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Wright CM, Dreyfuss AD, Baron JA, Maxwell R, Mendes A, Barsky AR, Doucette A, Svoboda J, Chong EA, Jones JA, Maity A, Plastaras JP, Paydar I. Radiation Therapy for Relapsed or Refractory Diffuse Large B-Cell Lymphoma: What Is the Right Regimen for Palliation? Adv Radiat Oncol 2022; 7:101016. [PMID: 36420208 PMCID: PMC9677220 DOI: 10.1016/j.adro.2022.101016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 06/23/2022] [Indexed: 01/25/2023] Open
Abstract
Purpose To report objective response rates (ORR), time to local failure (TTLF), and overall survival (OS) among patients with relapsed or refractory diffuse large B-cell lymphoma after salvage- or palliative-intent radiation therapy (RT) and to investigate whether outcomes differed with conventional versus hypofractionated (≥2.5 Gy/fraction) RT. Methods and Materials A single-institution observational cohort study was performed for patients who completed a course of RT for relapsed or refractory diffuse large B-cell lymphoma between January 1, 2008, and April 1, 2020. Predictors of ORR, TTLF, and OS were calculated using univariable and multivariable regression models. The Kaplan-Meier method was used to estimate TTLF and OS, and log-rank analysis was used to compare outcomes. Equivalent dose in 2 Gy fractions (EQD2) was calculated using an α/β of 10. Results One-hundred and sixty-nine patients were treated with 205 RT courses (73 [36%] salvage, 132 [64%] palliative), and hypofractionated RT was used in 100 RT courses (49%). Median RT dose was 30 Gy (range, 8-60 Gy). ORR was 60% for the total cohort (53% and 69% for palliative and salvage cohorts, respectively). Over a median follow-up time of 4 months, median OS in all patients was 5 months (3 and 22 months for palliative and salvage cohorts, respectively). No statistically significant differences in ORR, TTLF, and OS were observed with hypofractionation compared with conventional fractionation. EQD2 ≥35 Gy was associated with improved ORR (odds ratio, 3.79 [1.19-12.03]; P = .024) and prolonged TTLF (0.39 [0.18-0.87]; P = .022), while double-hit receptor status (8.18 [1.08-62.05]; P = .042), cell of origin (3.87 [1.17-8.74]; P = .0012), and bulky disease (≥7.5 cm; 2.12 [1.18-3.81]; P = .012) were associated with inferior TTLF. In the palliative-only cohort, a low-dose regimen of 8 Gy in 2 fractions was associated with similar ORR compared with other fractionation schema but trended towards inferior TTLF (P = .36). Conclusions Hypofractionation is not associated with differences in disease outcomes for patients with relapsed or refractory diffuse large B-cell lymphoma, while higher RT dose (EQD2 ≥35 Gy) may improve ORR and TTLF. Future work is warranted to elucidate the ideal dose and fractionation schema for such patients who will likely also undergo novel systemic agents and cellular therapies.
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Affiliation(s)
- Christopher M. Wright
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania,Corresponding author: Christopher M. Wright, MD
| | - Alexandra D. Dreyfuss
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A. Baron
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Russell Maxwell
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amberly Mendes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew R. Barsky
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail Doucette
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jakub Svoboda
- Department of Medicine, Hematology/Oncology Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elise A. Chong
- Department of Medicine, Hematology/Oncology Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua A. Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Maity
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P. Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ima Paydar
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Wright CM, Koroulakis AI, Baron JA, Chong EA, Tseng YD, Kurtz G, LaRiviere M, Venigalla S, Jones JA, Maity A, Mohindra P, Plastaras JP, Paydar I. Palliative Radiotherapy for Diffuse Large B-cell Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:650-658. [PMID: 34127417 DOI: 10.1016/j.clml.2021.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/13/2021] [Accepted: 05/09/2021] [Indexed: 11/17/2022]
Abstract
Recent improvements in chemoimmunotherapies, targeted agents, hematopoietic stem cell transplants, and cellular therapies have revolutionized treatment paradigms for patients with diffuse large B-cell lymphoma (DLBCL). Even in the relapsed or refractory setting, contemporary treatment options are delivered with curative intent and can lead to lasting remissions. Although such therapies have improved overall outcomes, they have increasingly led to a wide variety of presentations of recurrent tumors in need of palliation. Here, we review the use of radiotherapy (RT) in the palliation of DLBCL. We draw particular attention to the evolving role for hypofractionated RT and low-dose RT for DLBCL. We review the available literature on these topics and focus on commonly encountered clinical scenarios.
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Affiliation(s)
- Christopher M Wright
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
| | - Antony I Koroulakis
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
| | - Jonathan A Baron
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Elise A Chong
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Goldie Kurtz
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael LaRiviere
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Sriram Venigalla
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua A Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Maity
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland, Baltimore, MD, USA
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ima Paydar
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Al-Juhaishi T, Mckay J, Sindel A, Yazbeck V. Perspectives on chemotherapy for the management of double-hit lymphoma. Expert Opin Pharmacother 2020; 21:653-661. [PMID: 32066288 DOI: 10.1080/14656566.2020.1727445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION . Unlike most B-cell lymphomas, they have poor response to standard R-CHOP therapy, tend to quickly develop resistance to cytotoxic chemotherapies, and are associated with higher central nervous system (CNS) infiltration. This can lead to increased risk of relapse and worse prognosis. DHL/THL represent a subset of lymphomas with unmet medical need. AREA COVERED The authors present the available data for the current treatment regimens including intensive chemotherapy regimens, hematopoietic stem-cell transplantation (HSCT), and CNS prophylaxis. They also discuss treatment for relapsed disease including targeted therapies. EXPERT OPINION There is currently no accepted standard of care for DHL/THL. For frontline therapy, we recommend enrollment in a well-designed clinical trial if possible, otherwise DA-EPOCH-R with CNS prophylaxis is a commonly used first-line therapy. The authors recommend close surveillance for patients achieving complete response, but for those who fail to achieve a complete response, then clinical trials, more aggressive salvage chemotherapy regimens, or cellular therapies are usually considered.
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Affiliation(s)
- Taha Al-Juhaishi
- Department of Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University , Richmond, VA, USA
| | - John Mckay
- Department of Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University , Richmond, VA, USA
| | - Ariel Sindel
- Massey Cancer Center, Virginia Commonwealth University , Richmond, VA, USA
| | - Victor Yazbeck
- Department of Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University , Richmond, VA, USA.,Massey Cancer Center, Virginia Commonwealth University , Richmond, VA, USA
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Kim A, Stevenson P, Cassaday RD, Soma L, Fromm JR, Gopal AK, Smith SD, Till B, Lynch RC, Ujjani C, Shadman M, Warren EH, Menon M, Russell K, Tseng YD. Impact of Double- or Triple-Hit Pathology on Rates and Durability of Radiation Therapy Response Among Patients With Relapsed or Refractory Large B-Cell Lymphoma. Pract Radiat Oncol 2020; 10:44-52. [DOI: 10.1016/j.prro.2019.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/12/2019] [Accepted: 09/24/2019] [Indexed: 11/28/2022]
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Li LR, Wang L, He YZ, Young KH. Current perspectives on the treatment of double hit lymphoma. Expert Rev Hematol 2019; 12:507-514. [PMID: 31117849 DOI: 10.1080/17474086.2019.1623020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Double hit lymphoma (DHL) represents a new diagnostic category with genetic, immunohistochemical and clinical characteristics intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. Patients with DHL usually experience poor survival after frontline R-CHOP treatment and require alternative therapies. However, the ideal therapeutic options remain undefined. Areas covered: Traditional therapies for the treatment of DHL are discussed, including intensive induction, hematopoietic stem cell transplantation (HSCT), methotrexate CNS-directed prophylaxis, and radiation therapy. The authors further introduce small-molecule inhibitors targeting myc or bcl-2 signaling pathways, chimeric antigen receptor T-cell therapy, programmed death-1 monoclonal antibody and immunomodulatory drugs as novel approaches. Expert opinion: No standard treatment exists for DHL. At present, DA-EPOCH-R exhibits an upfront induction option. Central nervous system prophylaxis with methotrexate is recommended as part of the induction therapy. For those who do not obtain complete remission, HSCT or clinical trials should be considered. Targeted approaches, especially chimeric antigen receptor T-cell therapies and small-molecule inhibitors targeting myc or bcl-2, exhibit the potential of improving outcomes for patients with DHL. High-throughput sequencing is a promising technique both at diagnosis and relapse, in order to predict outcomes and potential novel therapies.
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Affiliation(s)
- Lin-Rong Li
- a Second Clinical Medical College , Southern Medical University , Guangzhou , China
| | - Liang Wang
- b Department of Hematology , Zhujiang Hospital of Southern Medical University , Guangzhou , China
| | - Ying-Zhi He
- b Department of Hematology , Zhujiang Hospital of Southern Medical University , Guangzhou , China
| | - Ken H Young
- c Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Tseng YD, Ng AK, Wirth A. New tools of the trade: parsing out the role of radiotherapy for early-stage diffuse large B-cell lymphoma. Leuk Lymphoma 2018; 60:861-863. [PMID: 30481090 DOI: 10.1080/10428194.2018.1531397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Yolanda D Tseng
- a Department of Radiation Oncology , University of Washington , Seattle , WA , USA
| | - Andrea K Ng
- b Department of Radiation Oncology , Dana-Farber/Brigham and Women's Cancer Center , Boston , MA , USA
| | - Andrew Wirth
- c Division of Radiation Oncology , Peter MacCallum Cancer Centre , Parkville , Victoria
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Grass GD, Mills MN, Ahmed KA, Liveringhouse CL, Montejo ME, Robinson TJ, Chavez JC, Harrison LB, Kim S. Radiotherapy for early stage diffuse large B-cell lymphoma with or without double or triple hit genetic alterations. Leuk Lymphoma 2018; 60:886-893. [PMID: 30457458 DOI: 10.1080/10428194.2018.1506586] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We investigated whether adding radiation (RT) to systemic therapy improved outcomes in early stage diffuse large B-cell lymphoma (DLBCL) patients with or without double- or triple-hit lymphoma (DHL/THL) biology. This analysis included 183 patients profiled with fluorescent in situ hybridization (FISH) for alterations in MYC, BLC2, and/or BCL6. A total of 146 (80%) were non-DHL/THL, 27 (15%) were DHL, and 10 (6%) were THL. Systemic therapy without RT resulted in inferior freedom from relapse (FFR) (HR: 2.28; 95% CI, 1.10-4.77; p = .02). The median FFR for non-DHL/THL was not reached and was 33 and 22.3 months for DHL and THL, respectively; p < .001. Low-risk (R-IPI <2) DHL/THL patients treated with rituximab-based therapy had 3-year FFR rates of 11% and 71% for systemic therapy without and with RT, respectively; p = .04. No differences in overall survival were observed between the treatment groups. Treatment intensification with RT may improve early stage DHL/THL outcomes.
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Affiliation(s)
- George Daniel Grass
- a Department of Radiation Oncology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
| | - Matthew N Mills
- b University of South Florida College of Medicine, Tampa , FL , USA
| | - Kamran A Ahmed
- a Department of Radiation Oncology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
| | | | - Michael E Montejo
- a Department of Radiation Oncology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
| | - Timothy J Robinson
- a Department of Radiation Oncology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
| | - Julio C Chavez
- c Department of Malignant Hematology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
| | - Louis B Harrison
- a Department of Radiation Oncology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
| | - Sungjune Kim
- a Department of Radiation Oncology , H. Lee Moffitt Cancer Center and Research Institute, Tampa , FL , USA
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