Palliative RT dose for refractory chemo-resistant NHL (DLBCL)

[Kroll2013]

What palliative RT dose do you use for aggressive NHL?
P.S Some of The studies comparing 24 Gy versus low dose palliative RT 2*2Gy included aggressive NHL subtypes.

Thx

---

Members don't see this ad.

 

[Cancerdancer]

30/10 or 20/5...if it's non-curable aggressive NHL that is causing sx's enough to the point that you're needing to palliate, you're not needing to worry about late effects, and wanna achieve your goal of regression/palliation. Suppose you could try 2x2 if it's somewhere you're worried about acute toxicity (esophagitis etc) but data suggests larger tumors > 5 cm don't respond as well to 2x2, and if it's < 5 cm often not causing sx's so not a very common scenario to encounter.

 

[Kroll2013]

30/10 or 20/5...if it's non-curable aggressive NHL that is causing sx's enough to the point that you're needing to palliate, you're not needing to worry about late effects, and wanna achieve your goal of regression/palliation. Suppose you could try 2x2 if it's somewhere you're worried about acute toxicity (esophagitis etc) but data suggests larger tumors > 5 cm don't respond as well to 2x2, and if it's < 5 cm often not causing sx's so not a very common scenario to encounter.

Indeed. this patient has a huge pelvic mass that is compressing the ureter of his unique transplanted kidney! that s why i am concerned about what minimum effective palliative dose in this setting and the tolerance constraints of a transplanted kidney.

 

[medgator]

Would probably do 30-36 Gy, unless localized and trying to be aggressive with DLBCL where I would consider going up to 45 Gy if the surrounding tissue permitted.

Indeed. this patient has a huge pelvic mass that is compressing the ureter of his unique transplanted kidney! that s why i am concerned about what minimum effective palliative dose in this setting and the tolerance constraints of a transplanted kidney.

I would not consider the ureter and kidney to have the same tolerance dose. If the tumor is right up against the kidney itself, you could try imrt

 

[Sheldor]

I agree with the above, I think for DLBCL you're safest bet is to take it to 30 Gy, and it should be fairly well tolerated if you went with IMRT like medgator suggested. I'd think that a transplant would qualify as medical necessity for IMRT.

 

[mikedc813]

There's no strong evidence that 2 Gy x 2 should be routinely used for DLBCL palliation, although small numbers of these patients have been included in analyses with predominantly indolent lymphoma patients. I would stick to 30/10, etc...

 

[Palex80]

One thing I have learned about 2 x 2 Gy palliative RT (by the way many series didn't do just 2 x 2 Gy but rather 1 x 4 Gy) is that YOU CAN ALWAYS RETREAT, provided you keep an eye on your patients.
Therefore in the last 2 years I have regularly treated any kind of lymphoma referred to me for palliative treatment with 2 x 2 Gy. Surely the response rates are not that good in aggressive lymphomas (like DLBCL) as they are indolent lymphomas, but who cares? I treat the patients and then ask to see them again 4 weeks after treatment. If adequate response is not there, I then treat aggressively with 10 x 3 Gy.

There's not much to lose there in my opinion, since its palliative. Yes, you will have to retreat something like 30-40% of your patients after 4 weeks, but the other 60% are well off with a side-effect-free treatment (2 x 2 Gy) and happy.
There are a couple of exceptions here, meaning you shouldn't do this in patients who have major symptoms because of their lymphoma and urgently need treatment.
If the lymphoma is causing obstruction in the bronchial system or is close to ulcerating (mostly leg-type DLBCL) you need fast and certain remission. I'd treat those right away with 10 x 3 Gy.
However lots of palliative lymphoma referrals are for non-urgent issues, like patients complaining about a neck mass when they shave or being disturbed when putting clothes on/off because of an axillary or inguinal mass. These are not urgent indications for treatment and you can "risk" delaying remission by 4 weeks in most of those patients. Bear in mind that giving 10 x 3 Gy to the neck is going to cause symptoms, irrelevant of the technique you are going to use, if the GTV is not tiny. 2 x 2 Gy will on the other hand work fine.

Side note: New data points out that 2 x 2 Gy can even be curative (even if the latest British trial said it isn't that good as 24 Gy) for certain indications:
http://www.ncbi.nlm.nih.gov/pubmed/23726002
Now, if I had an indolent ocular lymphoma, I would rather opt for 2 x 2 Gy than the full 24 Gy and "risk" retreatment.
2 x 2 Gy may not even cause a cataract and will definitely not lead to a dry eye, something which may happen if 24 Gy hit the lacrimal gland.