Follicular Lymphoma

[Damn_Daniel]

60 yo lady with neck mass, antibiotics didn't work. FNA - NHL, get an excisional. Excisional - follicular grad 1-2. PET negative. BM biopsy negative. IA

Any new outcomes data? Been relying on the Stanford for 20 years now... It's pretty outdated, since pre-molecular signature and pre-PET-CT. RFS was 44% at 10 years after RT for stage I/II. What do you quote now? Do you treat these folks? Stanford also has good watchful waiting data. Is lymphoma all Stanford does? Jeez. SEER data says definitely treat, RT has a survival benefit, but I never know what to do with all the database stuff. Have you noticed that JCO and Red Journal basically publish at least one NCDB or SEER analysis per issue? Big Data, y'all.

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[napoleondynamite]

observe vs definitive RT if that's her only site of disease and excellent performance status.

I would present both of those options to the patient. Toxicity of 24-30Gy even in the H&N region is pretty dang minimal and we do "cure" some of these folks with localized disease. So personally I'd encourage her to opt for XRT.

*NCCN prefers treatment also

 

[seper]

Treat it.

 

[RadOncDoc21]

I feel bad now, I just took a lady to 42 Gy because of Grade 2-3 and she refused any kind of systemic therapy (including Rituxan alone).

 

[Damn_Daniel]

Well played!

 

[deleted205418]

I would treat her. 24 Gy is efficacious and well tolerated. http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)70036-1/abstract

 

[medgator]

I feel bad now, I just took a lady to 42 Gy because of Grade 2-3 and she refused any kind of systemic therapy (including Rituxan alone).

why? Some of those G2-3s can be bad actors. A G3 follicular lymphoma can end up being like a DLBCL and if she refused chemo, I'd take a DLBCL to 45-50.4 as per NCCN guidelines. You can't address systemic disease but at least local issues won't be her problem.

 

[Damn_Daniel]

Maybe. I agree it's more aggressive, but without chemo for DLBCL, you'd want to treat an extensive field. The dose sensitivity is less of a concern, compared to larger fields.

 

[RadOncDoc21]

I did ISRT to the lymph node chain, but did dose escalate because of the grade and not having chemo but waffled on what dose to use. I considered using 24-30 Gy but wanted to give good local control... Now I'm wondering if I should have taken it higher.

My problem with an extensive field approach is that I would feel really bad to treat such a large area and still miss some disease, granted it would be at a lower dose.

I guess at the end of the day, chemo and possible more RT (to another site) is still an option.

To answer your case, NCCN says treat to 24 Gy (radiation preffered).

 

[Haybrant]

Treat it. If you look at Stanford paper after all those years they only selected a pretty small group to observe. If the best of the best (advani and Saul rosenberg) have such a small group that says something about their comfort level in selecting the right people.

 

[Haybrant]

Old thread, somewhat new question. Have a follicular lymphoma Stage II right cervical neck/right axilla/right supraclav (about 5 separate lesion) got Chemo and had complete initial response was complete but within 4 month scan developed recurrence. Sent from med onc to consider RT. Not symptomatic. If you were treating now what dose would you go to? Is 30 sufficient in recurrent setting for follicular?

 

[Palex80]

24 Gy or 30 Gy are both reasonable approaches. No reason to escalate in my opinion.

Actually the quoted data from Stanford showing not all that promising long lasting remission after treating stage I follicular lymphoma, are probably too pessimistic.
Stage migration certainly plays a role here. In the past lots and lots of patients were treated for presumed stage I follicular lymphomas, which were actually more than that. They were stage II-IV lymphomas, that we are able to see today using modern diagnostics. The Stanford data do not report on PET-staged patients. These patients only received CT scans. I have seen several patients in the past years, where PET unveiled nodes, that would have been missed in CT-only staging.
Furthermore patients in the past were staged only with "standard" histology of bone marrow. I have seen a few patients in the past years where flow cytometry of the bone marrow unveiled tiny little populations of lymphoma cells. I am talking about small populations of <5% of all b-cells, which did however carry all the signatures of a follicular lymphoma. Those are "very-early" stage IV patients, that would have been missed in the past (in fact bone marrow histology was normal), but who have a minimal bone marrow infiltration by follicular lymphoma. One that certainly is not going to be cured by RT.

 

[evilbooyaa]

Old thread, somewhat new question. Have a follicular lymphoma Stage II right cervical neck/right axilla/right supraclav (about 5 separate lesion) got Chemo and had complete initial response was complete but within 4 month scan developed recurrence. Sent from med onc to consider RT. Not symptomatic. If you were treating now what dose would you go to? Is 30 sufficient in recurrent setting for follicular?

What grade initially? What chemo did patient get? Bulky disease at presentation? Has it been re-biopsied to rule out grade migration? I think you need to completely re-stage the patient (including BM Bx) before doing RT, which would be salvage but with curative intent? Odds probably aren't great.

Not sure on data for RT in recurrent follicular but I'd probably lean towards a 36Gy dosing.

 

[Haybrant]

What grade initially? What chemo did patient get? Bulky disease at presentation? Has it been re-biopsied to rule out grade migration? I think you need to completely re-stage the patient (including BM Bx) before doing RT, which would be salvage but with curative intent? Odds probably aren't great.

Not sure on data for RT in recurrent follicular but I'd probably lean towards a 36Gy dosing.

Thanks Palex and EvilB. He did have a bone marrow up front that was negative. They considered him stage III up front and gave him R-Benda assuming he had a positive internal iliac node and called him Stage III (is R-Benda even a thing anymore?). When I look at it however (clearly they didn't look) the uptake in the pelvis is his ureter. It was Grade 1 presumably at diagnosis. It is not bulky, there are 5 scattered nodes about 1-2 cm max in size in the regions I noted. Palex you're ok with 30?

 

[evilbooyaa]

Thanks Palex and EvilB. He did have a bone marrow up front that was negative. They considered him stage III up front and gave him R-Benda assuming he had a positive internal iliac node and called him Stage III (is R-Benda even a thing anymore?). When I look at it however (clearly they didn't look) the uptake in the pelvis is his ureter. It was Grade 1 presumably at diagnosis. It is not bulky, there are 5 scattered nodes about 1-2 cm max in size in the regions I noted. Palex you're ok with 30?

If they thought he was stage III I'm wondering why they treated him at all initially...

I have seen R-Benda recently, but I can't remember exactly what diagnosis it was for... I think for a mantle cell? However, if they treated it as stage III without noticing that he wasn't actually stage III, then I question how correct the heme/onc will be on other things.

I would probably push for re-biopsy to make sure this isn't grade 3 now (as that gets treated like DLBCL), and re BM biopsy. If grade stable and BM bx negative I think 30 is not unreasonable. I wouldn't personally feel comfortable at 24 given short interval recurrence after chemo.

 

[Haybrant]

I have seen R-Benda recently, but I can't remember exactly what diagnosis it was for... I think for a mantle cell? However, if they treated it as stage III without noticing that he wasn't actually stage III, then I question how correct the heme/onc will be on other things..

haha Truth; It is this one med onc though who is like 105 years old, the rest are fairly on point.

 

[Palex80]

R-Benda is utilized a lot in Europe for follicular lymphoma and other indolent lymphomas. It's quite a good treatment in my opinion.

30 Gy is fine. We generally give 24 Gy based on the British trial that showed no differences between higher and lower dose in terms of control.
Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial. - PubMed - NCBI
This is however a recurrent lymphoma, so I would understand your point of wanting to give more dose.

Rebiopsy is something you should consider, since his remission was so short. 4 months are really very short for a grade I follicular lymphoma. I wouldn't do the bone marrow probably, but just resect and have a look at one of the progressive nodes. Does he have any other signs that may lead you to think he may have a DLBCL-transformation, like an elevated LDH? Being asymptomatic is actually an argument against transformation.