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

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So here is my big issue with how heme onc approaches RT for lymphoma: rigidity. Look, chemo is a great treatment for most lymphomas and RT probably isn’t going to do much of anything to help them. But…these are very radiosensitive tumors. When you meet the lymphoma that only has a meh response to chemo, if it’s localized(ish) there is a far less toxic option than salvage chemo and SCT. When a tumor tells you it doesn’t behave like you expected, you have to adjust. As an example for us, we have randomized data showing surgery doesn’t improve survival after primary chemo rads for cervical SCC. But when I meet the rare tumor with <25% regression after full dose EBRT and Brachy do I just tell them to come back for a PET in 3 months? NFW.
 
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TheWallnerus said:
I can possibly be making the point. You have a reduction of RT utilization by half in a disease. And survival for that disease doubles. It’s associative. Is it it causative? At the very least, trending toward elimination of RT from NHL would not seem to affect overall population NHL survival negatively. That the RT is getting better… do you mean by irradiating smaller areas, ie ISRT vs IFRT etc?

Thus
Q = k * V^-1

Where Q is quality of the RT (as Q gets bigger the RT gets better) and V is volume irradiated. Q approaches infinity as V approaches zero!
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That's not the equation that I use
 
Noticed these two in the current Red Journal.

Analysis of the recurrence pattern of positron emission tomography (PET)-negative HD16 patients.

Results: There were 328 and 300 PET-negative patients assigned to CMT and PET-guided treatment (ie, chemotherapy alone), respectively. Within a median 47-month follow-up, disease progression or recurrence was documented for 15 and 29 patients treated with and without IF-RT, respectively. Relapse localization was unknown in 1 CMT patient. Without IF-RT, 5-year incidence of in-field relapses was 10.5% (95% confidence interval, 6.5-14.6) compared with 2.4% (0.5-4.3) with CMT (P = .0008). There were no relevant differences in out-field recurrences (5-year incidence 4.1% [1.7-6.6] vs 6.6% [3.0-10.3], P = .54).

Conclusion: Consolidating IF-RT in early-stage favorable HL cannot be omitted from systemic therapy, even after a negative PET/computed tomography scan, without an increased risk of recurrence. In particular, local recurrences in the potential RT field can be prevented. Therefore, RT after 2 cycles of ABVD should continue to be considered as standard therapy.


Clinical Outcomes Confirm Conjecture: Modern Radiation Therapy Reduces the Risk of Late Toxicity in Survivors of Hodgkin Lymphoma


I still doubt I will ever see these patient in practice though.
 
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Not that I was ever seeing these cases outside of my oral boards but another RT indication in lymphoma has officially bitten the dust.

We previously reported the results of a randomized phase II study in patients with newly diagnosed primary CNS lymphoma (age 18-60 years). Patients were treated with high-dose methotrexate-based induction chemotherapy followed by whole-brain radiotherapy (WBRT) or high-dose chemotherapy (thiotepa-busulfan-cyclophosphamide) with autologous stem-cell transplantation (ASCT). The median follow-up was 33 months. In this report, we provide long-term data (median follow-up, 8 years) regarding the outcomes and toxicities. Fifty-three and 44 patients received induction chemotherapy followed by WBRT or ASCT, respectively. Their 8-year event-free survival from random assignment was 67% and 39% in the ASCT and WBRT arms, respectively (P = .03), with a significantly lower risk of relapse after ASCT (hazard ratio, 0.13; P < .001). One third of patients who relapsed after WBRT were alive after salvage treatment. Five and four patients died of ASCT and WBRT-related toxicities, respectively. The 8-year overall survival was 69% and 65% in the ASCT and WBRT arms, respectively (not significant). Balance (52% v 10%, P ≤ 0.001) and neurocognition (64% v 13%, P < .001) significantly deteriorated after WBRT compared with ASCT during the follow-up. This study shows that 40 Gy WBRT should be avoided in first-line treatment because of its neurotoxicity and suboptimal efficacy in reducing relapses while ASCT appears to be highly efficient in preventing relapses.

 
fiji128 said:
Not that I was ever seeing these cases outside of my oral boards but another RT indication in lymphoma has officially bitten the dust.

We previously reported the results of a randomized phase II study in patients with newly diagnosed primary CNS lymphoma (age 18-60 years). Patients were treated with high-dose methotrexate-based induction chemotherapy followed by whole-brain radiotherapy (WBRT) or high-dose chemotherapy (thiotepa-busulfan-cyclophosphamide) with autologous stem-cell transplantation (ASCT). The median follow-up was 33 months. In this report, we provide long-term data (median follow-up, 8 years) regarding the outcomes and toxicities. Fifty-three and 44 patients received induction chemotherapy followed by WBRT or ASCT, respectively. Their 8-year event-free survival from random assignment was 67% and 39% in the ASCT and WBRT arms, respectively (P = .03), with a significantly lower risk of relapse after ASCT (hazard ratio, 0.13; P < .001). One third of patients who relapsed after WBRT were alive after salvage treatment. Five and four patients died of ASCT and WBRT-related toxicities, respectively. The 8-year overall survival was 69% and 65% in the ASCT and WBRT arms, respectively (not significant). Balance (52% v 10%, P ≤ 0.001) and neurocognition (64% v 13%, P < .001) significantly deteriorated after WBRT compared with ASCT during the follow-up. This study shows that 40 Gy WBRT should be avoided in first-line treatment because of its neurotoxicity and suboptimal efficacy in reducing relapses while ASCT appears to be highly efficient in preventing relapses.

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Good riddance? I have not ever received a referral for CNS lymphoma consolidation.
 
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fiji128 said:
Not that I was ever seeing these cases outside of my oral boards but another RT indication in lymphoma has officially bitten the dust.

We previously reported the results of a randomized phase II study in patients with newly diagnosed primary CNS lymphoma (age 18-60 years). Patients were treated with high-dose methotrexate-based induction chemotherapy followed by whole-brain radiotherapy (WBRT) or high-dose chemotherapy (thiotepa-busulfan-cyclophosphamide) with autologous stem-cell transplantation (ASCT). The median follow-up was 33 months. In this report, we provide long-term data (median follow-up, 8 years) regarding the outcomes and toxicities. Fifty-three and 44 patients received induction chemotherapy followed by WBRT or ASCT, respectively. Their 8-year event-free survival from random assignment was 67% and 39% in the ASCT and WBRT arms, respectively (P = .03), with a significantly lower risk of relapse after ASCT (hazard ratio, 0.13; P < .001). One third of patients who relapsed after WBRT were alive after salvage treatment. Five and four patients died of ASCT and WBRT-related toxicities, respectively. The 8-year overall survival was 69% and 65% in the ASCT and WBRT arms, respectively (not significant). Balance (52% v 10%, P ≤ 0.001) and neurocognition (64% v 13%, P < .001) significantly deteriorated after WBRT compared with ASCT during the follow-up. This study shows that 40 Gy WBRT should be avoided in first-line treatment because of its neurotoxicity and suboptimal efficacy in reducing relapses while ASCT appears to be highly efficient in preventing relapses.

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Yup, saw this a few months ago when it came up as a clinical scenario.
The few patients I had treated for PCNSL.... didn't give me a good feeling afterwards.

Still a role for palliation, but WBRT for curative intent.... not good for patients.
 
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NotMattSpraker said:
Haha wow, of all the stupid conflicted and biased arguments from academics that I've read in the last few years, this one might take the cake.
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Dan Longo is notorious (not just for that take, but multiple others like that) for thinking radiation means the devil. Given that he finished training in the late 70s, early 80s.... he's just one of those med onc boomers who needs to retire/die because all he remembers is RT is the devil.
 
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So according to ASCO there is now almost no role for RT in the management of DLBCL.


Basically if limited stage and modified international prognostic index greater then or equal to one with interim PET after R-CHOP x 3 cycles shows Deauville score of 4 to 5 then go to RT is the only indication I'm seeing. At least it will make the lymphoma section on oral boards that much easier study for.
 
fiji128 said:
So according to ASCO there is now almost no role for RT in the management of DLBCL.


Basically if limited stage and modified international prognostic index greater then or equal to one with interim PET after R-CHOP x 3 cycles shows Deauville score of 4 to 5 then go to RT is the only indication I'm seeing. At least it will make the lymphoma section on oral boards that much easier study for.
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Consolidation before transplant should be one... as well as palliative -but certainly not a slam-dunk disease site for RT
 
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fiji128 said:
So according to ASCO there is now almost no role for RT in the management of DLBCL.


Basically if limited stage and modified international prognostic index greater then or equal to one with interim PET after R-CHOP x 3 cycles shows Deauville score of 4 to 5 then go to RT is the only indication I'm seeing. At least it will make the lymphoma section on oral boards that much easier study for.
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So 3 cycles and that's it for some? Dumb
 
I really don’t understand why MOs are fixated on this
 
Fpg1245 said:
I really don’t understand why MOs are fixated on this
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My personal hypothesis:

1) Folks at the top of medicine are "most senior" in a literal sense. The majority of people designing, funding, and conducting "big" trials are Baby Boomers.

2) Many/most of the Baby Boomers still in medicine trained in the 80s (+/- 5ish years).

3) Think about lymphoma in the 1980s if you're a resident or young attending. The specialty of MedOnc is still relatively new. ASCO was founded in 1964, so you've either trained or worked with the literal pioneers.

4) Those pioneers hold up Hodgkins as the "first advanced cancer to be cured by chemotherapy". And again, I mean that literally, with none other than DeVita himself as the first author on the 1970 paper.

5) Radiotherapy at the time was...not the technological marvel that it is today. Mantle fields. Mantle fields as far as the eye can see.

6) We all know about the toxicity associated with mantle fields.

7) So lymphoma almost becomes symbolic for Medical Oncology as a whole. Using systemic therapy to cure cancer! Spare the poor patients from the evil radiation!

8) Meanwhile, we all know the intellectual duds on our side of the aisle. Content to just sit quietly in our basements, writing white paper after white paper about how no one should pay us and we should do everything possible to omit radiation from every treatment algorithm.

You can see what lymphoma means to the chemotherapists in the ASCO 50th edition:

1675131158848.png


1675131296112.png


I absolutely love that jab in the last sentence: "I mean, I guess we'll keep an eye out for long term side effects when we save patients from that evil radiation, wink wink".
 
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fiji128 said:
So according to ASCO there is now almost no role for RT in the management of DLBCL.


Basically if limited stage and modified international prognostic index greater then or equal to one with interim PET after R-CHOP x 3 cycles shows Deauville score of 4 to 5 then go to RT is the only indication I'm seeing. At least it will make the lymphoma section on oral boards that much easier study for.
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I have even more bad news for you...
These patients are usually considered for CAR-T therapy following re-induction with R-ICE / polatuzumab-containing regimes in our center. No RT, unless residual tumor after re-infuction prior to CAR-T.
 
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medgator said:
Still dumb imo. I guess local management doesn't matter anymore
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It is probably is irrelevant what rad oncs think about management of this disease anymore. We will be/are consulted in the rare cases where med oncs think we might be able to add something. This year's Astro Refresher has a 1 hour lecture on lymphoma by Dr. Hoppe, can't even imaging what would take that long to cover these days.
 
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I had a conversation with one of my medonc colleagues about lymphoma just last week. In their opinion the newer chemo regimens have gotten so much better, even the newish trials which showed improvement with RT in some situations are no longer relevant.

I do treat follicular lymphoma and MALTs, with more orbital and gastric MALTS than I ever expected to see while in training, which is interesting- I have one gastric MALT and one orbital MALT on treatment right now.

I do feel bad about those poor souls who were designated to be the "lymphoma person" in the RT department. What now?
 
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OTN said:
I had a conversation with one of my medonc colleagues about lymphoma just last week. In their opinion the newer chemo regimens have gotten so much better, even the newish trials which showed improvement with RT in some situations are no longer relevant.

I do treat follicular lymphoma and MALTs, with more orbital and gastric MALTS than I ever expected to see while in training, which is interesting- I have one gastric MALT and one orbital MALT on treatment right now.

I do feel bad about those poor souls who were designated to be the "lymphoma person" in the RT department. What now?
Click to expand...

It’s mostly at large departments where the individual is basically administrative but keeps their hand in RT clinically. But yes as a stand alone it’s a joke
 
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I made this post a couple of years ago. It reinforces what @elemetaryschooleconomics posted above.

I was at a local cancer convention a few years ago where Dr. Richard Hoppe was one of the panelists for a lymphoma case. A couple of observations:

1. Every single Med Onc on that panel ****ted all over radiation as a modality in lymphoma. Not based on any contemporary data mind you, but mindlessly quoting the known sequelae of old mantle-type radiation including secondary malignancy, hypothyroidism, and acceleration of coronary artery disease. Hoppe didn't say one word in protest.

2. When we finally got the RT portion, one of the Stanford Med Oncs on the panel commented that he would only trust Hoppe's expertise in delivering ISRT after chemo. Ridiculous - we need to send a patient to a center of excellence to deliver 24 Gy in 12 fractions!

I actually tore into the panel during the Q&A session but I'm just "small" Rad Onc so I'm sure there was a lot of eye rolling and patronizing sighs in response.
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fiji128 said:
It is probably is irrelevant what rad oncs think about management of this disease anymore. We will be/are consulted in the rare cases where med oncs think we might be able to add something. This year's Astro Refresher has a 1 hour lecture on lymphoma by Dr. Hoppe, can't even imaging what would take that long to cover these days.
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Dr. Hop(p)e. How appropriate.

„I hope you will see a lymphoma patient in your practice one day…“
 
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