Gastric DLBCL

[Kroll2013]

53 yo woman, presenting stage IE gastric DLBCL extending to the duodenum.
she received 8 R-CHOP with complete remission.
Does she need adjuvant radiation therapy? 30Gy

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[medgator]

8 seems like a lot. Would usually opt for 3-6 and would add xrt. No data to suggest it can be eliminated

 

[Palex80]

6x R-CHOP is probably fine and you dont really need XRT after it, if you have a complete remission.

If you are going to give less chemo than 6x R-CHOP, you should irradiate with 30 Gy, that's certainly so.


Medgator is strictly speaking right. In all rituximab registration trials, extranodal disease was irradiated. So, this lady would have gotten XRT in the trials.
On the other hand we have quite good retrospective data, showing that you can ommit RT in Stage I patients with extranodal disease being treated with intensive (6 cycles) chemotherapy + rituximab, if they show complete remission.

 

[medgator]

6x R-CHOP is probably fine and you dont really need XRT after it, if you have a complete remission.

If you are going to give less chemo than 6x R-CHOP, you should irradiate with 30 Gy, that's certainly so.


Medgator is strictly speaking right. In all rituximab registration trials, extranodal disease was irradiated. So, this lady would have gotten XRT in the trials.
On the other hand we have quite good retrospective data, showing that you can ommit RT in Stage I patients with extranodal disease being treated with intensive (6 cycles) chemotherapy + rituximab, if they show complete remission.

sounds like the same rationale med oncs use here in the U.S. not to send us the early-stage hodgkins patients.... :-/

 

[Cancerdancer]

I would tend to advocate for it, based on the MDACC RR (Phan et al JCO 2010) showing better PFS and even OS in stage I pts who received 6 cycles R-CHOP and then received RT. Similar findings (though lower magnitude of benefit) seen in SEER analysis by Ballonoff et al (IJROBP 2008). Not randomized, but best data there is when the question is chemo +/- RT. Pattern of failure tends to be local, so I think RT should usually be included, and then the better question is whether 3-4 cycles of R-CHOP is sufficient vs 6.

 

[ramsesthenice]

I tend to agree. I would offer RT. And then I would find out why someone did 8 cycles. That is just strange.

 

[medgator]

I tend to agree. I would offer RT. And then I would find out why someone did 8 cycles. That is just strange.

SWOG study. Doesn't make it any less strange considering that was a pre-rituxan trial and the chemo alone arm was inferior.

http://www.ncbi.nlm.nih.gov/pubmed/9647875?dopt=Abstract