Stage I Follicular Lymphoma Case

[BobbyHeenan]

Hello. I appreciate any input. Thanks in advance.

I have an otherwise very healthy 60 year old female with no chronic medical problems other than minor LLE venous stasis/vericose veins. She was sent to vascular surgeon for work up of that (at least 5 year history of this, just bad enough to want to see someone recently...would get a few days of puffy foot, then go away. After a long shift up on feet it would swell at night) and they found on venous ultrasound a 4cm lymph node in her groin. Of course it just had to come out. So excision of the node was done, 4.2 cm Grade 1 follicular lymphoma. Post op PET shows nothing else other than operative cavity/seroma.

Med onc sent to me for ISRT.

Of course she now has 1+ LLE edema to mid shin. Puffy L foot. Can still wear her normal shoes but tighter on the left. She's had waxing and waning edema in the left foot for a number of years now, but she thinks the past few weeks after a long hike in the mountains it's been persistently a little worse.

I'm sending her to lymphedema PT. I'm debating observation ("curative" surgery) versus 24 Gy versus 2 Gy X 2...versus back to med onc for rituximab.

Any thoughts here? She is incredibly reasonable and understands my concerns regarding long term lymphedema. I'm not sure if there is an edema threshhold dose, but 24 Gy usually doesn't scare me at all...but here we are.

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[evilbooyaa]

Very similar to indolent hodgkin lymphoma, which was previously discussed as a grey zone case in IJROBP: https://www.redjournal.org/article/S0360-3016(17)34056-7/fulltext

But this is more indolent than the most indolent hodgkin's.

I would favor observation if it was resected to negative margins. Unlikely to negatively affect her survival and would be candidate for salvage at later date.

 

[seper]

I'd treat and go a bit higher that 24 Gy. Maybe 30-35 Gy? Stanford 1996 paper treated to a median of 40 Gy AFAIK. But of course, both you and your patient worry about lymphedema which is understandable.

 

[PhotonBomb]

If you won’t treat her I will. 24 Gy. Done. The additional lymphedema risk is quite low.

Observation isn’t wrong either, but it was a 4 cm node and lymphoma isn’t. Surgical disease. The basin at risk. Jus treat.

Rituxan? I hardly know her.

 

[BobbyHeenan]

So we've got one for observe, one for treat (with doses higher than 24 Gy), and one for treat with 24 Gy....

At least I'm not questioning my sanity for throwing the case up here for discussion....

If I tread I"m not going above 24 Gy.

Data to support that: Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial. - PubMed - NCBI

 

[PhotonBomb]

So we've got one for observe, one for treat (with doses higher than 24 Gy), and one for treat with 24 Gy....

At least I'm not questioning my sanity for throwing the case up here for discussion....

If I tread I"m not going above 24 Gy.

Data to support that: Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial. - PubMed - NCBI

Agree, 0.0 percent reason to go past 24. I wouldn’t let a dose past 24 sniff peer review

 

[medgator]

It's microscopic at this point, agree with 0 reason to go above 24/12 which is exactly what I would do

 

[RadOncG]

Observation.

What is the goal of treatment? Local control? Clearly you cannot improve survival with indolent untreated lymphoma.

Salvage radiation has nearly 100% local control on the small chance there is a local only recurrence that is symptomatic.

 

[FrostyHammer]

Not a lymphoma guy but doesn't NCCN recommend treatment for these? I'm wondering why if it's so indolent.

 

[radiation]

Interesting case. The old med onc lore would say that follicular lymphoma is incurable and all treatments just should be for symptom control. However, rad onc literature with pretty long follow up at this point says that you probably have a 50% chance of cure for Stage 1 disease with low-moderate, "definitive" RT. The radiation fields had historically covered at least the whole lymph basin - big IFRT in the past and smaller nowadays with ISRT, so not sure that a solitary node excision is enough. So thats how I would frame it since there is no surgical data for this disease, RT gives her the best chance of cure (if she wanted to pursue that). Biggest publication here with that approach

Definitive radiotherapy for localized follicular lymphoma staged by 18F-FDG PET-CT: a collaborative study by ILROG - PubMed

Radiotherapy (RT) can be curative in patients with localized follicular lymphoma (FL), with historical series showing a 10-year disease-free survival of 40 to 50%. As ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography with computerized tomography (PET-CT)...

www.ncbi.nlm.nih.gov

 

[medgator]

Observation.

What is the goal of treatment? Local control? Clearly you cannot improve survival with indolent untreated lymphoma.

Salvage radiation has nearly 100% local control on the small chance there is a local only recurrence that is symptomatic.

Disagree. Chance to cure as @radiation put well

 

[Mandelin Rain]

24 Gray, all day

 

[Reaganite]

Interested to hear what you guys consider ISRT for follicular lymphoma treated with radiation alone. In particular, because patients have not received chemo to potentially sterilize the entire nodal basin, do you use larger fields, or do you just target the gross nodes with margin?

 

[radiation]

Interested to hear what you guys consider ISRT for follicular lymphoma treated with radiation alone. In particular, because patients have not received chemo to potentially sterilize the entire nodal basin, do you use larger fields, or do you just target the gross nodes with margin?

In the ILROG paper, pts got everything from INRT, IFRT, and ISRT and there was no difference in outcomes. So probably dealers choice on whatever you are most comfortable with. Probably would treat gross node and include any nearby radiographically detectable nodes along the chain nearby. 24 gy is so low that most cases it probably doesnt add any tox to be a bit generous

 

[Palex80]

2 x 2 Gy has ZERO toxicity and will potentially prolong PFS substantially compared to observation.

If you don‘t want to give 24/2, I see no reason to not go for 2 x 2 Gy.

 

[Palex80]

Interested to hear what you guys consider ISRT for follicular lymphoma treated with radiation alone. In particular, because patients have not received chemo to potentially sterilize the entire nodal basin, do you use larger fields, or do you just target the gross nodes with margin?

I treated one patient with 24/2 to the right groin 2 years ago for a stage I FL. He recurred in the right extern iliac chain 6 months later. I treated ISRT right extern iliac 24/2. He recurred in the left extern iliac chain 9 months later. I treated ISRT left extern iliac and added the left groin + the internal/common nodes bilaterally after that, all 24/2.

Anxious to see what happens next... Probably retroperitoneal recurrence?

 

[BobbyHeenan]

Thanks all for the input.

In the ISRT papers and NCCN it talks about considering more extended coverage in radiation as monotherapy cases (like this FL or a lymphocyte predominant hodgkin's case).

If treating I'm leaning 24 Gy (goal: cure - as noted above some series including the classic Stanford series suggest about half of patients at 10 years never relapse with radiation alone) and covering the entire L inguinal basin and then most of the external iliac chain. Probably will stop at the common iliac.

I'll see her back after lymphedema PT eval and get her thoughts again.

 

[Mandelin Rain]

That's probably a little more than I'd cover, but reasonable.

 

[evilbooyaa]

Yes 24Gy of definitive radiation can be curative.

But if a patient has it surgically resected what ADDITIONAL benefit do you think RT is adding? It's an indolent disease, why are we rushing to a second local therapy for a patient who could easily be salvaged (and if they can't, they were going to progress after RT anyways)?

 

[BobbyHeenan]

Yes 24Gy of definitive radiation can be curative.

But if a patient has it surgically resected what ADDITIONAL benefit do you think RT is adding? It's an indolent disease, why are we rushing to a second local therapy for a patient who could easily be salvaged (and if they can't, they were going to progress after RT anyways)?

I get what you're saying and that's why I'm taking some time to help all parties make best decision/rec for the patient.

However, I'm not aware of any curative surgery for lymphoma data with long term follow up. She has a chance there are other nodes within this area that are positive, as well as the fact that it's unlikely the surgeon removed all disease. It's a > 4cm node, certainly ECE there. Pathologist laughed when I said "?any assessment on margin here?"

I think it's prudent to maximize her pre radiation lymphedema eval and see where we're at in month or two. I'm certainly in no rush and just want to do what is best here.

 

[evilbooyaa]

OK If the margins are not able to be called negative because pathology is lazy then I would treat as well. Personally, I would inform the pathologist that them not evaluating for margin status is going to buy this patient additional treatment. If it is positive or with ECE then I would treat as well. That being said, if you are going to treat regardless of margin status then it's probably not worth it to piss off your pathologist.

Say this patient had a lymph node dissection, rather than a simple excision - would you feel that is sufficient local therapy?

 

[medgator]

Fwiw isn't the chance of ece close to 100% with a node size of 4cm?

 

[PhotonBomb]

Fwiw isn't the chance of ece close to 100% with a node size of 4cm?

yes. node in that area of that size, it was a muck job.

there are so many cancer cells in that region it would make a grown man cry.

If you elect to observe, it's not because you don't think there is disease there.