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Radiotherapy Lymphomas
1. Radiotherapy L
R di th Lymphomas
h
Mary Gospodarowicz MD
Princess Margaret Hospital
University of Toronto, Toronto, Canada
2. Changing Landscape in Lymphoma
• 90% of cases in adults
• median age - 64 yrs
• 2008 Statistics
US Canada
• 66 120 new cases 7 000
• 19 160 deaths 3 100
• @ 500 000 people living with lymphoma
• 90% B-cell
B-
• @ 40% DLBCL
• 10% T-cell
T-
3. RT in Non-Hodgkin L mphoma
Non- Lymphoma
• Challenges
– Only 4 - 6% of all cancers
– Numerous distinct disease entities
• Mycosis fungoides
• Primary brain lymphoma
y yp
• Gastric MALT
• Burkitt’s
– Changing outcomes
– Little level 1 evidence to guide practice
4. Radiation Therapy in Cancer
• Local therapy
– Proven most effective agent in
providing l
idi local t
l tumour control
tl
– Proven capable of curing localized
disease in most cancers
– Compensates for diagnostic ambiguity
p g gy
• ‘histology agnostic’
– Few contraindications
5. Radiation Therapy in Cancer
• Local therapy
• Proven most effective agent in providing
local tumour control
• Proven capable of curing localized disease
in most cancers
• Compensates for diagnostic ambiguity
• ‘histology agnostic’
histology agnostic
• Few contraindications
6. RT in Lymphomas
L mphomas
• Objective of RT
Obj ti f
– Almost always to achieve local control
• Outcomes of interest
– Pattern of failure
• Local control
• Overall failure rate
– Survival
– Toxicity
7. Stage I&II Follicular Lymphoma 1967-99
1967-
Stage I-II
I- - 668 pts
• Stage I-II RT alone
I- - 460 pts
– median follow-up
ed a follow-
oo - 12.5 y s
5 yrs
• range - up to 32 yrs
• Treatment – IF RT 30-35 Gy
30-
• Relapse
• distant - 89 %
• distant + local - 6%
• isolated local relapse - 5%
9. PMH 1968 – 1999
Stage I-II Follicular L
St I- F lli l Lymphoma RT Al
h Alone
No relapse
80
Relapse
70
60
Age
50
40
30
20
0 5 10 15 20 25 30 35
Time to relapse or f ll
Ti l follow-up
10. Stage I-II MZL PMH 1989-2004
MALT 1989 - 2004
• 166 pts treated with RT
t t t d ith
• median follow-up 7.6 yrs (0.6 – 16.2)
follow-
• median age 60 yrs (23-93)
(23-
• F:M=2:1
• stage I 148 (89%)
• stage II
t 18 (11%)
16. Localized DLBCL
Heterogeneous disease
Phenotypic, molecular characteristics
Nodal vs. extranodal presentations
vs
Stage I vs. II (II localized vs.. extensive)
B-symptoms
LDH
Age d
A and performance status
f tt
Comorbidity
22. CHOP non-responders
non- p
Probability of Death from Lymphoma
PMH DLBCL – CMT 1984-2003
1984-
23. Rituximab Era
Rituximab
Rit i b gradually i t d
d ll introduced t th
d to the
management of all DLBCL
Outcomes improved
Role of RT questioned
q
No level 1 evidence
For the benefit of RT
For the lack of benefit of RT
32. RO Practice in Lymphomas
• Change in radiation oncology p
g gy practice
– Target volume rather than nodal region
treated
– GTV, CTB, PTV defined and treated
– Most practice in adjuvant setting
• N GTV CTV non-standard
No GTV, non- dd
– Need to monitor and report RT relevant
outcomes
• Local control
• Patterns of relapse
33. RT Planning
Requires optimal
R i ti l
pre-chemotherapy
imaging
34. Current Standard
• Target - post chemotherapy CTV
• Dose and fractionation
– 30 – 35 Gy in 15-20 fractions
15-
• 3D CRT / IMRT
– protect normal tissues
• CT planning
• Image guidance as required
35.
36. Role of RT
All trials show improved local control
Very safe treatment
Minimal acute and late severe toxicity
Modern techniques – lower acute toxicity
Best local therapy cannot improve
distant disease control
If systemic therapy results in 100% local
control – no need for RT
37. Current contro ersies
C rrent controversies
•L
Localized f lli l l
li d follicular lymphoma
h
– Curable with RT or just very slow natural
history
hi t
• MALT
– Role of RT in rare presentations
– Need to learn more about the natural
history
38. Current contro ersies
C rrent controversies
• Localized DLBCL
L li d
– Is RT needed in R-CHOP era
R-
• Does it add to the chemotherapy
– Must conduct studies that include optimal
chemotherapy and ask RT question
• Extranodal lymphomas
– Differences btwn EN and N presentations
39. Current contro ersies
C rrent controversies
• R l of RT i FDG PET era
Role f in
– Assessment of response to chemotherapy
using mid-treatment FDG PET
i mid-t t
id t
– Post chemotherapy PET assessed
response as selection factor for RT
• Role of RT in PET +ve and PET –ve cases
• Patterns of failures in above situations
40. Future
• Biologic imaging
g gg
• Disease extent
• Response
p
• Selection for adjuvant treatment
• Role of precision RT
• Molecular disease characteristics
• D fi iti of di
Definition f disease entities
titi
• Impact on the management
