palliative boom boom lymphoma case

[BobbyHeenan]

Hello friends.

Quick question...

96 year old inpatient brought from nursing home due to "infected abscess of groin that is draining." It's an 8 cm necrotic node breaking through skin. Surgeon grossly excises it and puts a drain in. He did close the skin but didn't completely resect it. She's post op day 4 with wound healing well but with a little drain in place. THe tumor fluid ?superimposed infection? did grow a bunch of bugs and she's on IV antibiotics.

Pre op CT scans show multiple large inguinal groin nodes but nothing else really. Prelim path shows a "aggressive B cell NHL" but pending a bunch of fish studies. Oddly CD 20 negative but BCL 6 positive.

I'm thinking about giving her a boom boom 2 Gy X 2 just before she heads back to the nursing home. Would you all give her this with drain in place or do it within 10 days of her surgery or do I need to wait? My concern is many nursing homes won't allow transport back to radiation. If she has lymphoma in her wound it may not eventually heal well, so I think there is rationale for treatment here.

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[Palex80]

You can try 2 x 2 Gy, although it's efficacy is not that good in aggressive lymphoma. Yet, if you look at the literature you will find patients with MCL and DLBCL who have been treated with 2 x 2 Gy.
I recently looked into those retrospective studies and was surprirsed to see that many of these patients did not receive 2 x 2 Gy but rather 1 x 4 Gy.
Here's an example:

Effective palliation by low dose local radiotherapy for recurrent and/or chemotherapy refractory non-follicular lymphoma patients - PubMed

In this work, we have studied the response rates and duration of response after low-dose (4 Gy) involved field radiotherapy (LD-IF-RT) in relapsed or chemotherapy refractory indolent and aggressive lymphoma patients. 71 patients (177 symptomatic sites) received LD-IF-RT consisting of 39 males...

www.ncbi.nlm.nih.gov

So, if logistics are an issue, go for 1 x 4 Gy. And if you want to keep logistics even more simple, why not simply go for electrons (provided there's no involvement in the iliac region, you may have wanted to cover)?
I don't see a problem with treating with the drain in, provided the wound healing shows no complications.

 

[elementaryschooleconomics]

Yeah I'd be worried about the nursing home getting her back under the best of times, let alone in the Covid Timeline.

 

[BobbyHeenan]

You can try 2 x 2 Gy, although it's efficacy is not that good in aggressive lymphoma. Yet, if you look at the literature you will find patients with MCL and DLBCL who have been treated with 2 x 2 Gy.
I recently looked into those retrospective studies and was surprirsed to see that many of these patients did not receive 2 x 2 Gy but rather 1 x 4 Gy.
Here's an example:

Effective palliation by low dose local radiotherapy for recurrent and/or chemotherapy refractory non-follicular lymphoma patients - PubMed

In this work, we have studied the response rates and duration of response after low-dose (4 Gy) involved field radiotherapy (LD-IF-RT) in relapsed or chemotherapy refractory indolent and aggressive lymphoma patients. 71 patients (177 symptomatic sites) received LD-IF-RT consisting of 39 males...

www.ncbi.nlm.nih.gov

So, if logistics are an issue, go for 1 x 4 Gy. And if you want to keep logistics even more simple, why not simply go for electrons (provided there's no involvement in the iliac region, you may have wanted to cover)?
I don't see a problem with treating with the drain in, provided the wound healing shows no complications.

Thanks - she does have a gross node that is at junction of ext iliac and inguinals, prob too deep for electrons but I'll look into it.

 

[BobbyHeenan]

Yeah I'd be worried about the nursing home getting her back under the best of times, let alone in the Covid Timeline.

Exactly my thought.

 

[PhotonBomb]

I would do single frac 8/1 and call it

 

[KHE88]

I can't find any data supporting the use of 2 Gy x 2 in aggressive lymphomas, just follicular, and I've never seen it done. I'd imagine you'd get some response.

Looks like Palex was able to find some data for lower dose, but I've cranked it up a bit in this setting with good results. 8 Gy x 1, 5 Gy x 2, 4 Gy x 3

If giving single fraction, I'd do 8 Gy. I don't see how the drain is going to make much of a difference.

 

[BobbyHeenan]

I can't find any data supporting the use of 2 Gy x 2 in aggressive lymphomas, just follicular, and I've never seen it done. I'd imagine you'd get some response.

Looks like Palex was able to find some data for lower dose, but I've cranked it up a bit in this setting with good results. 8 Gy x 1, 5 Gy x 2, 4 Gy x 3

If giving single fraction, I'd do 8 Gy. I don't see how the drain is going to make much of a difference.

I was more worried about drain/wound issues...as in would XRT to a freshly cut wound impair healing that much. Especially if concern for infection there given + culture.

probably not (see heterotopic or keloid), but in cancer I typically wait 3-4 weeks post op.

 

[Lamount]

I was more worried about drain/wound issues...as in would XRT to a freshly cut wound impair healing that much. Especially if concern for infection there given + culture.

probably not (see heterotopic or keloid), but in cancer I typically wait 3-4 weeks post op.

would be surprised if 2-8 Gy would impact wound healing... but untreated gross residual tumor might... so I would favor treating. Incidentally, some T cell lymphomas are BCL6 positive, like angioimmunoblastic.

 

[Palex80]

In the paper I quoted they looked at 30 cases of DLBCL and MCL treated with 2x2 Gy or 1x4 Gy.

Response rate was 80% and median time to local progression was 20 months.

One issue is the fact that this is a paper from 2005. Mantle Cell Lymphoma was considered "one entity" back then. We now know that it's at least two entities now. One than behaves indolent and one that behaves quite aggressive. Thus, it's difficult to tell if all those MCLs were actually aggressive.

Another issue is if any of those DLBCL-patients had transformed lymphomas. Sometimes you may have FL patients, which will transform to DLBCL only at a few sites. Then you treat with chemotherapy and the DLBCL is gone but the FL may come back (at other sites, being incurable through chemotherapy). It is questionable, if the authors also included patients like these in their analysis, who had a documented transformed FL->DLBCL. If they were referred for palliative RT then, perhaps what was treated were "FL-leftovers", rather than DLBCL.
They did not peform biopsies of all the individual sites they treated.

Evidence is thus limited...


I boom-boomed this chemotherapy-refractorty MCL last year. Patient progressed locally 6 months later and died.
3000 ml PTV.

 

[evilbooyaa]

I agree that boom boom is not well studied in aggressive NHL, but agree with just palliating with single fraction in this 96 year old nursing home resident. The other consideration is to do nothing if you're worried about wound closure with a drain in place.

We've done a lot of prophylactic palliation, but a few of my more recent cases I've seen I've basically seen them progress elsewhere leading to eventual mortality during my treatment and I'm starting to re-think whether it's really necessary to prophylactically palliate as much as we do.

That being said, in this case there may be an issue of wound closure and drain removal if the remaining NHL isn't treated. Would discuss with patient/family but likely end up with 8Gy x 1.