Reduction of the treated volume to involved node radiation therapy as part of combined modality treatment for early stage aggressive non-Hodgkin's lymphoma

Long-Term Results of IFRT vs. ISRT in Infradiaphragmal Fields in Aggressive Non-Hodgkins's Lymphoma Patients-A Single Centre Experience

(1) Background: This study aimed to examine the difference in efficacy and toxicity of involved-field (IFRT) and involved-site radiotherapy (ISRT) fields in infradiaphragmal aggressive non-Hodgkin lymphoma patients. (2) Methods: In total, 140 patients with infradiaphragmal lymphoma treated between 2003 and 2020 were retrospectively evaluated. There were 69 patients (49%) treated with IFRT, and 71 (51%) patients treated with ISRT. The median dose in the IFRT group was 36 Gy, (range 4-50.4 Gy), and in the ISRT group, it was 30 Gy (range 4-48 Gy). (3) Results: The median follow-up in the IFRT group was 133 months (95% CI 109-158), and in the ISRT group, it was 48 months (95% CI 39-57). In the IFRT group, locoregional control was 67%, and in the ISRT group, 73%. The 2- and 5-year overall survival (OS) in the IFRT and ISRT groups were 79% and 69% vs. 80% and 70%, respectively (p = 0.711). The 2- and 5-year event-free survival (EFS) in the IFRT and ISRT groups were 73% and 68% vs. 77% and 70%, respectively (p = 0.575). Acute side effects occurred in 43 (31%) patients, which is more frequent in the IFRT group, 34 (39%) patients, than in the ISRT group, 9 (13%) patients, p > 0.01. Late toxicities occurred more often in the IFRT group of patients, (10/53) 19%, than in the ISRT group of patients, (2/37) 5%, (p = 0.026). (4) Conclusions: By reducing the radiotherapy volume and the doses in the treatment of infradiaphragmatic fields, treatment with significantly fewer acute and long-term side effects is possible. At the same time, efficiency and local disease control are not compromised.

Time trends in primary therapy and relative survival of diffuse large B-cell lymphoma by stage: a nationwide, population-based study in the Netherlands, 1989-2018

It is unclear whether survival in diffuse large B-cell lymphoma (DLBCL) continues to increase in an era where rituximab-containing chemotherapy reigns for almost two decades. Therefore, we evaluated trends in primary therapy and relative survival (RS) among Dutch DLBCL patients diagnosed between 1989 and 2018. Analyses were performed separately according to the stage I (N = 6952) and stage II–IV disease (N = 20,676), stratified by calendar period and age (18–64, 65–74, and ≥75 years). The use of chemotherapy ± radiotherapy increased over time across all age and stage groups. As of the mid-2000s, >95% of chemotherapy-treated patients received chemoimmunotherapy, irrespective of age and stage. Overall, RS increased significantly over time across all age groups, especially after 2003 when rituximab-containing chemotherapy had become the standard of care. However, RS increased less pronounced between 2003–2010 and 2011–2018 than between 1989–2002 and 2003–2010. These findings were congruent across all studied stage groups. Five-year RS across the three age groups during 2011–2018 was 96%, 84%, and 67% for stage I DLBCL and 75%, 60%, and 46% for stage II–IV DLBCL. Collectively, survival in DLBCL increased modestly beyond the initial introduction of rituximab, with apparent survival differences across age and stage that warrant novel treatment approaches.

Hematologic Malignancies

Radiation therapy plays a critical role in the management of a wide range of hematologic malignancies. The optimal radiation dose and target volume, and safe and effective ways of integrating radiation with systemic agents, vary depending on the histologic subtypes, stage at presentation, patient performance status, response to systemic therapy if given, treatment intent, and patient preferences. Limiting doses to surrounding organs without sacrificing disease control is of paramount importance. Reducing radiation doses and treatment volume in selected cases, and the use of advanced radiotherapy technology, can improve the therapeutic ratio of patients receiving radiation therapy for hematologic malignancies.

Randomized Trial of Systemic Therapy After Involved-Field Radiotherapy in Patients With Early-Stage Follicular Lymphoma: TROG 99.03

Purpose

Follicular lymphoma (FL) is curable by involved-field radiotherapy (IFRT) in < 50% of patients with stage I to II disease. We hypothesized that adding systemic therapy to IFRT would improve long-term progression-free survival (PFS).

Patients and Methods

A multicenter randomized controlled trial enrolled patients with stage I to II low-grade FL after staging computed tomography scans and bone marrow biopsies. 18F-labeled fluorodeoxyglucose–positron emission tomography (PET) was not mandatory. Patients were randomly assigned to either arm A (30 Gy IFRT alone) or arm B (IFRT plus six cycles of cyclophosphamide, vincristine, and prednisolone [CVP]). From 2006, rituximab was added to arm B (R-CVP).

Results

Between 2000 and 2012, 150 patients were enrolled, 75 per arm. In arm B, 44 patients were allocated to receive CVP and 31 were allocated to receive R-CVP. At randomization, 75% had stage I, the median age was 57 years, 52% were male, and 48% were PET staged. With a median follow-up of 9.6 years (range, 3.1 to 15.8 years), PFS was superior in arm B (hazard ratio, 0.57; 95% CI, 0.34 to 0.95; P = .033). Ten-year PFS rates were 59% (95% CI, 46% to 74%) and 41% (95% CI, 30% to 57%) for arms B and A, respectively. Patients in arm B who received R-CVP had markedly superior PFS compared with contemporaneous patients in arm A (hazard ratio, 0.26; 95% CI, 0.07 to 0.97; P = .045). Fewer involved regions ( P = .047) and PET staging ( P = .056) were associated with better PFS. Histologic transformation occurred in four and 10 patients in arms B and A, respectively ( P = .1). Ten deaths occurred in arm A versus five in arm B, but overall survival was not significantly different ( P = .40; 87% and 95% at 10 years, respectively).

Conclusion

Systemic therapy with R-CVP after IFRT reduced relapse outside radiation fields and significantly improved PFS. IFRT followed by immunochemotherapy is more effective than IFRT in early-stage FL.

INFRADIAPHRAGMAL RADIOTHERAPY IN PATIENTS WITH LYMPHOMA: VOLUME DEFINITION AND SIDE EFFECTS

SUMMARY – Lymphomas are very radiosensitive and radiotherapy (RT) was the first treatment modality that enabled cure. It is the most effective single modality for local control of lymphomas. However, as a local form of treatment, curative intention is only possible if all lymphoma tissue can be incorporated in the volume to be irradiated with the prescribed total irradiation dose. That is why RT is a single modality only in early stage of nodular lymphocyte predominance Hodgkin’s lymphoma and low grade non-Hodgkin’s lymphoma. In most patients, RT can be used as consolidation therapy after chemotherapy or as salvage after failure of chemotherapy. In the past two decades, irradiation techniques have been improved in order to spare critical tissues and reduce toxicity. Although effective, RT is a neglected modality of treatment because of the appearance of new drugs and fear of side effects after irradiation. Radiation has been shown to be effective in the treatment of all stages and forms of lymphoma. Study data are still mostly derived from patients that received supradiaphragmal RT; therefore, there is no agreement about the best management approach in patients with infradiaphragmal lymphoma.

Reduction of Target Volume and the Corresponding Dose for the Tumor Regression Field after Induction Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma

Purpose

This study aims to investigate the feasibility of contouring target volume according to residual tumor and decreasing the dose to the tumor regression field after induction chemotherapy (IC) in locoregionally advanced nasopharyngeal carcinoma (NPC).

Materials and Methods

From August 2009 to August 2013, patients with stage III–IVB NPC were treated with IC and concurrent chemoradiotherapy. Gross tumor volume of nasopharynx (GTVnx)–residual and gross tumor volume of cervical lymph node (GTVnd)–residual were contoured according to post-IC residual primary tumor and any N+ disease, respectively. The tumor regression field was included in CTVnx1/CTVnd1 and prescribed a dose of 60 Gy. Outcomes and toxicities of all patients were evaluated.

Results

A total of 57 patients were enrolled. At a median follow-up of 68 months, three cases displayed locoregional recurrence and one case showed both distant metastasis and locoregional recurrence. All locoregional recurrences were in the GTVnx-residual/GTVnd-residual and in-field. The 5-year overall, locoregional relapse-free, distant metastasis-free, and progression-free survival rates were 82.2%, 87.7%, 85.8% and 80.3%, respectively.

Conclusion

After IC, contouring of GTVnx-residual/GTVnd-residual as residual tumor volume and distribution 60 Gy ofradiation dose to the tumorregression field may be feasible and need further investigation.

Proton versus photon deep inspiration breath hold technique in patients with hodgkin lymphoma and mediastinal radiation : A PLANNING COMPARISON OF DEEP INSPIRATION BREATH HOLD INTENSITY MODULATION RADIOTHERAPY AND INTENSITY MODULATED PROTON THERAPY

BACKGROUND

The benefits of proton therapy in the treatment of patients with Hodgkin lymphoma (HL) are controversially discussed. Therefore we compared intensitiy modulated proton therapy (IMPT) with intensity modulated radiotherapy (IMRT), in the form of volumetric modulated arc therapy (VMAT) in patients with Hodgkin lymphoma (HL), through a comparative treatment planning study.

METHODS

Radiation plans for 21 patients with Hodgkin Lymphoma (HL) were computed for IMPT and deep inspiration breath hold (DIBH) VMAT. Plans were optimized and computed assuming deep inspiration breath holding conditions. Dosimetric comparison on standard metrics from dose volume histograms was performed to appraise the relative merits of the two techniques, while proton plan robustness was assessed by re-computing the dose distribution of each plan by varying the Hounsfield Units to stopping power calibration by applying a ± 3 and 4% error.

RESULTS

DIBH-VMAT and IMPT both provided excellent coverage, conformity and heterogeneity of the clinical target volume (CTV) and planning target volume (PTV). IMPT reduced mean doses to the breasts, lungs, heart and normal tissue by 38-83%. IMPT significantly reduced mean doses to the heart to < 5 Gy despite bulky mediastinal disease and decreased breast doses in female patients to < 1 Gy. Despite the simulated 3 and 4% miscalibration errors, no remarkable or measurable impact was observed on the organs at risk (OARs).

CONCLUSIONS

This is the first comparison between DIBH-VMAT and IMPT in HL treatment. We could demonstrate statistically significant decreases in all dose/volume metrics of the OARs. Regardless of the planning paradigm used, range uncertainties can substantially under dose the PTV, while perhaps not leading to clinically significant deterioration of CTV coverage. With the geometry applied no impact was observed for OARs, suggesting IMPT as a superior technique for potentially reducing future health risks for HL patients.

Treatment results of radiotherapy following CHOP or R-CHOP in limited-stage head-and-neck diffuse large B-cell lymphoma: a single institutional experience

Purpose

This study evaluated outcomes of radiotherapy (RT) after chemotherapy in limited-stage head-and-neck diffuse large B-cell lymphoma (DLBCL).

Materials and Methods

Eighty patients who were treated for limited-stage head-and-neck DLBCL with CHOP (n = 43) or R-CHOP (n = 37), were analyzed. After chemotherapy, RT was administered to the extended field (n = 60) or the involved field (n = 16), or the involved site (n = 4). The median dose of RT ranged from 36 Gy in case of those with a complete response, to 45–60 Gy in those with a partial response.

Results

In all patients, the 5-year overall survival (OS) and disease-free survival (DFS) rates were 83.9% and 80.1%, respectively. In comparison with the CHOP regimen, the R-CHOP regimen showed a better 5-year DFS (86.5% vs. 73.9%, p = 0.027) and a lower rate of treatment failures (25.6% vs. 8.1%, p = 0.040). The volume (p = 0.047) and dose of RT (p < 0.001) were significantly reduced in patients treated with R-CHOP compared to that in those treated with CHOP.

Conclusion

The outcomes of RT after chemotherapy with R-CHOP were better than those of CHOP regimen for limited-stage head-and-neck DLBCL. In patients treated with R-CHOP, a reduced RT dose and volume might be feasible without increasing treatment failures.