International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationInvolved-Lesion Radiation Therapy After Chemotherapy in Limited-Stage Head-and-Neck Diffuse Large B Cell Lymphoma
Introduction
It is well known that the head and neck (HN) is involved in approximately 15% of all non-Hodgkin's lymphoma (NHL). The radiation target volume of HN NHL traditionally used to be involved-field radiation therapy (IFRT), which was mainly based on the RT technique for Hodgkin's disease (HD) and included the whole Waldeyer's ring and all cervical lymphatics down to the supraclavicular fossae 1, 2, 3, 4. A recent publication on RT for HD, however, supports the concept of involved nodal radiation therapy (INRT), which includes the prechemotherapy involved lymph nodes with adequate margin (in most cases, 1-cm isotropic margin) (5). This RT field size reduction from extended-field RT, IFRT, to INRT was proved to be safe without an increased risk of locoregional relapse by Campbell et al.(6), in whose study margins were <5 cm in INRT.
Investigators have applied involved-lesion radiation therapy (ILRT) with relatively small target volume covering the gross tumor with adequate margin since 1995. The purpose of the present study was to determine the influence of RT field size reduction and the pattern of failure in localized HN diffuse large B cell lymphoma (DLBL) treated with INRT as a part of sequential chemoradiotherapy.
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Diagnosis and clinical data
Between January 1995 and September 2006, 86 patients received combined cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP)-based chemotherapy and RT for localized (Stage I/II) HN DLBL at Samsung Medical Center. The diagnosis of DLBL was based on the current World Health Organization classification. All patients were staged by computed tomography (CT) and bone marrow examination. The following clinical data were collected from the medical records: patient demographics, complete
Clinical characteristics
The patients' median age was 55 years (range, 14–90 years), and 30 patients (34.9%) were older than 60 years. The male/female ratio was 1.1:1. Only 3 patients (3.5%) presented with poor performance status (ECOG 2). The oropharynx was the most frequent primary site in 35 patients (40.7%), followed by the cervical lymph node in 33 patients (38.4%). Five patients (5.8%) had B symptoms, and the serum LDH level was elevated above the upper limit of normal in 22 patients (25.6%). The numbers of
Discussion
The role of RT in localized aggressive lymphoma has been questioned since the reports of long-term results from the Southwest Oncology Group (SWOG) 8736 and Groupe d'Etudes des Lymphomes de l'Adulte LNH 93-1 trials 9, 10 were published. After considering the heterogeneity in target populations, study designs, and types of chemotherapy used, a consistent conclusion from these trials might be summarized, that RT cannot be replaced with chemotherapy because chemotherapy was unable to lead to
Conclusion
The role of RT in Stage I/II HN DLBL is increasing in terms of better local control rates, and its benefit might be more important with the development of chemotherapy, like R-CHOP, with better systemic control. From this point of view, to maximize the local control rate and to reduce RT complications, RT target volume delineation is very important. Our study is based on this background and the clinical characteristics of NHL. Despite a few limitations, the present study has shown results
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Cited by (19)
Involved Site Radiation Therapy in Adult Lymphomas: An Overview of International Lymphoma Radiation Oncology Group Guidelines
2020, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :IFRT after 3 to 4 cycles of R-CHOP has been an established strategy for favorable stage I to II DLBCL.75,76 Excellent results have been reported using modifications of ISRT (ie, margins of 1-5 cm on the GTV) in both retrospective and prospective nonrandomized studies.77-83 A study comparing strict INRT with IFRT showed no difference in outcome.82
Additional survival benefit of involved-lesion radiation therapy after r-chop chemotherapy in limited stage diffuse large b-cell lymphoma
2015, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :In our group receiving R-CHOP with ILRT, estimated PFS and OS rates at 5 years were 92.7% and 95%, respectively, which is not inferior to the outcomes of R-CHOP with IFRT reported by Phan et al (8), that is, 82% and 92%, respectively, for 5-year PFS and OS in stage I/II DLBCL. In addition, Yu et al (10) conducted a retrospective study of patients diagnosed with limited stage head and neck DLBCL and treated with RT, which was delivered to prechemotherapy tumor volumes with a 1-cm margin after chemotherapy (83.7% received CHOP, and 16.3% received R-CHOP therapy) and reported excellent outcomes (5-year OS and PFS rates were 89.2% and 88.9%, respectively). As mentioned above, this small ILRT field could provide outcomes comparable to previous large- field RT.
Thyroid Cancer
2015, Clinical Radiation OncologyThe role of radiotherapy and intrathecal CNS prophylaxis in extralymphatic craniofacial aggressive B-cell lymphomas
2014, BloodCitation Excerpt :A second important finding of this study is the observation that radiotherapy to ECFI sites does not appear to improve the outcome of these patients (Figure 2), irrespective of whether the patients received rituximab or not. Although several groups have recommended combined chemoradiotherapy for lymphomas arising in the paranasal sinuses9,10,14,30,31 in the pre-rituximab era, this recommendation has never been scrutinized in prospective trials of patients treated with rituximab. Our results show that radiotherapy to sites of craniofacial involvement did not improve the outcome of these patients (Figure 2) or of patients treated with or without rituximab; this conclusion is supported by a multivariable analysis adjusting for the IPI risk factors (supplemental Table 6) that showed that radiotherapy did not change the hazard for all ECFI patients (HR = 1.0) or for patients in CR/CRu after immunochemotherapy (HR = 1.0).
Modern radiation therapy for nodal non-hodgkin lymphoma - Target definition and dose guidelines from the international lymphoma radiation oncology group
2014, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Therefore, guidelines for lymphoma RT based on involved fields defined by anatomic landmarks and encompassing adjacent uninvolved lymph nodes (9) are no longer appropriate for modern, more-focused RT delivery aimed at reducing normal tissue exposure. Although we acknowledge the lack of randomized evidence to support radiation field size reduction, there is increasing evidence to suggest effective local control with such reduced field sizes (10, 11). Here we have highlighted the application of advances in the technological expertise available in the planning and delivery of RT and provide radiation oncologists treating NHL with guidelines on imaging, volume determination, and treatment planning.
Non-Hodgkin lymphoma of the nasopharynx: A report of four cases
2011, Cancer/Radiotherapie
Conflict of interest: none.