Indolent follicular lymphoma case

[CodeRedDew]

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Hello friends,

Just wanted to get some thoughts regarding a case - 60 y/o male who was found to have a stage IVA indolent follicular lymphoma with nonbulky nodal disease and a small but PET+ extranodal lesion involving the T7 spine/VB with minimal posterior extraosseous extension but visualized cortical breakthrough and ventral epidural impingement per MRI. Neurologically intact & asymptomatic. No systemic tx indicated at this time but MedOnc referred pt to our dept for consideration of XRT for local control to the at-risk T7 lesion.

Would you treat now or continue to observe with repeat MRI in 3-6 mos and save XRT at time of clinical or radiographic progression?


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[Haybrant]

What would be your reason to wait?

 

[RadOncDoc21]

Hello friends,

Just wanted to get some thoughts regarding a case - 60 y/o male who was found to have a stage IVA indolent follicular lymphoma with nonbulky nodal disease and a small but PET+ extranodal lesion involving the T7 spine/VB with minimal posterior extraosseous extension but visualized cortical breakthrough and ventral epidural impingement per MRI. Neurologically intact & asymptomatic. No systemic tx indicated at this time but MedOnc referred pt to our dept for consideration of XRT for local control to the at-risk T7 lesion.

Would you treat now or continue to observe with repeat MRI in 3-6 mos and save XRT at time of clinical or radiographic progression?


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Treat now, can even consider lower doses “boom-boom” but I would likely treat typical palliative dose due to location.

 

[CodeRedDew]

What would be your reason to wait?

I wish I had a good answer for you, but per my attending “given the pt is asymptomatic with an unusual presentation as follicular lymphoma usually doesn’t have extranodal lesions in the spine, we should continue to observe”. I didn’t really understand why?? He also didn’t recommend bx either as it would likely be difficult/non-dx anyway.

Reason why I’m posting here is because I really didn’t agree with the management and wanted to get some additional opinions before I ran the case by another faculty member. I don’t see a reason to wait as treatment morbidity would be very minimal/if any at all with a potential for great benefit in possibly preventing VCF and/or continued progression into the spinal canal.

But I’d be curious to hear if anyone has any reasons NOT to treat now in this case?


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[gmsquid]

24 in 12, really good local control and could treat again easily.

 

[Mandelin Rain]

Waiting till progression = waiting till frank cord compression = nonsensical

 

[Haybrant]

I wish I had a good answer for you, but per my attending “given the pt is asymptomatic with an unusual presentation as follicular lymphoma usually doesn’t have extranodal lesions in the spine, we should continue to observe”. I didn’t really understand why?? He also didn’t recommend bx either as it would likely be difficult/non-dx anyway.

Reason why I’m posting here is because I really didn’t agree with the management and wanted to get some additional opinions before I ran the case by another faculty member. I don’t see a reason to wait as treatment morbidity would be very minimal/if any at all with a potential for great benefit in possibly preventing VCF and/or continued progression into the spinal canal.

But I’d be curious to hear if anyone has any reasons NOT to treat now in this case?


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Ya I think a lot of us found ourselves in situations like this where we didn’t really understand the situation fully and afterall they are the attending so they must know but it gnaws at you. Im surprised to hear it though, that recommendation does not sounds like a rad onc but good on you to have the correct intuition. You don’t mess around w situations like this. Oh follicular lymphoma is indolent huh? Well why the heck is the thing invading the vertebral body then? Biology is king not terminology, remember that.

 

[Mandelin Rain]

If he’s worried about the “unusual presentation of FL”, Check a psa.

 

[Mandelin Rain]

“I prefer the lymphoma seeds the CSF and the patient is nonambulatory before I treat.”

I really don’t get the thought process here. Maybe there is more to the story.

 

[radiation]

Agree with what everyone here has said. Poor outcomes noted with extranodal follicular lymphoma, especially in this untreated case

Detection of extranodal and spleen involvement by FDG-PET imaging predicts adverse survival in untreated follicular lymphoma - PubMed

Predicting early clinical failure in patients with untreated follicular lymphoma (FL) is important but difficult. This study aimed to determine the incidence and patterns of extranodal (EN) and spleen disease using PET/CT, and assess their utility in predicting early clinical failure. PET/CT...

www.ncbi.nlm.nih.gov

Bone involvement is not that uncommon, 10% in the Mayo series above

Agree with starting 2 gy x 2 regimen at the very least as noted by RadOncDoc21 and if doesnt have robust shrinkage immediately then continue onto 24 gy in 12

 

[Palex80]

Agree with what everyone here has said. Poor outcomes noted with extranodal follicular lymphoma, especially in this untreated case

Detection of extranodal and spleen involvement by FDG-PET imaging predicts adverse survival in untreated follicular lymphoma - PubMed

Predicting early clinical failure in patients with untreated follicular lymphoma (FL) is important but difficult. This study aimed to determine the incidence and patterns of extranodal (EN) and spleen disease using PET/CT, and assess their utility in predicting early clinical failure. PET/CT...

www.ncbi.nlm.nih.gov

Bone involvement is not that uncommon, 10% in the Mayo series above

View attachment 292199

Agree with starting 2 gy x 2 regimen at the very least as noted by RadOncDoc21 and if doesnt have robust shrinkage immediately then continue onto 24 gy in 12

Why give 24/2 for a palliative treatment of follicular lymphoma.

2 x 2 Gy would be my first choice, but why have the patient come 2.5 weeks to you when you only have to treat such a small volume?
Give him 20 /4-5 and call it a day.
🙂

 

[Palex80]

I wish I had a good answer for you, but per my attending “given the pt is asymptomatic with an unusual presentation as follicular lymphoma usually doesn’t have extranodal lesions in the spine, we should continue to observe”. I didn’t really understand why?? He also didn’t recommend bx either as it would likely be difficult/non-dx anyway.

Reason why I’m posting here is because I really didn’t agree with the management and wanted to get some additional opinions before I ran the case by another faculty member. I don’t see a reason to wait as treatment morbidity would be very minimal/if any at all with a potential for great benefit in possibly preventing VCF and/or continued progression into the spinal canal.

But I’d be curious to hear if anyone has any reasons NOT to treat now in this case?

I would accept your attending's opinion if the med onc decided to treat with systemic therapy anyways and wanted to ask if one should irradiate "on-top" to be on the safe side. One could then well advocate that response rates of follicular lymphoma to first line systemic treatment (for example obinutuzumab + bendamustine) are very, very good and one can ommit radiation therapy now given the lack of symptoms.

Not giving the patient any treatment right now can be dangerous in my opinion. I wouldn't go down that road...

 

[gmsquid]

Maybe concerned the lesion isn’t FL? If that’s the case biopsy it. Then treat based on histo.

 

[CodeRedDew]

Maybe concerned the lesion isn’t FL? If that’s the case biopsy it. Then treat based on histo.

Which is basically what he was thinking but in the end, elected for continued obs rather than biopsy due to risk of complication/chance of non-dx biopsy and we’d be basically stuck in the same position. Regardless of histology though, it’s threatening the SC ‍♂️.

And MedOnc didn’t feel too strongly about chemo given the pt’s limited disease burden. PSA was normal btw.


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[CodeRedDew]

Why give 24/2 for a palliative treatment of follicular lymphoma.

2 x 2 Gy would be my first choice, but why have the patient come 2.5 weeks to you when you only have to treat such a small volume?
Give him 20 /4-5 and call it a day.
🙂

I would also favor a more protracted course as the FORT trial showed significantly better local control with 24/2 compared to 2x2 (among other series of various histologies showing more durable control/improved functional outcomes with higher doses). 20/4-5 is a good middle ground though.


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[Mandelin Rain]

I think your intuition is spot on. The natural history of any untreated cancer is to grow. When the cancer is already abutting the cord, it doesn't take much growth to cause significant morbidity.

I'd treat to 24Gy, now. If you think it's a different histology, all the more reason to treat it now. On the PET, what was the SUV of this lesion vs the nodal disease? This could be the sole site of transformed disease. As mentioned before, it's not behaving in an indolent manner having already eaten through bony cortex.

 

[xrthopeful]

I would honestly just do 20/5 or 30/10. It’s acting like a high grade

 

[OTN]

If it were me I would want it treated. What's the downside to treatment from the patient's standpoint, other than financial toxicity? The downside of waiting is possible paralysis/CSF seeding. Equation seems straightforward to me.

 

[evilbooyaa]

I correlate this similarly to Multiple Myeloma - usually you can do 20-24/10-12, but for spinal disease guidelines recommend 30/10.

In this scenario I would 100% treat. I don't drop the m-word frequently, but I think your attending is risking a malpractice lawsuit by NOT treating in this scenario, like if the patient progresses and has any neurological deficits as a result of not getting therapy. Agree that if patient was going to be getting chemo could try to hold off. The downside of treating here is quite minimal.

Exact dosing choices in this situation will be variation in practice. I would favor 24/12 per FORT but I can see the argument for 20/5 or 30/10. Is this lesion PET-avid while remaining lesions are not? If so this could be a focal transformation that would push me much harder to 20/5 or 30/10. I would not personally be a fan of 2x2 just because of the location (and potential concern for transformation) of this lymphoma.

 

[RickyScott]

I correlate this similarly to Multiple Myeloma - usually you can do 20-24/10-12, but for spinal disease guidelines recommend 30/10.

In this scenario I would 100% treat. I don't drop the m-word frequently, but I think your attending is risking a malpractice lawsuit by NOT treating in this scenario, like if the patient progresses and has any neurological deficits as a result of not getting therapy. Agree that if patient was going to be getting chemo could try to hold off. The downside of treating here is quite minimal.

Exact dosing choices in this situation will be variation in practice. I would favor 24/12 per FORT but I can see the argument for 20/5 or 30/10. Is this lesion PET-avid while remaining lesions are not? If so this could be a focal transformation that would push me much harder to 20/5 or 30/10. I would not personally be a fan of 2x2 just because of the location (and potential concern for transformation) of this lymphoma.

Agree with the above, but at the very least 2 Gy x 2 will never hurt anybody or burn bridges and cause 0 side effects. No downside! Unless systemic treatment is soon planned, attending is an evidence-based, "if the patient doesnt have pain, what am I palliating" idiot. In addition to growing into cord, Vertebrae could suddenly collapse within the next few months and pt would be in real trouble.

 

[xrthopeful]

I almost feel like there HAS to be more to the story as to why the attending won’t treat

 

[CodeRedDew]

I almost feel like there HAS to be more to the story as to why the attending won’t treat

You would think so right? But unfortunately, this isn’t the case :-/ he is an old school attending who is very resistant to any changes in his management/treatment decisions.


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[Mandelin Rain]

When was it ever appropriate to not treat cancer threatening the spinal cord? That's like Week 1, Day 1 type stuff.

 

[taserlaser]

When was it ever appropriate to not treat cancer threatening the spinal cord? That's like Week 1, Day 1 type stuff.

I mean treat, yes, but doesn’t necessarily have to be RT. As I’m sure we know, full on caveats which do not necessarily apply to this case of wanting tissue diagnosis, r/o curable pathology which would rapidly respond to first line chemo in a curative regimen, etc etc. I’m dealing with a retreatment right now to a lumbar mass that’s received twice single 8 Gy as palliative RT as a reflex from two separate providers but actually has a curative tumor and is now requiring RT to gross disease doses as part of their curative intent treatment plan. Not great that I now have to treat past TD5/5 levels. Taking the consideration to make sure RT is indeed the best modality is worthwhile, as rare as the situation is. I agree with RT upfront in the above case as described and with many of the comments above, but reflexively treating everything in cord vicinity will burn someone eventually without asking the proper questions.

 

[Aphtalyfe]

You would think so right? But unfortunately, this isn’t the case :-/ he is an old school attending who is very resistant to any changes in his management/treatment decisions.


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I'd curbside another senior attending and see if they will intervene. "Hi Dr. Soandso would you mind taking a look at this scan and seeing what you think?"

I've also had some success with asking leading questions to stubborn attendings. "So what would happen if this progresses?" "What sort of toxicity would we see if we treated now?" "If it does progress and they have symptoms... how fast does radiation work for lymphoma?" "How long can someone have malignant cord compression and expect regain of normal function?"

I'd also do more than 2 Gy x 2 given the need for local control. 24/12 would be my choice... and if for some reason you needed to retreat you could do so without needing SBRT. If it ends up being something more aggressive then you can re-treat to a higher dose with SBRT.

 

[Mandelin Rain]

I mean treat, yes, but doesn’t necessarily have to be RT. As I’m sure we know, full on caveats which do not necessarily apply to this case of wanting tissue diagnosis, r/o curable pathology which would rapidly respond to first line chemo in a curative regimen, etc etc. I’m dealing with a retreatment right now to a lumbar mass that’s received twice single 8 Gy as palliative RT as a reflex from two separate providers but actually has a curative tumor and is now requiring RT to gross disease doses as part of their curative intent treatment plan. Not great that I now have to treat past TD5/5 levels. Taking the consideration to make sure RT is indeed the best modality is worthwhile, as rare as the situation is. I agree with RT upfront in the above case as described and with many of the comments above, but reflexively treating everything in cord vicinity will burn someone eventually without asking the proper questions.

Yes. Obviously don't treat curable cases to palliative doses if there's not a good reason, and yes chemotherapy can be used instead of XRT in FL (in this case... it's not...). I would add that 10 days of RT to a small T-spine volume is easier to tolerate than months of RCHOP or RB.

I'll stand by: "When was it ever appropriate to not treat cancer threatening the spinal cord?"

 

[evilbooyaa]

When was it ever appropriate to not treat cancer threatening the spinal cord? That's like Week 1, Day 1 type stuff.

We treat most bone mets with MRI evidence of just epidural extension even if asymptomatic, even if it's not frankly causing radiographic cord compression (unless patient is actively dying). We call it prophylactic palliation. Maybe overkill, but does anybody else do this as well?

 

[taserlaser]

We treat most bone mets with MRI evidence of just epidural extension even if asymptomatic, even if it's not frankly causing radiographic cord compression (unless patient is actively dying). We call it prophylactic palliation. Maybe overkill, but does anybody else do this as well?

Depends exactly on the situation, but often.

 

[Mandelin Rain]

We treat most bone mets with MRI evidence of just epidural extension even if asymptomatic, even if it's not frankly causing radiographic cord compression (unless patient is actively dying). We call it prophylactic palliation. Maybe overkill, but does anybody else do this as well?

Almost always. If PSA is coming down on ADT or chemo just started, I might watch to see if a response. But I wouldn't just let patient have NO treatment.

 

[Lamount]

We treat most bone mets with MRI evidence of just epidural extension even if asymptomatic, even if it's not frankly causing radiographic cord compression (unless patient is actively dying). We call it prophylactic palliation. Maybe overkill, but does anybody else do this as well?

This doesn't come up all that often for me because I seldomly would see an MRI spine on an asymptomatic patient. If I were treating a symptomatic lesion and incidentally saw another asymptomatic tumor with epidural extension, I would try to treat (assuming the field wasn't humongous)... but I would be remiss to halt systemic therapy that seems to be working to treat a stable painless lesion, unless there was severe canal narrowing

 

[Palex80]

I mean treat, yes, but doesn’t necessarily have to be RT. As I’m sure we know, full on caveats which do not necessarily apply to this case of wanting tissue diagnosis, r/o curable pathology which would rapidly respond to first line chemo in a curative regimen, etc etc. I’m dealing with a retreatment right now to a lumbar mass that’s received twice single 8 Gy as palliative RT as a reflex from two separate providers but actually has a curative tumor and is now requiring RT to gross disease doses as part of their curative intent treatment plan. Not great that I now have to treat past TD5/5 levels. Taking the consideration to make sure RT is indeed the best modality is worthwhile, as rare as the situation is. I agree with RT upfront in the above case as described and with many of the comments above, but reflexively treating everything in cord vicinity will burn someone eventually without asking the proper questions.

Wait, wait, wait... A "lumbar mass" and you are talking about "curative intent treatment plan"? Please elaborate...

 

[taserlaser]

Wait, wait, wait... A "lumbar mass" and you are talking about "curative intent treatment plan"? Please elaborate...

I mean the odd duck lymphoma/Ewing’s/chordomas/chondrosarc/etc. Your point is well taken though.

 

[CodeRedDew]

I think your intuition is spot on. The natural history of any untreated cancer is to grow. When the cancer is already abutting the cord, it doesn't take much growth to cause significant morbidity.

I'd treat to 24Gy, now. If you think it's a different histology, all the more reason to treat it now. On the PET, what was the SUV of this lesion vs the nodal disease? This could be the sole site of transformed disease. As mentioned before, it's not behaving in an indolent manner having already eaten through bony cortex.

mSUV of the bony lesion was 8, which was slightly higher than any of the nodal sites which ranged from 5-7.


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[evilbooyaa]

This doesn't come up all that often for me because I seldomly would see an MRI spine on an asymptomatic patient. If I were treating a symptomatic lesion and incidentally saw another asymptomatic tumor with epidural extension, I would try to treat (assuming the field wasn't humongous)... but I would be remiss to halt systemic therapy that seems to be working to treat a stable painless lesion, unless there was severe canal narrowing

Fair enough and that's reasonable, but it's usually a discussion with med-onc. I agree most MRIs are in symptomatic patients, but I've seen them in asymptomatic patients as well. I agree that can monitor if not getting RT, otherwise if patient is getting treated anyways (even if it's separate fields, like say a T11 lesion is symptomatic but patient has a T5 asymptomatic lesion with epidural extension, we'd just treat both with two separate isocenters).

mSUV of the bony lesion was 8, which was slightly higher than any of the nodal sites which ranged from 5-7.


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With SUVs that close I wouldn't worry as much about transformation. Would probably lean towards 24/12 so could re-treat if necessary rather than burning cord tolerance with 30/10.

 

[Palex80]

With SUVs that close I wouldn't worry as much about transformation. Would probably lean towards 24/12 so could re-treat if necessary rather than burning cord tolerance with 30/10.

You won't have to retreat with 30/10. 🙂

 

[RadOncDoc21]

Fair enough and that's reasonable, but it's usually a discussion with med-onc. I agree most MRIs are in symptomatic patients, but I've seen them in asymptomatic patients as well. I agree that can monitor if not getting RT, otherwise if patient is getting treated anyways (even if it's separate fields, like say a T11 lesion is symptomatic but patient has a T5 asymptomatic lesion with epidural extension, we'd just treat both with two separate isocenters).



With SUVs that close I wouldn't worry as much about transformation. Would probably lean towards 24/12 so could re-treat if necessary rather than burning cord tolerance with 30/10.

I’ve retreated patients after 30/10 with the indication being either paralysis from cord compression vs paralysis from something like 8 Gy x’1 or using either IMRT or SBRT if I have some time to get a plan going. I think in that scenario I’m ok with going over cord tolerance. Even in the case of progressive disease that’s not invading the cord (yet).

For this case, any dose should control disease and if it doesn’t it’s definitely not a follicular lymphoma. I guess my question is why not just do 30/10 or 20/5 and be done vs assuming it’s a low grade lymphoma?

 

[RadOncDoc21]

You won't have to retreat with 30/10. 🙂

I’m with you, do 30/10 and be done.