulted in a further de-escalation of side effects and modernization of lymphoma treatment. This paper aims to summarize the use of FDG-PET-imaging for radiation therapy planning in malignant lymphoma in the context of historic and future developments, as well as associated limitations and challenges ahead. We will discuss the contemporary standard of care as recommended by international expert guidelines like the ILROG, the national comprehensive cancer network (NCCN), as well as the newly updated German S3-guidelines.
Collapse
Affiliation(s)
| | - Michael Oertel
- University Hospital Muenster, Department of Radiation Oncology, Muenster, Germany
| | - Stephan Rehn
- University Hospital Muenster, Department of Radiation Oncology, Muenster, Germany
| | - Carsten Kobe
- Department of Nuclear Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hans Theodor Eich
- University Hospital Muenster, Department of Radiation Oncology, Muenster, Germany.
| |
Collapse
|
2
|
Oertel M, Berdel C, Held G, Herfarth K, Schmidberger H, Ernst M, Lenz G, Borchmann P, Eich HT. The new German evidence-based guideline on diffuse large B-cell lymphoma-key aspects for radiation oncologists. Strahlenther Onkol 2023; 199:115-120. [PMID: 36598520 PMCID: PMC9877084 DOI: 10.1007/s00066-022-02035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Diffuse large B‑cell lymphoma (DLBCL) is an aggressive lymphoma subtype treated successfully with immunochemotherapy. However, there are conflicting data on the role and impact of consolidative radiation therapy (RT). The publication of the national evidence-based guideline on DLBCL prompted us to review relevant passages on radiation oncology. METHODS The following article reviews the evidence and recommendations given in the current German evidence-based guideline on DLBCL regarding RT and summarizes pivotal aspects. Additional literature is presented to provide a comprehensive background for the published recommendations. RESULTS RT shall be administered to all patients with localized positron emission tomography(PET)-positive residues after completion of immunochemotherapy and should use a dose of 30-40 Gray in normofractionation. For RT planning, PET information before and after immunochemotherapy shall be used, with either a PET-CT in the RT treatment position or an image fusion to the planning CT. Conformal techniques shall be used for target volume coverage, with a risk-benefit evaluation for the individual patient. Additionally, RT may be used in the treatment context of various subtypes of DLBCL as well as in the recurrent or refractory treatment situation. CONCLUSION RT remains an integral part of the treatment repertoire of DLBCL. With the use of PET-guided treatment, RT is indicated for patients with metabolically active tumors. In the context of the ongoing development of targeted therapies, new RT indications may evolve.
Collapse
Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149 Muenster, Germany
| | - Christian Berdel
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Gerhard Held
- Department of Hematology/Oncology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Klaus Herfarth
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Heinz Schmidberger
- Department of Radiotherapy and Radiation Oncology, University Hospital Mainz, Mainz, Germany
| | - Moritz Ernst
- Evidence-based Oncology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Georg Lenz
- Department of Medicine A, Hematology, Oncology, University Hospital Muenster, Muenster, Germany
| | - Peter Borchmann
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University Hospital of Cologne, Cologne, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, Albert-Schweitzer-Campus 1, building A1, 48149 Muenster, Germany
| |
Collapse
|
3
|
McKay MJ, Taubman KL, Lee S, Scott AM. Radiotherapy planning of lymphomas: role of metabolic imaging with PET/CT. Ann Nucl Med 2022; 36:162-171. [PMID: 35028879 DOI: 10.1007/s12149-021-01703-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022]
Abstract
Accurate target delineation is an absolute requirement for modern radiotherapy planning. Historically, structural imaging modalities have been used for this purpose, but there is a considerable role for functional imaging with PET/CT to contribute in this area. PET/CT's role in radiotherapy planning is well established and its use is indispensable in the clinical management of the lymphomas, particularly Hodgkin Lymphoma. A crucial use of PET/CT is as a baseline scan for delineation of the initial lymphomatous involvement, since this will determine the contouring of the gross-, clinical- and planning-target volumes (GTV, CTV, PTV). This article reviews the principles of contemporary radiotherapy, examines the evidence for the contribution of PET/CT to radiotherapy planning in lymphoma and the practicalities and challenges of applying this powerful technology to this situation.
Collapse
Affiliation(s)
- Michael J McKay
- Northern Cancer Service, North West Cancer Centre, Burnie, TAS, 7320, Australia. .,Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia. .,Rural Clinical School, Northwest Regional Hospital, University of Tasmania, Burnie, TAS, 7320, Australia.
| | - Kim L Taubman
- Department of Medical Imaging, St Vincents Hospital, Fitzroy, VIC, 3065, Australia
| | - Szeting Lee
- Department of Molecular Imaging and Therapy, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Andrew M Scott
- Olivia Newton-John Cancer Research Institute, School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia.,Department of Molecular Imaging and Therapy, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, VIC, 3052, Australia
| |
Collapse
|
4
|
Milgrom SA, Rechner L, Berthelsen A. The optimal use of PET/CT in the management of lymphoma patients. Br J Radiol 2021; 94:20210470. [PMID: 34415777 DOI: 10.1259/bjr.20210470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
18F-fluoro-deoxyglucose positron emission tomography (PET)/computed tomography (CT) scans play an important role in the management of lymphoma patients. They are critical to accurately stage disease and assess its response to therapy. In addition, PET/CT scans enable precise target delineation for radiation therapy planning. In this review, we describe the use of PET/CT scans in lymphoma, with a focus on their role in staging disease, assessing response to therapy, predicting prognosis, and planning RT.
Collapse
Affiliation(s)
| | - Laura Rechner
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
| | - Anne Berthelsen
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
5
|
Meignan M, Cottereau AS, Specht L, Mikhaeel NG. Total tumor burden in lymphoma - an evolving strong prognostic parameter. Br J Radiol 2021; 94:20210448. [PMID: 34379496 DOI: 10.1259/bjr.20210448] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Total metabolic tumor volume (TMTV), a new parameter extracted from baseline FDG-PET/CT, has been recently proposed by several groups as a prognosticator in lymphomas before first-line treatment. TMTV, the sum of the metabolic volume of each lesion, is an index of the metabolically most active part of the tumor and highly correlates with the total tumor burden. TMTV measurement is obtained from PET images processed with different software and techniques, many being now freely available. In the various lymphoma subtypes where it has been measured, such as diffuse large B-cell lymphoma, Hodgkin lymphoma, Follicular Lymphoma, and Peripheral T-cell lymphoma, TMTV has been reported as a strong predictor of outcome (progression-free survival and overall survival) often outperforming the clinical scores, molecular predictors, and results of interim PET. Combined with these scores, TMTV improves the stratification of the populations into risk groups with different outcomes. TMTV cut-off separating the high-risk from the low-risk population impacts the outcome whatever the technique used for its measurement and an international harmonization is ongoing. TMTV is a unique and easy tool that could replace the surrogate of tumor burden included in the prognostic indexes used in lymphoma and help tailor therapy. Other parameters extracted from the baseline PET may give an information on the dissemination of this total tumor volume such as the maximum distance between the lesions. Trials based on TMTV would probably demonstrate its predictive value.
Collapse
Affiliation(s)
- Michel Meignan
- LYSA Imaging, Henri Mondor University Hospitals, University Paris Est, Créteil, France
| | | | - Lena Specht
- Dept. of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - N George Mikhaeel
- Department of Clinical Oncology, Guy's & St Thomas' NHS Trust and School of Cancer and Pharmaceutical Sciences, King's College London University, London, United Kingdom
| |
Collapse
|
6
|
Wirth A, Mikhaeel NG, Aleman BM, Pinnix CC, Constine LS, Ricardi U, Illidge TM, Eich HT, Hoppe BS, Dabaja B, Ng AK, Kirova Y, Berthelsen AK, Dieckmann K, Yahalom J, Specht L. Involved Site Radiation Therapy in Adult Lymphomas: An Overview of International Lymphoma Radiation Oncology Group Guidelines. Int J Radiat Oncol Biol Phys 2020; 107:909-933. [DOI: 10.1016/j.ijrobp.2020.03.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/11/2020] [Indexed: 12/15/2022]
|
7
|
Impact of positron emission tomography with computed tomography for image-guided radiotherapy. Cancer Radiother 2020; 24:362-367. [PMID: 32284178 DOI: 10.1016/j.canrad.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 12/27/2022]
Abstract
Therapeutic effectiveness in radiotherapy is partly related to correct staging of the disease and then precise therapeutic targeting. Positron emission tomography (PET) allows the stage of many cancers to be determined and therefore is essential before deciding on radiation treatment. The definition of the therapeutic target is essential to obtain correct tumour control and limit side effects. The part of adaptive radiotherapy remains to be defined, but PET by its functional nature makes it possible to define the prognosis of many cancers and to consider radiotherapy adapted to the initial response allowing an increase over the entire metabolic volume, or targeted at a subvolume at risk per dose painting, or with a decrease in the dose in case of good response at interim assessment.
Collapse
|
8
|
The Optimal Use of Imaging in Radiation Therapy for Lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group (ILROG). Int J Radiat Oncol Biol Phys 2019; 104:501-512. [DOI: 10.1016/j.ijrobp.2019.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/28/2019] [Accepted: 02/03/2019] [Indexed: 12/21/2022]
|
9
|
|
10
|
Kazda T, Pafundi DH, Kraling A, Bradley T, Lowe VJ, Brinkmann DH, Laack NN. Dosimetric impact of amino acid positron emission tomography imaging for target delineation in radiation treatment planning for high-grade gliomas. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 6:94-100. [PMID: 33458396 PMCID: PMC7807641 DOI: 10.1016/j.phro.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 11/18/2022]
Abstract
Background and purpose The amino-acid positron emission tomography (PET) tracer 3,4-dihydroxy-6-[18F] fluoro-l-phenylalanine (18F-DOPA) has increased sensitivity for detecting regions of biologically aggressive tumors compared to T1 contrast-enhanced (T1-CE) magnetic resonance imaging (MRI). We performed dosimetric evaluation of treatment plans prepared with and without inclusion of 18F-DOPA-based biological target volume (BTV) evaluating its role in guiding radiotherapy of grade III/IV gliomas. Materials and methods Eight patients (five T1-CE, three non-contrast-enhancing [NCE]) were included in our study. MRI only-guided anatomic plans and MRI+18FDOPA-PET-guided biologic plans were prepared for each patient, and dosimetric data for target volumes and organs at risk (OAR) were compared. High-dose BTV60Gy was defined as regions with tumor to normal brain (T/N) >2.0, while low-dose BTV51Gy was initially based on T/N >1.3, but refined per Nuclear Medicine expert. Results For T1-CE tumors, planning target volumes (PTV) were larger than MRI-only anatomic target volumes. Despite increases in size of both gross target volumes and PTV, with volumetric-modulated arc therapy planning, no increase of dose to OAR was observed while maintaining similar target dose coverage. For NCE tumors, MRI+18F-DOPA PET biologic imaging identified a sub-region of the large, T2-FLAIR abnormal signal which may allow a smaller volume to receive the high dose (60 Gy) radiation. Conclusions For T1-CE tumors, PTVs were larger than MRI-only anatomic target volumes with no increase of dose to OARs. Therefore, MRI+18F-DOPA PET-based biologic treatment planning appears feasible in patients with high-grade gliomas.
Collapse
Affiliation(s)
- Tomas Kazda
- Department of Radiation Oncology, Faculty of Medicine Masaryk University and Masaryk Memorial Cancer Institute, Brno, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
| | - Deanna H. Pafundi
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Alan Kraling
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Thomas Bradley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Val J. Lowe
- Department of Nuclear Medicine, Mayo Clinic, Rochester, MN, United States
| | - Debra H. Brinkmann
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Nadia N. Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
- Corresponding author at: Department of Radiation Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905,United States.
| |
Collapse
|
11
|
|
12
|
FDG-PET and radiotherapy in lymphoma. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
13
|
Suarez-Gironzini V, Khoo V. Imaging Advances for Target Volume Definition in Radiotherapy. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0092-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|