Lymphoma: (HD or NHL)- role of RT in real life

[ProtonElectronNeutron]

I see all these studies discussing the role of RT for lymphomas. But, in practice, I see the exact opposite- Hematologist do what they want do do. They sent to RO when there is not a CR after all the chemo they can give or for palliation. Everyone feel the same?

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[scarbrtj]

I see all these studies discussing the role of RT for lymphomas. But, in practice, I see the exact opposite- Hematologist do what they want do do. They sent to RO when there is not a CR after all the chemo they can give or for palliation. Everyone feel the same?

Radiation Therapy in Hodgkin Disease: Why Risk a Pyrrhic Victory?

 

[medgator]

Can't remember the last time I got an HD referral... Do see a decent amount of NHL though... Usually early stage low grade, or high grade with combined therapy for cure or consolidation

 

[FrostyHammer]

Radiation Therapy in Hodgkin Disease: Why Risk a Pyrrhic Victory?

Always a treat to see an article centered on radiation therapy written by a hemeonc...smh

 

[Palex80]

I see all these studies discussing the role of RT for lymphomas. But, in practice, I see the exact opposite- Hematologist do what they want do do. They sent to RO when there is not a CR after all the chemo they can give or for palliation. Everyone feel the same?

The role of RT in lymphoma is decreasing in the past years, but the reason are not "evil" hematologists. It's evidence as well.

HD17 recently showed that consolidation with RT can be omitted if interim-PET-negative after 2x BEACOPP esc followed by 2x ABVD in early unfavorable Hodgkin's.

Flyer showed that giving 4x R-CHOP is enough for early stage DLBCL without any RT. The Miller-approach of 3x CHOP + RT was preferred by many over 8x CHOP. Then R came along and the number of CHOP-cycles dropped to 6. But when the difference now is only one more cycle of R-CHOP which will allow you to skip RT, can you blame the hematologists for "pushing" the RT-free option?

In early favorable Hodgkin's things are less crystal clear. Omitting RT there will lead to an excessive risk for recurrence, but I've seen many patients opt to drop RT, even if that means 7-8% higher recurrence risk. On the other hand, if the volume is big and right in the mediastinum and you are an 19 year old young woman, what would you rather accept? 7-8% higher risk of recurrence by omitting RT or 3-5% (?) higher risk of RT-induced breast cancer? Protons can help there, but that's it....

One possible outlook will be RT in the setting of CAR-T-therapy. But still, there's a lot of work to do there!

 

[BobbyHeenan]

The role of RT in lymphoma is decreasing in the past years, but the reason are not "evil" hematologists. It's evidence as well.

HD17 recently showed that consolidation with RT can be omitted if interim-PET-negative after 2x BEACOPP esc + 2x ABVD in early unfavorable Hodgkin's.

Flyer showed that giving 4x R-CHOP is enough for early stage DLBCL without any RT. The Miller-approach of 3x CHOP + RT was preferred by many over 8x CHOP. The R came along and the number of CHOP-cycles dropped to 6. But when the difference now is only one more cycle of R-CHOP which will allow you to skip RT, can you blame the hematologists for "pushing" the RT-free option?

In early favorable Hodgkin's things are less crystal clear. Omitting RT there will lead to an excessive risk for recurrence, but I've seen many patients opt to drop RT, even if that means 7-8% higher recurrence risk. On the other hand, if the volume is big and right in the mediastinum and you are an 19 year old young woman, what would you rather accept? 7-8% higher risk of recurrence by omitting RT or 3-5% (?) higher risk of RT-induced breast cancer? Protons can help there, but that's it....

One possible outlook will be RT in the setting of CAR-T-therapy. But still, there's a lot of work to do there!

Aside: I don't think I've ever seen BEACOPP used in my neck of the woods in the US for up front treatment of HL.

Is anyone seeing this?

 

[fiji128]

Seeing lymphoma patients has always been rare for me. Can't even recall seeing a HL patient in the past few years. HL is fast becoming the new testicular cancer for us. I have seen a few patient with bulky recurrent lymphoma where heme onc wanted RT (20 Gy in 5 fractions) prior to CAR-T.

Here is a rare "win" for RT in the world hematologic malignancies. TBI (12 Gy in 6 fx over 2 days) prior to allogeneic stem cell transplant vs chemo conditioning alone in pediatric ALL. 2-year overall survival was significantly higher following TBI (0.91; 95% CI, 0.86 to 0.95; P < .0001) versus chemoconditioning (0.75; 95% CI, 0.67 to 0.81).

https://ascopubs.org/doi/full/10.1200/JCO.20.02529

 

[evilbooyaa]

If there is an option that allows a specialty to give MORE of its therapy, at the expense of another field (which it does not rely on for referrals) is there any surprise that many would believe in their own therapy? If we could hyperfractionate our H&N instead of giving chemotherapy and have equivalent outcomes, would there not be a significant proportion of people who would get that?

Even Rad Oncs like to give 60Gy for stage III rather than 45Gy for neoadjuvant now. Yes, Durva is probably a major reason, but just to make a point.

At least in HL and DLBCL chemo is REQUIRED (besides NLPHL, which I have seen appropriate referrals for).

In general, anything that should only be treated with RT alone I have generally seen appropriate referrals for. I do see some DLBCL as well. Not a ton of Hodgkin's at this point.

 

[scarbrtj]

A wise old man by the name of Eli Glatstein told me when I was barely old enough to shave: "We are just one drug away from being out of the radiation business in lymphoma." He was truly a wise old man.

 

[medgator]

A wise old man by the name of Eli Glatstein told me when I was barely old enough to shave: "We are just one drug away from being out of the radiation business in lymphoma." He was truly a wise old man.

Yet here i am, zapping a stage I FL... Maybe I'm treating the referring and myself more than the patient

 

[drewdog1973]

Yet here i am, zapping a stage I FL... Maybe I'm treating the referring and myself more than the patient

Maybe?

 

[evilbooyaa]

Yet here i am, zapping a stage I FL... Maybe I'm treating the referring and myself more than the patient

The rare lymphomas that do not have a NCCN acceptable (or even recommended) treatment using chemotherapy alone will get referred for RT. They're not money grubbing folks that do things completely off the wall - they'll still mostly pick NCCN paradigms.

Seen a fair number of cutaneous lymphomas that have been appropriately referred, as well as stage I follicular, stage I/II NLPHL, etc.

 

[bachiraki]

Had a case of 61 year old with DLBCL this morning in tumor board. Disease at the initial site (retroperitoneum, only site of recurrence) recurred 12 months after completion R-CHOP. Med Oncs recommended Auto Stem cell transplant and possible CART therapy.....

 

[FrostyHammer]

They're not money grubbing folks that do things completely off the wall

This is a rosy view, until one notices off-label immunotherapy use - the most extreme of which I have heard a doc in Texas who gave an HPV oropharynx case immunotherapy alone. without any local therapy...

 

[RadOncDoc21]

This is a rosy view, until one notices off-label immunotherapy use - the most extreme of which I have heard a doc in Texas who gave an HPV oropharynx case immunotherapy alone. without any local therapy...

Agree, I’ve worked in a few different places and have seen some of the darker sides of medicine. Let’s just say life is nothing I was taught during residency.

 

[medgator]

This is a rosy view, until one notices off-label immunotherapy use - the most extreme of which I have heard a doc in Texas who gave an HPV oropharynx case immunotherapy alone. without any local therapy...

Why did the med onc get referred a definitive h&n case first?

 

[Palex80]

Yet here i am, zapping a stage I FL... Maybe I'm treating the referring and myself more than the patient

Boom-boom?

 

[Palex80]

Had a case of 61 year old with DLBCL this morning in tumor board. Disease at the initial site (retroperitoneum, only site of recurrence) recurred 12 months after completion R-CHOP. Med Oncs recommended Auto Stem cell transplant and possible CART therapy.....

Which is basically (almost) correct (I presume they are going to do some kind of relapse chemotherapy (R-DHAP or R-ICE) prior to auto stem cell transplant).

Two questions arise:
1. Should this patient have gotten consolidative RT at first presentation? Depends on the amount of R-CHOP he got, the response on PET-CT after completion of R-CHOP and whether or not it was bulky disease.
2. Should this patient receive RT now? Data of this are even more scarce. I'd probably say yes if it arose in an area where there was bulky disease initially.

 

[evilbooyaa]

Boom-boom?

FORT update, IMO, says that Boom Boom for anything besides pure palliation of indolent NHL should be DEAD in the water in favor of 24/12. Some may advocate for it in orbital or gastric MALTs or wherever else 24Gy will cause 'toxicity', but I just don't see the fear of it.

 

[evilbooyaa]

This is a rosy view, until one notices off-label immunotherapy use - the most extreme of which I have heard a doc in Texas who gave an HPV oropharynx case immunotherapy alone. without any local therapy...

Yes, I have heard that anecdote, and IMO there are tons of Rad Onc anecdotes that are similarly as bad. I suppose I'm not seeing routine off-label IT use.

 

[Palex80]

FORT update, IMO, says that Boom Boom for anything besides pure palliation of indolent NHL should be DEAD in the water in favor of 24/12. Some may advocate for it in orbital or gastric MALTs or wherever else 24Gy will cause 'toxicity', but I just don't see the fear of it.

Indeed.
I was kidding, trying to make the point that even when we get to irradiate, we often treat with very short schedules.

 

[medgator]

Indeed.
I was kidding, trying to make the point that even when we get to irradiate, we often treat with very short schedules.

Not in this case...24/12... Pt in good shape

 

[Palex80]

Yes, I have heard that anecdote, and IMO there are tons of Rad Onc anecdotes that are similarly as bad. I suppose I'm not seeing routine off-label IT use.

I recently saw a case in our local tumor board.

Stage IIIA NSCLC diagnosed and commenced treatment in another clinic. Bulky nodes in the mediastinum. Patient got Pembrolizumab, came back after 4 cycles with a partial remission in PET (apparently the tumor board of the other clinic thought "it wasn't worth it" to make him face concomitant radiochemotherapy given his poor prognosis with a bulky, unresectable stage III NSCLC).
Came to our clinic for surgery: ypT0 pN1 R0. All mediastinal nodes disappeared and only 5mm vital tumor found in hilar node.

I don't know what to say...
Is this the future for stage III NSCLC in some patients and how do we pick them out?
Patient is going to receive Pembro for a full year now. Lucky guy.

 

[ProtonElectronNeutron]

Which is basically (almost) correct (I presume they are going to do some kind of relapse chemotherapy (R-DHAP or R-ICE) prior to auto stem cell transplant).

Two questions arise:
1. Should this patient have gotten consolidative RT at first presentation? Depends on the amount of R-CHOP he got, the response on PET-CT after completion of R-CHOP and whether or not it was bulky disease.
2. Should this patient receive RT now? Data of this are even more scarce. I'd probably say yes if it arose in an area where there was bulky disease initially.

I believe he should have got consolidation RT and hopefully that would have prevented the recurrence.

 

[ProtonElectronNeutron]

I have been going through the evidence of omission of RT in HL. And try listening to the ASTRO refresher lecture from 2020. Almost all RT omission studies have shown at least 7% decrease in EFS.
My problem is- RT is omitted for the fear of toxicity; but when they recur, the pts are hit with BMT which has >10-20% mortality.

 

[RadOncDoc21]

Why did the med onc get referred a definitive h&n case first?

Sometimes “cancer care” in a community means that all cancers go through med onc.

 

[Palex80]

I have been going through the evidence of omission of RT in HL. And try listening to the ASTRO refresher lecture from 2020. Almost all RT omission studies have shown at least 7% decrease in EFS.
My problem is- RT is omitted for the fear of toxicity; but when they recur, the pts are hit with BMT which has >10-20% mortality.

Wait, wait, wait...

Autologous stem cell transplantation has a mortality rate of <1% in high-volume centers.
For example here are data from myeloma patients, who regularly get autologous stem cell transplantation.
What you are referring to is allogeneic stem cell transplantation which is experimental for hodgkins lymphoma and reserved for patients failing literally every other available salvage treatment.

It is also worth noting that current salvage treatment for hodgkins lymphoma does not discriminate between patients who have gotten radiation therapy or not in the past. High dose chemotherapy and autologous stem cell transplant for recurrent hodgkins lymphoma has been around for decades. Hematologists have been using that in late 80s and early 90s just as they use it today. Yet we do not know IF all patients recurring after a deescalated treatment actually still need it.
A patient with an early stage favorable hodgkins recurring in the late 90s had undergone 4x ABVD + 30 Gy of IFRT.
Nowadays the very same patient recurring may have only received 3x ABVD (as per RAPID).
Are these recurring lymphomas the same? Or did the patient recurring after "more" first line treatment carry more aggressive disease?
One could make the argument to deescalate salvage treatment for patients recurring after deescalated first line treatment, since these patients were not optimally treated at first (trade-off between efficacy and toxicity).

But we are not there yet...

 

[ramsesthenice]

The role of RT in lymphoma is decreasing in the past years, but the reason are not "evil" hematologists. It's evidence as well.

HD17 recently showed that consolidation with RT can be omitted if interim-PET-negative after 2x BEACOPP esc followed by 2x ABVD in early unfavorable Hodgkin's.

Flyer showed that giving 4x R-CHOP is enough for early stage DLBCL without any RT. The Miller-approach of 3x CHOP + RT was preferred by many over 8x CHOP. Then R came along and the number of CHOP-cycles dropped to 6. But when the difference now is only one more cycle of R-CHOP which will allow you to skip RT, can you blame the hematologists for "pushing" the RT-free option?

In early favorable Hodgkin's things are less crystal clear. Omitting RT there will lead to an excessive risk for recurrence, but I've seen many patients opt to drop RT, even if that means 7-8% higher recurrence risk. On the other hand, if the volume is big and right in the mediastinum and you are an 19 year old young woman, what would you rather accept? 7-8% higher risk of recurrence by omitting RT or 3-5% (?) higher risk of RT-induced breast cancer? Protons can help there, but that's it....

One possible outlook will be RT in the setting of CAR-T-therapy. But still, there's a lot of work to do there!

True but there are some plenty that feel like RT plays no role in lymphoma. Consider the following example:

65 y/o patient has IIA DLBCL in the left neck and SCV. You give 6 cycles of RCHOP and they have 1 cm of residual uptake in what was initially a 6 cm node. What do you do?

1) Salvage chemo and BMT
2) Radiation

This was for one of my former prostate patients and you can imagine what they did and how I feel about it. It gets worse. They tried ICE but he actually didn't respond to it either so they opted to try CAR-T and asked me to radiate in the interim. I gave it 25 Gy and he had a CR before they even started CAR-T. Funny how that happens.

 

[RadOncDoc21]

True but there are some plenty that feel like RT plays no role in lymphoma. Consider the following example:

65 y/o patient has IIA DLBCL in the left neck and SCV. You give 6 cycles of RCHOP and they have 1 cm of residual uptake in what was initially a 6 cm node. What do you do?

1) Salvage chemo and BMT
2) Radiation

This was for one of my former prostate patients and you can imagine what they did and how I feel about it. It gets worse. They tried ICE but he actually didn't respond to it either so they opted to try CAR-T and asked me to radiate in the interim. I gave it 25 Gy and he had a CR before they even started CAR-T. Funny how that happens.

Another example of what happens when we voluntarily take ourselves out of the equation (less RT trials). I’m sure he did very well with the RT course.

 

[FrostyHammer]

Why did the med onc get referred a definitive h&n case first?

Who the heck knows...the only thing I can think of is that the ENT was thinking about concurrent chemorads but referred to hemeonc only for the initial time-being thinking that the hemeonc would eventually refer to radonc (or something else prevented them from getting to the radonc). But purely speculative

 

[ProtonElectronNeutron]

The role of RT in lymphoma is decreasing in the past years, but the reason are not "evil" hematologists. It's evidence as well.

HD17 recently showed that consolidation with RT can be omitted if interim-PET-negative after 2x BEACOPP esc followed by 2x ABVD in early unfavorable Hodgkin's.

Flyer showed that giving 4x R-CHOP is enough for early stage DLBCL without any RT. The Miller-approach of 3x CHOP + RT was preferred by many over 8x CHOP. Then R came along and the number of CHOP-cycles dropped to 6. But when the difference now is only one more cycle of R-CHOP which will allow you to skip RT, can you blame the hematologists for "pushing" the RT-free option?

In early favorable Hodgkin's things are less crystal clear. Omitting RT there will lead to an excessive risk for recurrence, but I've seen many patients opt to drop RT, even if that means 7-8% higher recurrence risk. On the other hand, if the volume is big and right in the mediastinum and you are an 19 year old young woman, what would you rather accept? 7-8% higher risk of recurrence by omitting RT or 3-5% (?) higher risk of RT-induced breast cancer? Protons can help there, but that's it....

One possible outlook will be RT in the setting of CAR-T-therapy. But still, there's a lot of work to do there!

I agree with evidence that you discussed. HD16 for favorable early stage reported that RT omission is NOT non-inferior even in PET negative cases. HD17 for unfavorable HL reported that RT omission is non inferior if you use dose escalated BEACOPP. But, no one in the US uses BEACOPP let alone dose escalated. I see RAPID study being used to substantiate RT omission, but the conclusion of study was RT omission is NOT non inferior (technically).

Agree with your comment on omission of RT in a 19 year old women. But how about a 70 year old with some cardiac and lung issues, who is struggling with chemo?

 

[FrostyHammer]

I recently saw a case in our local tumor board.

Stage IIIA NSCLC diagnosed and commenced treatment in another clinic. Bulky nodes in the mediastinum. Patient got Pembrolizumab, came back after 4 cycles with a partial remission in PET (apparently the tumor board of the other clinic thought "it wasn't worth it" to make him face concomitant radiochemotherapy given his poor prognosis with a bulky, unresectable stage III NSCLC).
Came to our clinic for surgery: ypT0 pN1 R0. All mediastinal nodes disappeared and only 5mm vital tumor found in hilar node.

I don't know what to say...
Is this the future for stage III NSCLC in some patients and how do we pick them out?
Patient is going to receive Pembro for a full year now. Lucky guy.

The only off-label IO use I am OK with is treating some IIIB NSCLCs as stage IV (after all, their prognosis has historically been similar) and giving them up-front pembro or chemo-pembro, then if they don't met out give local therapy with chemorads. I can't fault it too much because they'd have gotten durva anyway, so it's just substituting one IO for another IO. I suppose if I worked for AstraZeneca I wouldn't like that, but if I worked for Merck I sure would.

Also, along those lines, I really believe that this is the future of stage III NSCLC in response to Palex's comment:
- Up-front IO if higher PD-L1, up-front chemoIO if lower PD-L1 (for selection based on biology in efforts to individualize subsequent therapy)
- If good response, take to surgery or consolidate with chemoRT if inoperable (surgeons will always hold sway, sadly)
- If bad response, consolidate with chemoRT (throwing us the trash cases as usual)
- Adjuvant IO for lots of time or until progression (if you want to see healthcare costs triple - this is how you do it)

 

[FrostyHammer]

HD17 for unfavorable HL reported that RT omission is non inferior if you use dose escalated BEACOPP. But, no one in the US uses BEACOPP let alone dose escalated.

But does the chemo regimen even matter if they got a metabolic CR? That is the question.

 

[scarbrtj]

Another example of what happens when we voluntarily take ourselves out of the equation (less RT trials). I’m sure he did very well with the RT course.

Breast is the worst. But lymphoma might be the worsest!

 

[communitydoc13]

HD17 recently showed that consolidation with RT can be omitted if interim-PET-negative after 2x BEACOPP esc followed by 2x ABVD in early unfavorable Hodgkin's.

My takeaway from this is that even with dose escalated chemo, 1/3 of unfavorable HL should get XRT (are we really seeing this) and that in this population XRT seemed to make up for PET positivity after initial chemo (primary refractory excluded). Am I seeing the residual PET avid cases? Can't tell with this disease and in an older community.

I believe he should have got consolidation RT and hopefully that would have prevented the recurrence.

This seems to be the case for the unfavorable HL group in HD17. PET avid after chemo who got XRT seemed to do as well as PET negative.

HD16 for favorable early stage reported that RT omission is NOT non-inferior even in PET negative cases.

Interesting here that XRT did not make up for PET avidity for incomplete responders as well. Clearly the chemo regimen matters in terms of the meaning of metabolic CR and the ability of XRT to address incomplete responders.

Here is a rare "win" for RT in the world hematologic malignancies. TBI (12 Gy in 6 fx over 2 days) prior to allogeneic stem cell transplant vs chemo conditioning alone in pediatric ALL. 2-year overall survival was significantly higher following TBI (0.91; 95% CI, 0.86 to 0.95; P < .0001) versus chemoconditioning (0.75; 95% CI, 0.67 to 0.81).

Crazy how pediatric treatment of hematologic malignancies is more inclusive of XRT than adult malignancies. Peds Onc almost completely protocol based and interestingly they have retained XRT in the population most vulnerable to it. That being said, I am not eager to give 12 Gy to a 5 year old and have little doubt that there will be cognitive and other toxicity.

But does the chemo regimen even matter if they got a metabolic CR? That is the question.

Clearly it does. See above regarding HD16 and HD17.

Aside: I don't think I've ever seen BEACOPP used in my neck of the woods in the US for up front treatment of HL.

Never seen it.

 

[fiji128]

Here are the NCCN guidelines for favorable stage I/II classical Hodgkin Lymphoma in 2017 vs 2021. This shows there was a much larger role for ISRT in 2017 versus 2021.

 

[fiji128]

Here are the NCCN guidelines for unfavorable stage I/II classical Hodgkin Lymphoma in 2017 vs 2021. This also shows there was a much larger role for ISRT in 2017 versus 2021.

 

[fiji128]

Here are the NCCN guidelines for stage III/IV classical Hodgkin Lymphoma in 2017 vs 2021. RT not even showing up on this one in 2021.

 

[RadOncDoc21]

So why is lymphoma still on our oral boards?

 

[medgator]

So why is lymphoma still on our oral boards?

Probably same reason penile cancer is, whatever that is

 

[fiji128]

So why is lymphoma still on our oral boards?

To make sure you’re familiar with the treatment history and to show you know how to safely omit RT.

 

[RadOncDoc21]

To make sure you’re familiar with the treatment history and to show you know how to safely omit RT.

Basically just defer RT and you’ll pass.

 

[RadOncDoc21]

Back in my day it was all about ISRT and how we were moving possibly towards the use of INRT but I had no clue we would just skip over that step entirely.

 

[scarbrtj]

Like Fox News calling it for Biden in Arizona on election night, I think I'm ready to add this one to the tote board. I'd put utilization rates for all the diagnoses but it'd depress you too much.

 

[medgator]

Like Fox News calling it for Biden in Arizona on election night, I think I'm ready to add this one to the tote board. I'd put utilization rates for all the diagnoses but it'd depress you too much.

Pancreas?

 

[Palex80]

I agree with evidence that you discussed. HD16 for favorable early stage reported that RT omission is NOT non-inferior even in PET negative cases. HD17 for unfavorable HL reported that RT omission is non inferior if you use dose escalated BEACOPP. But, no one in the US uses BEACOPP let alone dose escalated.

Precisely. Noone does it now. But when the "radiation-unfriendly" hematologist reads those trial results, he/she may decide to change his/her mind...

 

[Palex80]

True but there are some plenty that feel like RT plays no role in lymphoma. Consider the following example:

65 y/o patient has IIA DLBCL in the left neck and SCV. You give 6 cycles of RCHOP and they have 1 cm of residual uptake in what was initially a 6 cm node. What do you do?

1) Salvage chemo and BMT
2) Radiation

This was for one of my former prostate patients and you can imagine what they did and how I feel about it. It gets worse. They tried ICE but he actually didn't respond to it either so they opted to try CAR-T and asked me to radiate in the interim. I gave it 25 Gy and he had a CR before they even started CAR-T. Funny how that happens.

FLYER reports 96% 3-years-PFS with 4x R-CHOP + 2R without radiation therapy for non-bulky stage I-II DLBCL.

Your patient is 65 and FLYER recruited only 18-60, but you see the point, right?
The vast majority of patients can be cured with 4x R-CHOP in stage I-II DLBCL without any radiation therapy. This is a considerable achievement. FLYER pretty much killed off radiation therapy for non-bulky and non-testicular DLBCL stage I-II. What is radiation therapy supposed to do? Push the 96% PFS to 100% PFS?

History of therapeutic approach in DLBCL Stage I-II over the past 20 years is something like:

8x CHOP --> 3x CHOP + RT --> 3x R-CHOP + RT + 2R or 6x R-CHOP + 2R --> 4x R-CHOP + 2R

So, it's half the chemo compared to 20 years ago. Why? Probably effect of Rituximab and (equally important IMHO) stage migration / treatment guidance with modern diagnostics (PET-CT & flow-cytometry). A lot of those stage I-II DLBCLs diagnosed in the 90s were probably understaged stage III/IV.

On a side note: DA-R-EPOCH also killed off radiation therapy for primary mediastinal B-cell lymphoma, 7 years ago. Prior to that most patients used to get R-CHOP + RT. RT was deemed crucial for cure and proven to be effective in multiple retrospective analyses. After DA-R-EPOCH started being delivered, I am only seeing 1 patient every couple of years which has residual PET-positive disease or a local recurrence. Pretty much everyone is getting DA-R-EPOCH. Frankly, I am glad. PMBCL often affects young women.

 

[medgator]

III/IV.

On a side note: DA-R-EPOCH also killed off radiation therapy for primary mediastinal B-cell lymphoma, 7 years ago. Prior to that most patients used to get R-CHOP + RT. RT was deemed crucial for cure and proven to be effective in multiple retrospective analyses. After DA-R-EPOCH started being delivered, I am only seeing 1 patient every couple of years which has residual PET-positive disease or a local recurrence. Pretty much everyone is getting DA-R-EPOCH. Frankly, I am glad. PMBCL often affects young women.

Got a young man with pmbcl now referred for consolidation after DA-EPOCH-R, slightly above background suv on the most recent scan, my understanding was that all of them still get consolidation xrt?

 

[ProtonElectronNeutron]

Kudos to my SDN radoncs!! This lymphoma discussion was way better that what I had got during my training re: lymphoma management.

 

[ProtonElectronNeutron]

Got a young man with pmbcl now referred for consolidation after DA-EPOCH-R, slightly above background suv on the most recent scan, my understanding was that all of them still get consolidation xrt?

There is no role for consolidation RT if its CR. Again, that phase II trial didn’t have RT in it.
COG is testing this question in their trials. Pedonc have my respect for testing things properly and following the protocols.