Lymphoma case: How much would you treat?

[Palex80]

60 year old lady with a low grade lymphoma Stage IV (lymph nodes & bone marrow) not in need of treatment so far.
Transformation in the cervical region to a diffuse large b-cell lymphoma, both neck sides and waldeyer's-ring involved (like a Stage II DLBCL).

She underwent immunochemotherapy with 6xR-CHOP.
PET documents an overall good response, but one node is still avid after competion of therapy.

How would YOU treat?

Strategy 1:
Cervical nodes on both sides + waldeyer's ring to 30 Gy, boost avid node to 46 Gy.

Strategy 2:
Just the avid node to 46 Gy.

Strategy 3:
This is palliative, she has a stage IV low grade NHL. No treatment.

I am probably going for strategy 1
Tough call...
30 Gy on both neck sides is going to have some long term toxicity, even with IMRT.
On the other hand, it may even be "curative" for a certain amount of years, until her low grade lymphoma progresses or transforms again.

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[Gfunk6]

I agree with Strategy 1. The main reason to withhold treatment in Stage IV follicular lymphoma is that it is an indolent disease and therapy at advanced stages does not improve survival. This is a quite a different situation since she's had a DLBCL transformation.

I full agree with INRT (with IMRT) rather than IFRT to reduce toxicity. Your doses seem reasonable as well.

 

[TarHeelRadOnc]

I agree with Strategy 1. The main reason to withhold treatment in Stage IV follicular lymphoma is that it is an indolent disease and therapy at advanced stages does not improve survival. This is a quite a different situation since she's had a DLBCL transformation.

I full agree with INRT (with IMRT) rather than IFRT to reduce toxicity. Your doses seem reasonable as well.

I had a similar case recently, except transformation to DLBCL with in inguinofemoral chain. Treated same way with R-CHOP x 6 + 30.6/17 to involved field. Agree with GFunk that INRT is reasonable to try to reduce toxicity, but if Waldeyer's ring involved I'm not certain you'll do a lot better with parotid sparing using INRT vs IFRT.... but probably worth a try. Would definitely use IMRT either way.

 

[ShirleyT]

was the original histology follicular/marginal zone or SLL? If SLL and transformed, it sounds like Richter's which is very aggressive with poor prognosis, i am not sure if i would treat at all if Richter's. if follicular or malt, i would treat

 

[Palex80]

was the original histology follicular/marginal zone or SLL? If SLL and transformed, it sounds like Richter's which is very aggressive with poor prognosis, i am not sure if i would treat at all if Richter's. if follicular or malt, i would treat

It was marginal zone lymphoma with bone marrow involvement. Repeat bone marrow biopsy after R-CHOP showed persistent disease (but a lot less involvement than intially).

 

[Reaganite]

Was the entire Waldeyer's ring involved? If not, I'd agree with Gfunk and consider true INRT (vs. treating all of Waldeyer's ring) to try to spare some salivary gland function if possible.

Take this for what it's worth, but I've also heard at least one lymphoma big wig say if there's a CR to R-CHOP and patient has bilateral waldeyer's ring/high cervical disease, he'd consider treating only to 26Gy to try to spare a little more parotid. Not that this necessarily applies in your case since your patient had an apparent PR, but just an interesting point. Is there any chance that node is a false positive? (I once saw a guy post chemo who had a "residual" node in level 1b which turned out to be due to a dental infection).

 

[Palex80]

Both tonsils were involved, but there wasn't any extension into the nasopharynx or the prevertebral tissue.

No, I don't think it's a false positive node.
Actually, I had another look of at the PET-scan and finally got my hands on the missing diagnostic CT: I am not even certain it's a "true" node, it actually looks like extranodal parapharyngeal involvement, residual from the initial Waldeyer's ring involvement.
You can't see anything endocopically accroding to the report of the otorinolaryngologist, so it's probably located under the mucosa.


I think, I'm gonna stick with 30 Gy for everything and boost the avid site to 46 Gy, the recently publicated British randomized trial comparing doses also found 30 Gy to be reasonable for high-grade lymphoma. I am gonna try to spare the nasopharynx, in order to limit dose to the cranial parts of the parotids.