Lymphoma: (HD or NHL)- role of RT in real life

[ramsesthenice]

FLYER reports 96% 3-years-PFS with 4x R-CHOP + 2R without radiation therapy for non-bulky stage I-II DLBCL.

Your patient is 65 and FLYER recruited only 18-60, but you see the point, right?
The vast majority of patients can be cured with 4x R-CHOP in stage I-II DLBCL without any radiation therapy. This is a considerable achievement. FLYER pretty much killed off radiation therapy for non-bulky and non-testicular DLBCL stage I-II. What is radiation therapy supposed to do? Push the 96% PFS to 100% PFS?

History of therapeutic approach in DLBCL Stage I-II over the past 20 years is something like:

8x CHOP --> 3x CHOP + RT --> 3x R-CHOP + RT + 2R or 6x R-CHOP + 2R --> 4x R-CHOP + 2R

So, it's half the chemo compared to 20 years ago. Why? Probably effect of Rituximab and (equally important IMHO) stage migration / treatment guidance with modern diagnostics (PET-CT & flow-cytometry). A lot of those stage I-II DLBCLs diagnosed in the 90s were probably understaged stage III/IV.

On a side note: DA-R-EPOCH also killed off radiation therapy for primary mediastinal B-cell lymphoma, 7 years ago. Prior to that most patients used to get R-CHOP + RT. RT was deemed crucial for cure and proven to be effective in multiple retrospective analyses. After DA-R-EPOCH started being delivered, I am only seeing 1 patient every couple of years which has residual PET-positive disease or a local recurrence. Pretty much everyone is getting DA-R-EPOCH. Frankly, I am glad. PMBCL often affects young women.

Did you read my post? Dude had residual gross residual after 6 cycles of R-CHOP. And 3 cycles of ICE. He was not in the 96%. This is kinda my point. Chemo is usually enough but in the cases it’s not we shouldn’t forget the RT can be an effective modality. If you radiate someone with HPV+ oropharngeal cancer and they have residual disease afterward do you tell them RT is 90+% effective or send them for surgery?

---

Members don't see this ad.

 

[fiji128]

Back in my day it was all about ISRT and how we were moving possibly towards the use of INRT but I had no clue we would just skip over that step entirely.

I have completely forgotten about experimental INRT and doing pretreatment PETs in same position as our CT simulation/treatment position. I guess that approach is pretty much consigned to the dust been of history now.

 

[medgator]

There is no role for consolidation RT if its CR. Again, that phase II trial didn’t have RT in it.
COG is testing this question in their trials. Pedonc have my respect for testing things properly and following the protocols.

This was a double hit lymphoma, maybe that's why? Nccn mentions consolidation isrt being preferred in double/triple hit lymphomas

 

[ramsesthenice]

FLYER reports 96% 3-years-PFS with 4x R-CHOP + 2R without radiation therapy for non-bulky stage I-II DLBCL.

Your patient is 65 and FLYER recruited only 18-60, but you see the point, right?
The vast majority of patients can be cured with 4x R-CHOP in stage I-II DLBCL without any radiation therapy. This is a considerable achievement. FLYER pretty much killed off radiation therapy for non-bulky and non-testicular DLBCL stage I-II. What is radiation therapy supposed to do? Push the 96% PFS to 100% PFS?

History of therapeutic approach in DLBCL Stage I-II over the past 20 years is something like:

8x CHOP --> 3x CHOP + RT --> 3x R-CHOP + RT + 2R or 6x R-CHOP + 2R --> 4x R-CHOP + 2R

So, it's half the chemo compared to 20 years ago. Why? Probably effect of Rituximab and (equally important IMHO) stage migration / treatment guidance with modern diagnostics (PET-CT & flow-cytometry). A lot of those stage I-II DLBCLs diagnosed in the 90s were probably understaged stage III/IV.

On a side note: DA-R-EPOCH also killed off radiation therapy for primary mediastinal B-cell lymphoma, 7 years ago. Prior to that most patients used to get R-CHOP + RT. RT was deemed crucial for cure and proven to be effective in multiple retrospective analyses. After DA-R-EPOCH started being delivered, I am only seeing 1 patient every couple of years which has residual PET-positive disease or a local recurrence. Pretty much everyone is getting DA-R-EPOCH. Frankly, I am glad. PMBCL often affects young women.

My first response was not very eloquent so I will try again. A lot of our med oncs use data like FLYER to suggest RT plays no role for early stage DLBCL in the rituxan era. And 96% of the time they are right! I don’t advocate for routine consolidative RT. With those odds, the NNT is almost certainly > NNH. But everything I just said has zero relevance to this particular patient after their tumor has declared loud and clear that it’s biology is not like most patients. I think we often do patients a disservice when we decide RT, or surgery, or chemo (etc) play no role in X disease and then ignore biology in action.

 

[RadOncDoc21]

My first response was not very eloquent so I will try again. A lot of our med oncs use data like FLYER to suggest RT plays no role for early stage DLBCL in the rituxan era. And 96% of the time they are right! I don’t advocate for routine consolidative RT. With those odds, the NNT is almost certainly > NNH. But everything I just said has zero relevance to this particular patient after their tumor has declared loud and clear that it’s biology is not like most patients. I think we often do patients a disservice when we decide RT, or surgery, or chemo (etc) play no role in X disease and then ignore biology in action.

Especially when it works!

 

[Palex80]

Did you read my post? Dude had residual gross residual after 6 cycles of R-CHOP. And 3 cycles of ICE. He was not in the 96%. This is kinda my point. Chemo is usually enough but in the cases it’s not we shouldn’t forget the RT can be an effective modality. If you radiate someone with HPV+ oropharngeal cancer and they have residual disease afterward do you tell them RT is 90+% effective or send them for surgery?

I fully understand that and I am sorry if my post sounded off the point.


FLYER reported:
At the end of therapy, 267 (91%) of 293 patients in the four-cycles group had a complete response or unconfirmed complete response. Eight (3%) patients had a partial response.

Patients with "partial response or unconfirmed response" in FLYER did receive additional treatment, you can read it all in the supplementary material. Most of what I saw there were 2 additional cycles of R-CHOP (patients with wrong initial staging - likely stage III/IV disease - thus making them ineligible for the deescalated approach, raising the number of cycles to 6x R-CHOP makes sense there, it would be s.o.c.) or radiotherapy for skelettal involvement (which is s.o.c. since it's difficult to confirm CR in the bone).

Your patient is probably in that tiny little population that has residual disease after 4x R-CHOP in stage I-II disease and thus probably something like 2% (?) out of all patients.

So we "lose" 98% of all patients, we would have perhaps treated with the "Miller approach" and get to keep the 2% with residual disease... It's sad.

 

[Palex80]

Got a young man with pmbcl now referred for consolidation after DA-EPOCH-R, slightly above background suv on the most recent scan, my understanding was that all of them still get consolidation xrt?

Not necessarily.
PET-CT evaluation following DA-R-EPOCH for PMBCL can be tricky.
You say "slightly above background", so that would be Deauville 3, I presume?

Without seeing the images it's difficult to make a statement, I would discuss this with your nuclear medicine colleagues.
It is justified to simply wait and repeat scan after 8 weeks in equivocal findings.

I personally woulnd't treat now, unless it's a clear Deauville 4 or 5.
We even had patients go for mediastinoscopy with equivocal findings, which persisted (but did not grow on repeat scans) and very often results came back negative.
Here's an interesting paper:

End-of-treatment and serial PET imaging in primary mediastinal B-cell lymphoma following dose-adjusted EPOCH-R: a paradigm shift in clinical decision making

Dose-adjusted-EPOCH-R obviates the need for radiotherapy in most patients with primary mediastinal B-cell lymphoma. End-of-treatment PET, however, does not accurately identify patients at risk of treatment failure, thereby confounding clinical decision ...

www.ncbi.nlm.nih.gov

 

[medgator]

Not necessarily.
PET-CT evaluation following DA-R-EPOCH for PMBCL can be tricky.
You say "slightly above background", so that would be Deauville 3, I presume?

It is justified to simply wait and repear scan after 8 weeks in equivocal findings.
I personally woulnd't treat now, unless it's a clear Deauville 4 or 5.
We even had patients go for mediastinoscopy with equivocal findings, which persisted (but did not grow on repeat scans) and very often results came back negative. There are several papers on that actually.
For example:

End-of-treatment and serial PET imaging in primary mediastinal B-cell lymphoma following dose-adjusted EPOCH-R: a paradigm shift in clinical decision making

Dose-adjusted-EPOCH-R obviates the need for radiotherapy in most patients with primary mediastinal B-cell lymphoma. End-of-treatment PET, however, does not accurately identify patients at risk of treatment failure, thereby confounding clinical decision ...

www.ncbi.nlm.nih.gov

What about in double/triple hit ones?

 

[Palex80]

What about in double/triple hit ones?

I wish we had data to back it up. And I wish we would be able to make decisions based on biology.

My general impression is that double/triple hit DLBCLs are often managed with more intensive systemic therapy, because it seems that R-CHOP simply isn't enough for the vast majority of patients. However, no trials have been completed looking at this question specifically for these patients with more aggressive variants.
If you look at the recently reported big trial on "all-comers" DLBCL, there was no difference between DA-R-EPOCH and R-CHOP. And even if the subgroup analyses (when pathology was available), double-hit DLBCL didn't seem to benefit from DA-R-EPOCH. Beware, this is an unplanned subgroup analysis and certainly underpowered to prove anything.

I am not aware of any data pointing out, we should be irradiating "more" doible-hit DLBCL. And I am pretty certain, noone is going to look into that in a prospective, randomized trial (unfortunately).

 

[ramsesthenice]

I fully understand that and I am sorry if my post sounded off the point.


FLYER reported:
At the end of therapy, 267 (91%) of 293 patients in the four-cycles group had a complete response or unconfirmed complete response. Eight (3%) patients had a partial response.

Patients with "partial response or unconfirmed response" in FLYER did receive additional treatment, you can read it all in the supplementary material. Most of what I saw there were 2 additional cycles of R-CHOP (patients with wrong initial staging - likely stage III/IV disease - thus making them ineligible for the deescalated approach, raising the number of cycles to 6x R-CHOP makes sense there, it would be s.o.c.) or radiotherapy for skelettal involvement (which is s.o.c. since it's difficult to confirm CR in the bone).

Your patient is probably in that tiny little population that has residual disease after 4x R-CHOP in stage I-II disease and thus probably something like 2% (?) out of all patients.

So we "lose" 98% of all patients, we would have perhaps treated with the "Miller approach" and get to keep the 2% with residual disease... It's sad.

No worries. It was a just a perfect re-enactment of what took place over multiple tumor boards. He was indeed in the teeny tiny fraction of patients that just don't respond. There were no cytogenetic abnormalities or anything to predict this. When he still had disease after 6 cycles and a junior med onc dared suggest we consider RT for this patient with stage 2 disease the senior med onc chastised him repeatedly saying word for word "lymphoma is a systemic disease, there is no role for radiation." Concrete thinking can be a dangerous thing. This kind of crap can always be a little hard to swallow, but in this case we were talking about a patient I have treated and had an established relationship for the last 5 years. It made it even harder.

 

[scarbrtj]

Pancreas?

I had dinner with the head of surg onc of local Academic University recently. He has a "pancreas lab" and is a big pancreas guy. Got him started talking about pancreas ca, obv, and I let him talk and talk and talk. The word "radiation" didn't fall from his lips once over his multi-minute spiel whilst many named systemtic agents did. I'm not saying there's no RT role. It's just a low role in the de novo setting "in real life" as the OP said. I'm being provocative...

 

[evilbooyaa]

Got a young man with pmbcl now referred for consolidation after DA-EPOCH-R, slightly above background suv on the most recent scan, my understanding was that all of them still get consolidation xrt?

No, the Dunleavy NEJM trial that Palex cited (Dose-adjusted EPOCH-rituximab therapy in primary mediastinal B-cell lymphoma - PubMed) were treated without RT and had excellent outcomes. I had a case of Deauville 3 after that chemo in residency in a young male and was told by multiple lymphoma rad oncs nationwide they would favor observation.... except Dabaja who recommended consideration of treatment.

It is a small study, single arm Ph II, but it's a rare disease, and the EFS is so good without RT I'm not sure what RT will add.

I think if the patient has residual Deauville 4 or 5 disease, then should get RT (IMO). Deauville 1/2, definitely no RT. What to do with Deauville 3 is probably no RT as that's still considered a metabolic CR, but could see if somebody wanted to treat.

*EDIT* - Sorry, didn't see there was a page 2. I'm late to the party. Carry on.

 

[medgator]

No, the Dunleavy NEJM trial that Palex cited (Dose-adjusted EPOCH-rituximab therapy in primary mediastinal B-cell lymphoma - PubMed) were treated without RT and had excellent outcomes. I had a case of Deauville 3 after that chemo in residency in a young male and was told by multiple lymphoma rad oncs nationwide they would favor observation.... except Dabaja who recommended consideration of treatment.

It is a small study, single arm Ph II, but it's a rare disease, and the EFS is so good without RT I'm not sure what RT will add.

I think if the patient has residual Deauville 4 or 5 disease, then should get RT (IMO). Deauville 1/2, definitely no RT. What to do with Deauville 3 is probably no RT as that's still considered a metabolic CR, but could see if somebody wanted to treat.

*EDIT* - Sorry, didn't see there was a page 2. I'm late to the party. Carry on.

Nccn mentions consolidating any dlbcl with a double/triple hit. Again data free zone here as palex80 alluded to.

How about i treat lymphoma when the med Onc tells me to??

 

[evilbooyaa]

Nccn mentions consolidating any dlbcl with a double/triple hit. Again data free zone here as palex80 alluded to.

How about i treat lymphoma when the med Onc tells me to??

Missed that - for DH/TH, totally reasonable to consolidate for stage I/II.

 

[scarbrtj]

How about i treat lymphoma when the med Onc tells me to??

We treat when med onc tells us to and Evicore says it is medically necessary.

 

[bachiraki]

Great Discussion guys. Thanks a lot!!.. What is current standard of care for stage III non-germinal center DLBCL with disease on both sides of diaphragm (cervical, axillary mediastinal and bulky (11.6 cm) retroperitoneal and illiac lymph nodes). After 6 cycles of R-CHOP, Shall we still offer radiation to bulky sites even after Deauville- 3 scans at the end of all 6 cycles of R-CHOP?

I have spoken with few hematologists around the country with different schools of approach. One group suggested observation after complete metabolic response (Deauville-3 or less) and BMT in the event of recurrence. Another group suggested immediate BMT after 6 cycles of R-CHOP even after CR. Only one hematologist believed in consolidated RT to initial bulky sites even after CR.

What’s your approach now a days?

 

[RadOncDoc21]

Great Discussion guys. Thanks a lot!!.. What is current standard of care for stage III non-germinal center DLBCL with disease on both sides of diaphragm (cervical, axillary mediastinal and bulky (11.6 cm) retroperitoneal and illiac lymph nodes). After 6 cycles of R-CHOP, Shall we still offer radiation to bulky sites even after Deauville- 3 scans at the end of all 6 cycles of R-CHOP?

I have spoken with few hematologists around the country with different schools of approach. One group suggested observation after complete metabolic response (Deauville-3 or less) and BMT in the event of recurrence. Another group suggested immediate BMT after 6 cycles of R-CHOP even after CR. Only one hematologist believed in consolidated RT to initial bulky sites even after CR.

What’s your approach now a days?

Whatever the referring doc wants me to do. Unfortunately, this has been my practice over the past year in regards to everything. I’m a rad onc who sold his soul.

 

[medgator]

Whatever the referring doc wants me to do. Unfortunately, this has been my practice over the past year in regards to everything. I’m a rad onc who sold his soul.

Definitely when it comes to lymphoma. Hell no when it comes to solid tumors

 

[RadOncDoc21]

Definitely when it comes to lymphoma. Hell no when it comes to solid tumors

A man got to eat (biryani).

 

[scarbrtj]

A man got to eat (biryani).

Brand-specific natch

 

[evilbooyaa]

Great Discussion guys. Thanks a lot!!.. What is current standard of care for stage III non-germinal center DLBCL with disease on both sides of diaphragm (cervical, axillary mediastinal and bulky (11.6 cm) retroperitoneal and illiac lymph nodes). After 6 cycles of R-CHOP, Shall we still offer radiation to bulky sites even after Deauville- 3 scans at the end of all 6 cycles of R-CHOP?

I have spoken with few hematologists around the country with different schools of approach. One group suggested observation after complete metabolic response (Deauville-3 or less) and BMT in the event of recurrence. Another group suggested immediate BMT after 6 cycles of R-CHOP even after CR. Only one hematologist believed in consolidated RT to initial bulky sites even after CR.

What’s your approach now a days?

Would certainly discuss RT to bulky or sites of initial bone invasion. Up to patient if they want a potential reduction in recurrence for a slight increase in risk of toxicity and having to come in for 3-4 weeks of RT...

Similar to the omission of RT in elderly ER+ stage I Breast cancer argument - may not be an OS benefit (as the ones who recur can get salvaged with transplant) but would expect a lower rate of local recurrence in the bulky site of disease.

If treating, I would treat just the bulky area (across, not sup/inf as I've seen some descriptions of 'bulky' basically encompass across multiple nodal chains)

 

[ramsesthenice]

Whatever the referring doc wants me to do. Unfortunately, this has been my practice over the past year in regards to everything. I’m a rad onc who sold his soul.

I take the Urban Meyer approach. Let your top prospects do their thing, hope they don't do anything too egregious, and let a fixer handle things when they inevitably go awry.

 

[FrostyHammer]

Brand-specific natch

Somewhere right now, I'm sure KHE88 is smiling...

 

[seper]

There is kind of explosion of targeted therapy going on in DLBCL (ibrutinib, vorinostat, and more). VERY good responses in refractory/recurrent disease. That what makes XRT less attractive for our HemOnc friends

 

[RadOncDoc21]

Somewhere right now, I'm sure KHE88 is smiling...

Not to derail the thread too much more but I was thinking about him after seeing that 2 masks are now being recommended.

 

[scarbrtj]

Not to derail the thread too much more but I was thinking about him after seeing that 2 masks are now being recommended.

Well not for nothin' but you can get maskne. Which we can treat!

 

[RadOncDoc21]

Well not for nothin' but you can get maskne. Which we can treat!

You know derm will take all of those! Leave it to them to find more things to treat while we rad oncs wither away. Pretty soon we’ll be in the medical history books much like majoring in fields such as zoology.

 

[medgator]

I take the Urban Meyer approach. Let your top prospects do their thing, hope they don't do anything too egregious, and let a fixer handle things when they inevitably go awry.

And peace out with a "health problem" when things start to go south. Gotta love Urban Liar

 

[Palex80]

Great Discussion guys. Thanks a lot!!.. What is current standard of care for stage III non-germinal center DLBCL with disease on both sides of diaphragm (cervical, axillary mediastinal and bulky (11.6 cm) retroperitoneal and illiac lymph nodes). After 6 cycles of R-CHOP, Shall we still offer radiation to bulky sites even after Deauville- 3 scans at the end of all 6 cycles of R-CHOP?

We do, especially in elderly patients based on this analysis. This was not a randomized trial but a comparison between two cohorts of the same trial.

I have spoken with few hematologists around the country with different schools of approach. One group suggested observation after complete metabolic response (Deauville-3 or less) and BMT in the event of recurrence. Another group suggested immediate BMT after 6 cycles of R-CHOP even after CR. Only one hematologist believed in consolidated RT to initial bulky sites even after CR.

What’s your approach now a days?

I see no reason to escalate treatment with BMT in patients achieving a CR. Trials who have tested upfront high-dose chemotherapy have not shown a survival benefit.

 

[Palex80]

Would certainly discuss RT to bulky or sites of initial bone invasion. Up to patient if they want a potential reduction in recurrence for a slight increase in risk of toxicity and having to come in for 3-4 weeks of RT...

Agreed.

Concerning the 3-4 weeks of RT: This is something we should also address. I know data only exist for normofractionated treatments in the curative setting. But if a 71 year old gentleman is sent for consolidative RT after 4x R-CHOP for a stage I bone lymphoma on L5, I am not going to give him 15 x 2 Gy to the L5. I'll hypofractionate him. Maybe 6 x 4 Gy or something.

 

[FrostyHammer]

We do, especially in elderly patients based on this analysis. This was not a randomized trial but a comparison between two cohorts of the same trial.

And because of UNFOLDER as well I believe, which is more direct randomized data

 

[RickyScott]

Rectal is the next lymphoma, then maybe (resected/resectable pancreas
Edit- forgot about gastric- haven’t seen one in a few years.

 

[lyltothend]

Radiation oncology is becoming the cigar butt of specialties.

 

[scarbrtj]

Rectal is the next lymphoma, then maybe (resected/resectable pancreas
Edit- forgot about gastric- haven’t seen one in a few years.

"But mom, I thought all the new rad oncs added over the last decade were supposed to increase the radiation indications. Have they been.... lying?" Too hurt by the pain in her young child's words to respond, she continued tucking him into bed hoping he'd let all his worries drift away after a soft lullaby and a good night's sleep. That always seemed to fix everything in the past.

 

[medgator]

Rectal is the next lymphoma, then maybe (resected/resectable pancreas
Edit- forgot about gastric- haven’t seen one in a few years.

Don't tell any of the med oncs around me.... Still getting plenty of rectal/panc

 

[Palex80]

And because of UNFOLDER as well I believe, which is more direct randomized data

Indeed.

UNFOLDER is however basically negative. Their primary endpoint was not PFS but EFS, which meant that patients achieving a PR after R-CHOP +/- RT (on CT) were counted as an event. Since it's easier to achieve a CR with additional RT, the RT-arm performed better. However, this did not translate into a PFS or OS benefit possibly because not every PR means residual vital tumor. A very badly designed trial, basically...

 

[ramsesthenice]

Indeed.

UNFOLDER is however basically negative. Their primary endpoint was not PFS but EFS, which meant that patients achieving a PR after R-CHOP +/- RT (on CT) were counted as an event. Since it's easier to achieve a CR with additional RT, the RT-arm performed better. However, this did not translate into a PFS or OS benefit possibly because not every PR means residual vital tumor. A very badly designed trial, basically...

Palex, you have officially scared me into getting my SA-CME credits knocked out early this year. The ratio of effort required to study for boards vs clinical utility for an American rad oncs seems to have plummeted even further for lymphoma over the last few years. Thats impressive, because it was basically in the cellar five years ago.

 

[scarbrtj]

"The ratio of effort required to study for boards vs clinical utility for an American rad oncs seems to have plummeted even further for lymphoma over the last few years. That's impressive, because it was basically in the cellar five years ago." - Ramsesthenice

 

[evilbooyaa]

"The ratio of effort required to study for boards vs clinical utility for an American rad oncs seems to have plummeted even further for lymphoma over the last few years. That's impressive, because it was basically in the cellar five years ago." - Ramsesthenice

Makes me think about the poor academic attendings at multiple institutions who 'specialize' in RT for Lymphoma.

RT for lymphoma:

 

[medgator]

Makes me think about the poor academic attendings at multiple institutions who 'specialize' in RT for Lymphoma.

RT for lymphoma:

Probably a good service for treating penile ca too

 

[RadOncDoc21]

Probably a good service for treating penile ca too

Well we see how urologist can be with prostate cancer. Again, I worked in different systems and depending on the community, a rad onc can either have a good number of prostates, bladder, penile (I’m kidding) or nothing at all.

All of my prostates come from the VA, at least those urologist are reasonable.

 

[OTN]

In 2019 and 2020 I treated 2 patients with penile cancers and 2 patients with HD. The vast, vast majority of my lymphoma patients now are either follicular or MALT-based. So it goes.

 

[RickyScott]

In 2019 and 2020 I treated 2 patients with penile cancers and 2 patients with HD. The vast, vast majority of my lymphoma patients now are either follicular or MALT-based. So it goes.

Academic departments should consider a dollar store “grab bag ” service of disease sites were radiation has retreated to marginal status: lymphoma, seminoma, most of GI, and soon gyn, which may be renamed “cylinder radiation.”

 

[scarbrtj]

Academic departments should consider a dollar store “grab bag ” service of disease sites were radiation has retreated to marginal status: lymphoma, seminoma, most of GI, and soon gyn, which may be renamed “cylinder radiation.”

Ha. The MRgRT crowd seems set to eliminate T&O from cervical ca e.g. I seem to recall some data where people had found that EBRT is no substitute for brachy, but this is special EBRT from a linac that works with an MRI so I guess that's different.

Cervical cancer treatment world first at The Christie

Cervical cancer treatment world first at The Christie A Stockport woman is set to become the first ever patient in the world to be entirely treated for cervical cancer using a state-of-art radiotherapy treatment at The Christie NHS Foundation Trust.Karen Hall, 57, will be treated using the MR-gui...

www.pharmiweb.com

Coming back to add that seminoma is a perfect prototype/template on how RT disappears... roughly:
Treat very large area→treat smaller area→treat even smaller area→dose reduce→RT elimination vs systemics (or observation)

 

[RadOncDoc21]

Ha. The MRgRT crowd seems set to eliminate T&O from cervical ca e.g. I seem to recall some data where people had found that EBRT is no substitute for brachy, but this is special EBRT from a linac that works with an MRI so I guess that's different.

Cervical cancer treatment world first at The Christie

Cervical cancer treatment world first at The Christie A Stockport woman is set to become the first ever patient in the world to be entirely treated for cervical cancer using a state-of-art radiotherapy treatment at The Christie NHS Foundation Trust.Karen Hall, 57, will be treated using the MR-gui...

www.pharmiweb.com

Wasn’t there a similar argument to add a brachy boost in prostate patients to prevent some biochemical failure in int/high risk patients. I guess now it’s whoever has the most expensive machine, then they get to do whatever they want.

I swear our field is the worstest!

 

[RickyScott]

Ha. The MRgRT crowd seems set to eliminate T&O from cervical ca e.g. I seem to recall some data where people had found that EBRT is no substitute for brachy, but this is special EBRT from a linac that works with an MRI so I guess that's different.

Cervical cancer treatment world first at The Christie

Cervical cancer treatment world first at The Christie A Stockport woman is set to become the first ever patient in the world to be entirely treated for cervical cancer using a state-of-art radiotherapy treatment at The Christie NHS Foundation Trust.Karen Hall, 57, will be treated using the MR-gui...

www.pharmiweb.com

Coming back to add that seminoma is a perfect prototype/template on how RT disappears... roughly:
Treat very large area→treat smaller area→treat even smaller area→dose reduce→RT elimination vs systemics (or observation)

cervix very rare now for me. Myeloma has also largely vanished.

 

[ramsesthenice]

cervix very rare now for me. Myeloma has also largely vanished.

Wow. We implant 6-8 unique patients per month.

 

[seper]

why would they make such a choice? What type of choice are they making?

Surprised to see that coming from UK. EBRT will never trump brachy for localized cervical Ca. Perhaps this lady also had extensive PA adenopathy and it was not wise to push brachy boost to primary.

 

[scarbrtj]

Wow. We implant 6-8 unique patients per month.

Just goes to show for what is a "rare" cancer. Only about 13K cervical ca cases/year in the U.S. Assume 75% are brachy candidates. So about 10K new cerv brachy pts a year for the entire country. This would yield about 2 cervical cancer patients per rad onc per year in the U.S. So if you're seeing 6 unique a month, or 72 a year, that means you see roughly 30 times more cervical cancer patients than the "average" rad onc. There's *significant* variation in case loads and case makeup from rad onc to rad onc in the U.S. Emphasis on significant. This is what happens in oversupply!

 

[communitydoc13]

We do, especially in elderly patients based on this analysis. This was not a randomized trial but a comparison between two cohorts of the same trial.

Just a single case but today's case. Late 60s lady with prior Adriamycin for breast CA and single 7 cm focus of non-double hit, germinal center in an extranodal site (lateral liver).

MO plan for 6 cycles of RCHOP and fortunately his colleagues brought up prior chemo and possible adriamycin dose limitation.

I brought up above analysis (Thanks to Palex!) and noted that toxicity of 36 Gy to lateral liver probably close to zero.

I was dismissed right away; "well, lets see how she does with the chemo".