Radiotherapy for follicular lymphome

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Palex80

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So, here's an interesting case.

A 55 year old female was presented to us with the diagnosis of follicular lymphoma grade I.
A 2 cm cervical lymphoma was completely resected , the tumour was very superficial. No further suspicious lymph nodes were found in the CT scans, bone marrow is clear, normal LDH.

We were asked to treat the patient in "curative" intention.

What would you do?

1. Watch and Wait (Why not? It was completely removed after all.)
2. IFRT 30 Gy (Probably standard treatment)
3. EFRT 30 Gy (Older type of treatment, maybe better results, but more toxicity too)
4. INRT 30 Gy (Why not? Has anyone ever showed that INRT is worse than IFRT for follicular lymphoma)
5. IFRT 4 Gy (2x2 Gy like in the EORTC/Netherlands series)


Ooops, spelling error in title: "lymphoma"

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In the US, I think the most conservative treatment would definitely be #2 as you stated. However, there is emerging retrospective evidence that intralesion rituximab injections in cutaneous B-cell lymphoms w/o evidence of systemic disease may be effective. I wouldn't do this outside a clinical trial however. Latest study is PMID 19197721.
 
So, here's an interesting case.

A 55 year old female was presented to us with the diagnosis of follicular lymphoma grade I.
A 2 cm cervical lymphoma was completely resected , the tumour was very superficial. No further suspicious lymph nodes were found in the CT scans, bone marrow is clear, normal LDH.

We were asked to treat the patient in "curative" intention.

What would you do?

1. Watch and Wait (Why not? It was completely removed after all.)
2. IFRT 30 Gy (Probably standard treatment)
3. EFRT 30 Gy (Older type of treatment, maybe better results, but more toxicity too)
4. INRT 30 Gy (Why not? Has anyone ever showed that INRT is worse than IFRT for follicular lymphoma)
5. IFRT 4 Gy (2x2 Gy like in the EORTC/Netherlands series)


Ooops, spelling error in title: "lymphoma"

I'd go with 2, IFRT 30 Gy. INRT doesn't have enough of a track record to call it worse or similar, but IMO there's relatively little therapeutic gain in this situation, as the curative doses for lymphoma are relatively modest. I like the 2Gy x2 approach in older patients and those with relapsed disease, but view it (as Haas and Girinsky do) as a palliative measure, though frequently a durable one.

In fairness, I don't think anyone would call you out for a watch and wait approach, either. The small experience of delayed RT published by Stanford had a median OS of 19 years, and with the long natural history of follicular NHL, I don't know that we will ever be able to adequately determine whether early intervention changes the natural history of the disease. In an otherwise healthy 55 yr old, I'd personally lean toward the treatment side, but would present the options to allow an informed choice to be made.
 
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I would also recommend treatment with IFRT to ~30 Gy but would explain the data to the patient so that she could choose. While there are no randomized data proving that this increases cure rate, long term studies indicated that 1/3-1/2 of early stage patients with low grade lymphoma will not relapse after this treatment, suggesting cures are possible. Given the low toxicity of the treatment, many patients elect to have treatment in my experience.

Alternatively, one could observe. I think 2 Gy x 2 is not appropriate since this is a palliative regimen and there is nothing to palliate here. EFRT is overkill and too toxic. There are no data indicating INRT is as good as IFRT, so I would not offer that outside of a trial.
 
Great, thanx for all your input.

I would go with Option 2 as well (IFRT 30 Gy).
The interesting part with this patient in my opinion is, that the lymphoma was completely resected before treatment. Therefore the remaing tumor load will be very low.
In light of this and considering that neck irradiation can have some long term effects (especially on salivary glands), I have to say that Option 1 is a true alternative for this patient.
On the other hand preliminary data from the Dutch series on 2x2 Gy were only published on patients were treatment was given for refractory lymphoma and in a palliative setting. However bearing in ming the very high complete remission rates achieved in this patients series in patients with large tumors and refractory disease (after chemotherapy and/or radiotherapy, thus more aggressive lymphomas) one could speculate that 2x2 Gy may be enough and possibly linked with a lot less toxicity.
If the patient does relapse after 2x2 Gy on a regional level, salvage treatment with 30 Gy would still be possible.

Just a couple of thoughts...

I find it quite striking, that although follicular lymphoma is not a very rare disease in radiation oncology we actually have very little evidence concerning it.
There is a German Phase III trial undergoing comparing radiation volumes in FL. Beyond that I would say its quite a shame we have so little randomized evidence, bearing in mind that we have been treating follicular lymphoma for several decades with radiation therapy.
 
I'm surprised no one mentions option #6 : rituximab alone.I bet a lot of medonc's would argue for that.









So, here's an interesting case.

A 55 year old female was presented to us with the diagnosis of follicular lymphoma grade I.
A 2 cm cervical lymphoma was completely resected , the tumour was very superficial. No further suspicious lymph nodes were found in the CT scans, bone marrow is clear, normal LDH.

We were asked to treat the patient in "curative" intention.

What would you do?

1. Watch and Wait (Why not? It was completely removed after all.)
2. IFRT 30 Gy (Probably standard treatment)
3. EFRT 30 Gy (Older type of treatment, maybe better results, but more toxicity too)
4. INRT 30 Gy (Why not? Has anyone ever showed that INRT is worse than IFRT for follicular lymphoma)
5. IFRT 4 Gy (2x2 Gy like in the EORTC/Netherlands series)


Ooops, spelling error in title: "lymphoma"
 
I'm surprised no one mentions option #6 : rituximab alone.I bet a lot of medonc's would argue for that.
Surely, that's an option. Thank you for pointing it out.
I was rather outlining the available options from the view of the radiation oncologist.
 
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