R di th R di th Radiotherapy Lymphomas Radiotherapy Lymphomas L L h h Mary Gospodarowicz MD Mary Gospodarowicz MD Princess Margaret Hospital Princess Margaret Hospital University of Toronto, Toronto, Canada University of Toronto, Toronto, Canada
Changing Landscape in Lymphoma Changing Landscape in Lymphoma Changing Landscape in Lymphoma Changing Landscape in Lymphoma • 90% of cases in adults 90% of cases in adults • median age median age - - 64 yrs 64 yrs • 2008 Statistics 2008 Statistics US US Canada Canada • 66 120 new cases 7 000 66 120 new cases 7 000 • 19 160 deaths • 19 160 deaths 19 160 deaths 19 160 deaths 3 100 3 100 3 100 3 100 • @ 500 000 people living with lymphoma @ 500 000 people living with lymphoma • 90% B 90% B-cell 90% B 90% B cell cell cell • @ 40% DLBCL @ 40% DLBCL • 10% T 10% T- -cell cell
RT in Non RT in Non Hodgkin L mphoma RT in Non RT in Non-Hodgkin Lymphoma Hodgkin L mphoma Hodgkin Lymphoma • Challenges Challenges Challenges Challenges – Only 4 Only 4 - - 6% of all cancers 6% of all cancers – Numerous distinct disease entities Numerous distinct disease entities Numerous distinct disease entities Numerous distinct disease entities • Mycosis fungoides Mycosis fungoides • Primary brain lymphoma Primary brain lymphoma y y y y p p • Gastric MALT Gastric MALT • Burkitt’s Burkitt’s – Changing outcomes Changing outcomes – Little level 1 evidence to guide practice Little level 1 evidence to guide practice
Radiation Therapy in Cancer Radiation Therapy in Cancer Radiation Therapy in Cancer Radiation Therapy in Cancer • Local therapy • Local therapy Local therapy Local therapy –Proven most effective agent in Proven most effective agent in providing local tumour control providing local tumour control idi idi l l l t l t t t l l –Proven capable of curing localized Proven capable of curing localized disease in most cancers disease in most cancers –Compensates for diagnostic ambiguity Compensates for diagnostic ambiguity p p g g g g y y • ‘histology agnostic’ ‘histology agnostic’ –Few contraindications Few contraindications Few contraindications Few contraindications
Radiation Therapy in Cancer Radiation Therapy in Cancer Radiation Therapy in Cancer Radiation Therapy in Cancer • Local therapy • Local therapy Local therapy Local therapy • Proven most effective agent in providing Proven most effective agent in providing local tumour control local tumour control local tumour control local tumour control • Proven capable of curing localized disease Proven capable of curing localized disease in most cancers in most cancers in most cancers in most cancers • Compensates for diagnostic ambiguity Compensates for diagnostic ambiguity • ‘histology agnostic’ ‘histology agnostic’ histology agnostic histology agnostic • Few contraindications Few contraindications
RT in L mphomas RT in L mphomas RT in Lymphomas RT in Lymphomas • Objective of RT Obj Obj Objective of RT ti ti f RT f RT – Almost always to achieve local control Almost always to achieve local control • Outcomes of interest Outcomes of interest – Pattern of failure Pattern of failure • Local control Local control • Overall failure rate Overall failure rate – Survival Survival – Toxicity Toxicity
Stage I&II Follicular Lymphoma 1967 Stage I&II Follicular Lymphoma 1967 Stage I&II Follicular Lymphoma 1967-99 Stage I&II Follicular Lymphoma 1967 99 99 99 Stage I Stage I- -II II - 668 pts - 668 pts • Stage I Stage I- -II RT alone II RT alone - 460 pts - 460 pts – median follow median follow- ed a ed a o o o o -up up up up - - 12.5 yrs 12.5 yrs 5 y s 5 y s • range range - - up to 32 yrs up to 32 yrs • Treatment Treatment – IF RT 30 Treatment Treatment IF RT 30-35 Gy IF RT 30 IF RT 30 35 Gy 35 Gy 35 Gy • Relapse Relapse • distant distant distant distant - - 89 % 89 % 89 % 89 % • distant + local distant + local - - 6 % 6 % • isolated local relapse • isolated local relapse isolated local relapse isolated local relapse - - 5% 5% 5% 5%
PMH 1968 PMH 1968 PMH 1968 PMH 1968 – 1999 1999 1999 1999 Stage I Stage I- -II Follicular Lymphoma RT Alone II Follicular Lymphoma RT Alone 460 patients 460 patients
PMH 1968 – PMH 1968 – 1999 1999 Stage I St St Stage I-II Follicular Lymphoma RT Alone I I II F lli II Follicular Lymphoma RT Alone II F lli l l L L h h RT Al RT Al No relapse 80 Relapse 70 60 Age 50 40 30 20 0 5 10 15 20 25 30 35 Ti Time to relapse or follow-up l f ll
Stage I-II MZL PMH 1989-2004 MALT 1989 MALT 1989 - - 2004 2004 • 166 pts treated with RT 166 166 pts treated with RT 166 t t t t t d t d ith RT ith RT • median follow median follow- -up 7.6 yrs (0.6 up 7.6 yrs (0.6 – – 16.2) 16.2) • median age 60 yrs median age 60 yrs (23 (23- -93) 93) • F : M = 2 : 1 F : M = 2 : 1 F : M 2 : 1 F : M 2 : 1 • stage I stage I 148 (89%) 148 (89%) • stage II stage II t t II II 18 (11%) 18 (11%) 18 (11%) 18 (11%)
Stage I-II MZL PMH 1989-2004 Presenting Sites Presenting Sites Orbit and adnexa Orbit and adnexa 70 (42%) 70 (42%) Skin & soft tissues Skin & soft tissues 4 4 Salivary gland Salivary gland 28 (17%) 28 (17%) Breast Breast 4 4 Stomach Stomach St St h h 22 (13%) 22 (13%) 22 (13%) 22 (13%) R R Rectum Rectum t t 1 1 Thyroid Thyroid 21 (13%) 21 (13%) Meninges Meninges 1 1 Other head & neck* Other head & neck* Other head & neck Other head & neck 6 6 Thymus Thymus Thymus Thymus 1 1 Lung Lung 4 4 Bladder Bladder 4 * nasopharynx nasopharynx - - 3, 3, maxillary maxillary sinus sinus - - 1 1 larynx larynx - - 1, Hypopharynx 1, Hypopharynx - - 1 1
Stage I/II MALT lymphoma Stage I/II MALT lymphoma - g g y y p p - Relapse Relapse p Stomach/Thyroid (n=43) Relapse 2 yrs: 13/31 (52%) 5 yrs: 25/31 (81%) Other sites (n=123) > 5 yrs: y 6/31 (19%) ( ) 10-year RFR Thyroid 95% Stomach 100% Salivary gland 68% Orbit 67%
Stage I/IIE MALT lymphoma Stage I/IIE MALT lymphoma - Survival Stage I/IIE MALT lymphoma Stage I/IIE MALT lymphoma Survival Survival Survival --- 10 yr CSS - 98% — 10 yr OS - 87% …. 10 yr RFR- 77% 10 yr RFR 77%
Limited Limited- -stage mantle stage mantle- g -cell lymphoma cell lymphoma y y p p Leitch et al Leitch et al Annals of Oncology 14: 1555 1561 2003 Leitch et al. Leitch et al. Annals of Oncology 14: 1555–1561, 2003
Int J Radiat Oncol Biol Phys 65: 1185 91 2006 Int J Radiat Oncol Biol Phys 65: 1185–91, 2006
Localized DLBCL Localized DLBCL Localized DLBCL Localized DLBCL � Heterogeneous disease � Heterogeneous disease Heterogeneous disease Heterogeneous disease � Phenotypic, molecular characteristics Phenotypic, molecular characteristics � Nodal vs. extranodal presentations Nodal vs extranodal presentations Nodal vs extranodal presentations Nodal vs. extranodal presentations � Stage I vs. II (II localized vs.. extensive) Stage I vs. II (II localized vs.. extensive) � B-symptoms B symptoms symptoms symptoms � LDH LDH � Age and performance status A A Age and performance status d d f f t t t t � Comorbidity Comorbidity
Spectrum of Localized DLBL Spectrum of Localized DLBL Spectrum of Localized DLBL Spectrum of Localized DLBL
PMH Experience 1984 PMH Experience 1984 2003 PMH Experience 1984 PMH Experience 1984 - -2003 2003 2003 � 600 patients with stage I 600 patients with stage I- -II II � Age 15 Age 15 - - 91 91 median median - - 57 yrs 57 yrs � Follow Follow- -up 0.4 up 0.4 – 22 yrs 22 yrs y median median - - 10.1 yrs 10.1 yrs y � Stage I Stage I - - 317 317 B-symptoms B symptoms - - 64 64 � Stage II Stage II - g - 283 283 Extranodal - Extranodal - 354 354 � Chemo 3/4 courses Chemo 3/4 courses - - 233 233 � Chemo 5/6 courses � Chemo 5/6 courses Chemo 5/6 courses - 336 Chemo 5/6 courses 336 336 336 � median RT dose median RT dose – – 35 Gy 35 Gy � pre � pre pre-rituximab pre rituximab rituximab rituximab
Overall Survival Overall Survival Overall Survival Overall Survival PMH DLBCL PMH DLBCL – – CMT 1984 CMT 1984- -2003 2003
Survival by age Survival by age Survival by age Survival by age PMH DLBCL PMH DLBCL – – CMT 1984 CMT 1984- -2003 2003
Probability of Local Relapse Probability of Local Relapse Probability of Local Relapse Probability of Local Relapse PMH DLBCL PMH DLBCL – – CMT 1984 CMT 1984- -2003 2003
CHOP non CHOP non- -responders responders p Probability of Death from Lymphoma Probability of Death from Lymphoma PMH DLBCL PMH DLBCL – – CMT 1984 CMT 1984- -2003 2003
Recommend
More recommend
