Marginal Zone Lymphoma of the Conjunctiva

[XRT_doc]

Would you treat the whole orbit if there's conjunctival involvement but no orbital involvement?

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[Palex80]

Actually, I'd give 2 x 2 Gy to the involved regions.

http://www.ncbi.nlm.nih.gov/pubmed/23726002

I think it's a good trade-off between tumor control and toxicity. You can always salvage the patient later. 2 x 2 Gy is practically toxicity-free.

 

[XRT_doc]

Actually, I'd give 2 x 2 Gy to the involved regions.

http://www.ncbi.nlm.nih.gov/pubmed/23726002

I think it's a good trade-off between tumor control and toxicity. You can always salvage the patient later. 2 x 2 Gy is practically toxicity-free.

I'm going for a cure. What's the standard of care for this? MZL can be cured with 24 Gy.

 

[napoleondynamite]

I'm with Palex. I would also do the 2x2.

 

[Palex80]

I'm going for a cure. What's the standard of care for this? MZL can be cured with 24 Gy.

Of course you can cure it with 24 Gy. But you will also make the patient need a new lens in a couple of years due to cataract and may also induce a dry eye, especially if you treat the entire orbit and with it the lacrimal gland.
Look at the quoted paper: 85% CR at 2 years is promising. Follow up the patient and salvage if needed with full dose.

 

[Damn_Daniel]

I'd have said 20-24, but that paper is really good. And totally right about the cataracts. Didn't even think of that.
I've had success with 2 Gy x 2 for other sites. Sometimes go just a tad higher, like 2 Gy x 5 if it's in an area not near anything sensitive. Seems a bit more durable that way.

 

[radiaterMike]

I'd have said 20-24, but that paper is really good. And totally right about the cataracts. Didn't even think of that.
I've had success with 2 Gy x 2 for other sites. Sometimes go just a tad higher, like 2 Gy x 5 if it's in an area not near anything sensitive. Seems a bit more durable that way.

Paper seems good but the follow up is only about 2 years. You could approach 24 Gy and be ok with lacrimal glands if you dose paint away hotspots. Patient will get cataracts albeit that is treatable.

2 Gy x 2 won't burn bridges if you need to repeat it a few times and is apparently effective but it is probably is not standard of care outside of palliation (neither NCCN nor ILROG recognize 2 Gy x 2 for anything outside palliation )

2 Gy x 5 is interesting albeit not evidence based. Maybe a good compromise but I would worry about deviating too far from standard of care.


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[napoleondynamite]

Dose paint? I doubt you'd get IMRT approved by insurance, even though I agree it would be much better.

I swear, 3D have become my most difficult plans in the era of RapidArc.

 

[Palex80]

I agree 2x2Gy only has short follow up, but I would treat a patient to full dose if he/she recurrs after 2x2Gy.
And yes, NCCN does not recommend it, but NCCN is not always up to date.
This is something you can discuss with the patient. "I think that a short RT schedule will probably heal you from this disease, with a chance of well over 3 to 1 (that's a safe estimate for long term eficaccy proably), without any late side effects, but we could still do the standard treatment, which is proven, but will produce cataract and may induce a dry eye. Please pick."

I know many people are not comfortable with 2x2 Gy, but sometimes I get the feeling many physicians only care about reimbursement of long course stamdard RT. This is a disease where radical RT is not known to produce an OS benefit (this is not nodal follicular lymphoma!) and with most data based on the pre-rituximab era.

 

[Damn_Daniel]

What do you mean? I don't have RapidArc or VMAT or anything like that, but we are thinking about it.

Dose paint? I doubt you'd get IMRT approved by insurance, even though I agree it would be much better.

I swear, 3D have become my most difficult plans in the era of RapidArc.