Primary CNS Lymphoma: Focus on role of Radiation

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  • Flow chart of therapeutic management of PCNSL in everyday practice. (1) Mostly marginal zone B-cell lymphoma, small lymphocytic lymphoma, and lymphoplasmacytic lymphoma. (2) Mostly intravascular large B-cell lymphoma and neurolymphomatosis. (3) Conclusion from the IELSG no. 20 trial.40 (4) Several regimens are available (Table 3). (5) A higher amount of available evidence suggests WBRT. The discussion with selected patients about the pros and cons of the use of consolidation WBRT or HDC/ASCT is recommended. (6) Available literature suggesting that some elderly patients in CR after primary chemotherapy could be watchful waited without OS impairment is constituted by a few small retrospective series. However, to delay WBRT until relapse is an acceptable strategy considering the increased risk of disabling neurotoxicity in these patients. (7) Radiation field and dose should be chosen on the bases of response to primary chemotherapy. WBRT dose reduction to 23-30 Gy in patients in CR after chemotherapy is recommended. DLBCL indicates diffuse large B-cell lymphoma; HD-MTX, high-dose methotrexate; ara-C, cytarabine; WBRT, whole-brain radiotherapy; CR, complete remission; PR, partial response; SD, stable disease; PD, progressive disease; and HDC/ASCT, high-dose chemotherapy supported by autologous stem cell transplantation.

Transcript

  • 1. Dr. Rico Liu Consultant, Department of Clinical Oncology, Queen Mary Hospital Honorary Clinical Associate Professor, Department of Clinical Oncology, The University of Hong Kong Deputy Hospital Chief Executive, Queen Mary Hospital BTG 2013 Feb 2013
  • 2. Points for discussion Effects of radiation Radiotherapy is not for everyone but for whom and when The role of new technology
  • 3. Effects of radiation External Radiotherapy •High energy Xray • Photon- •Gama ray- from radioactive decay, e.g. Colbert •High energy particles • Electron • Proton Brachytherapy Systemic radiotherapy apoptosis
  • 4. Effects of therapeutic radiation
  • 5. Normal tissue tolerance Milano et al., Semin Radiat Oncol. 17 (2007): 131-140
  • 6. Treatment improves survival Median survival (mo) Untreated ~2 WBRT alone ~12 Chemotherapy follows by WBRT ~ 48 Henry JM et al. Cancer 34: 1293, 1974 Nelson DF et al. IJROBP Volume 23, Issue 1, 1992, Pages 9–17 Ferreri AJ et al. Ann Oncol. 2000 Aug;11(8):927-37
  • 7. PCNSL: Radiotherapy alone RTOG 8315 Phase II study of WBRT 40Gy + 20Gy boost N = 41 Overall median survival 12.2 months Benefit of boost doubtful: disease recurrence frequently occurred in the boosted field, survival no better than previous study without use of boost Ocular involvement: 36Gy to both eyes (or Rx with high dose MTX) Nelson DF et al. IJROBP Volume 23, Issue 1, 1992, Pages 9–17
  • 8. PCNSL: Chemo + radiotherapy  CR 58%, PR 36% (Overall RR 94%)  Overall survival 37 months  15% ( 12 patients) developed severe delayed neurologic toxicity  8 out of 12 died ( 5/8 from the group > 60 years of age and 3/8 from < 60 years of age)
  • 9. Delayed neurotoxicity is worse for elderly patients Omuro AM et al. Arch Neurol. 2005 Oct;62(10):1595-600
  • 10. G-PCNSL-SG-1 trial
  • 11. Not enough evidence to forgo WBRT Limitations of the trial Low statistical power High protocol violations High rate of lost to follow up Small sample size in the analysis of neurotoxicity
  • 12. Lower dose of RT for patients with CR
  • 13. WBRT- set up
  • 14. Therapeutic management of PCNSL Ferreri A J M Blood 2011;118:510-522Role of radiotherapy
  • 15. The role of new technology Neuro Oncol (August 2009) 11 (4): 423-429
  • 16. Summary PCNSL is rare Chemotherapy +/- radiotherapy offer the best survival Delayed neurotoxicity is common and can cause major disability and death Reduce risk of delayed neurotoxicity lower consolidation dose for patients <60 defer WBRT for those older patients >60 Radiotherapy remains an effective treatment for patients considered not suitable for chemotherapy
  • 17. Thank You