Role Of Consolidative Radiation Therapy Research Articles

Combined modality for localized gastric diffuse large B-cell lymphoma: Long-term outcomes of 50 patients.

7079 Background: R-CHOP is the primary treatment for gastric diffuse large B-cell lymphoma (GDLBCL); for localized disease, the role of consolidative radiation therapy (RT) after chemotherapy remains underexplored. This study focuses on localized GDLBCL undergoing a combined modality therapy of R-CHOP followed by gastric RT, comparing outcomes between those receiving short-course (3-4 cycles) and full-course (6 cycles) R-CHOP. Methods: A retrospective analysis identified 50 consecutive PGDLBCL pts treated with R-CHOP followed by RT between 1/2000-1/2021. Baseline characteristics and follow-up data were collected. Lugano PET criteria and endoscopy (EGD) assessed overall response rate. Kaplan-Meier and univariable cox regression models estimated overall survival (OS) and (PFS). Results: Of the 50 pts with localized (Stage I-II) disease, 34 (68%) received 3-4 cycles of R-CHOP and 16 (32%) received 6 cycles. Pre-RT disease evaluation varied, with 36 (72%) undergoing EGD and PET, 4 (8%) EGD and CT, and 6 (12%) PET alone. One pt (3%) exhibited active DLBCL post 3-4 cycle R-CHOP, while 5 (31%) did so after 6 cycles (p=0.1). Median time from last R-CHOP dose to RT start date was 1.2 months with a median 3060 cGy delivered dose for both groups (range 2340-3060 in the 3-4 cycle group, 3000-4500 in the 6-cycle group). Median follow-up time from RT end is 58 months. No in-field failures occurred post-complete response (CR); however, 1 pt did not achieve a CR following R-CHOP and RT, progressing in the stomach and subsequently at new, out-of-field (OOF) sites. 3 pts had OOF progression without relapses in the stomach in a median time of 21 months. Low-grade lymphoma in the stomach post-DLBCL CR was observed in 2 pts, 3 and 22 months from RT end, with 1 OOF marginal zone lymphoma 2 years-post RT. OS and PFS did not significantly differ between the 3-4 and 6 cycle groups (96-month OS 70% vs. 86%, p=0.8; 96-month PFS 76% vs. 86%, p=0.7). OS and DLBCL PFS were analyzed for pts with evidence of residual DLBCL pre-RT compared to those without evidence of disease after R-CHOP. The 24-month DLBCL PFS was 92% in the CR group and 67% for those with incomplete response (p=0.14), with 92% and 67% 24-month survival probability (p=0.11). On univariate analysis, pre-RT evidence of active DLBCL by PET and/or EGD, pre-RT PET FDG uptake, and achieving CR on first-post-RT imaging were not statistically significant for DLBCL PFS. Conclusions: Recognizing the limitations of a retrospective study, our study documents the effectiveness of short-course R-CHOP followed by RT in localized GDLBCL, with similar outcomes to the full 6-cycle regimen. Excellent disease control was observed, with few instances of DLBCL or low-grade lymphoma relapse. Further analysis will include a cohort receiving R-CHOP alone without consolidative RT. This analysis aims to contribute to the evolving standard of care for GDLBCL, providing insights for future treatment strategies.

Consolidative Radiotherapy after Complete Remission following R-CHOP Immunochemotherapy in Stage III-IV Diffuse Large B-Cell Lymphoma Patients: A Systematic Review and Meta-Analysis.

Patients with diffuse large B-cell lymphoma (DLBCL) are treated with rituximab in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). The role of consolidative radiation therapy (RT) remains unclear among patients with advanced DLBCL who achieved complete remission (CR) after R-CHOP immunochemotherapy. The current systematic review and meta-analysis aimed to clarify the role of consolidative RT among these patients. The MEDLINE, Embase, and Cochrane Library databases were searched for studies comparing RT to no RT following CR after R-CHOP immunochemotherapy in Ann Arbor stage III-IV DLBCL patients. Overall survival (OS) was the primary endpoint, and disease-free survival (DFS) was the secondary endpoint. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to assess the primary and secondary outcomes. Review Manager (version 5.4) was used to analyze the data. Six retrospective studies involving 813 patients who received R-CHOP ± consolidative RT were identified. OS was higher in the consolidative RT group, with an HR of 2.01 and a 95% CI of 1.30 to 3.12 (p = 0.002). DFS was also higher in the RT group, with an HR of 2.18 and a 95% CI of 1.47 to 3.24 (p < 0.0001). The results suggested that consolidative RT improved OS and DFS compared to no RT among advanced-stage DLBCL patients. Further research is needed to determine the optimal radiation fields and the appropriate indications for consolidative RT for advanced-stage DLBCL patients in the rituximab era.

Patients and Families' Participation in Multidisciplinary Tumor Conferences Improves Patient and Family-Focused Cancer Care: Lessons Learned From a Debate on the Role of Radiation Therapy in Primary Mediastinal Non-Hodgkin Lymphoma.

Incorporation of patients' preferences often leads to improved outcomes when included in the multidisciplinary tumor conference/board (MTC). However, patients' wishes are not included or considered in the MTC decision-making. We need better strategies and approaches for patient-inclusive, shared decision-making. When finding ourselves at a crossroads regarding the next step in a patient's treatment, we saw a unique opportunity for an MTC with the patient and her husband in attendance. The results of a full literature review regarding the role of consolidative radiation therapy (RT) in a patient with primary (thymic) B-cell lymphoma after completion of chemotherapy and fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) scan with a Deauville score of 4 were presented in a creative, engaging debate-style forum with visual aids. The patient and her husband were able to follow the discussion and, in the end, a consensus recommendation, heavily focused on the patient's preferences, was offered and adopted, which ultimately resulted in the avoidance of excess treatment and likely improved her long-term quality of life outcome. These collaborative and innovative interactions benefit not only our patients but enrich our lives too as healthcare providers and strengthen us as a cancer care team in terms of understanding diversity in decision-making processes.

Improved Progression-Free Survival for Bulky and Non-Bulky Advanced Stage Diffuse Large B-Cell Lymphoma With Consolidative Radiation Therapy: A Bi-Institutional Analysis.

BackgroundThe role of consolidative radiation therapy (RT) for advanced-stage diffuse large B-cell lymphoma (DLBCL) is not fully established. A growing body of data suggests a role for consolidative RT in select stage III-IV DLBCL patients and emerging data from randomized studies further address the role of RT in advanced-stage patients initially presenting with bulky disease.MethodsPatients with treatment-naive stage III-IV DLBCL treated at two institutions who achieved a clinically complete response to systemic therapy were included. Patients with either bulky or non-bulky disease were included, but those with the relapsed or refractory disease were excluded. Kaplan-Meier analysis was performed to determine the impact of consolidative RT. Univariate and multivariable analyses were performed using a Cox proportional hazards model.ResultsOne hundred eighty-eight patients received systemic therapy consisting of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; 79%), another rituximab-based regimen (9%), or chemotherapy alone (12%). Clinical response was assessed using conventional CT or PET-CT. Sixty-eight patients (36%) received consolidative RT (median dose 30 Gy). Consolidative RT conferred a 36.7% absolute benefit in five-year progression-free survival (PFS; 85.9% vs. 49.2%, log rank p < 0.0001), a 14.5% absolute benefit in five-year overall survival (OS; 87.4% vs. 72.9%, log rank p = 0.0134), and a 37.0% absolute benefit in five-year LC (91.9% vs. 54.9%, log rank p < 0.0001). On multivariable analysis, consolidative RT was associated with improved PFS (HR 0.23, 95% CI 0.10-0.52, p < 0.001) and LC (HR 0.20, 95% CI 0.07-0.59, p = 0.003). Patients receiving consolidative RT demonstrated significantly improved PFS for tumors measuring both <5 cm (log rank p = 0.0454) and ≥5 cm (log rank p = 0.0003).ConclusionsFor patients with stage III-IV DLBCL who achieve clinical complete response after systemic therapy, consolidative RT improves PFS for all patients, including those with the non-bulky disease. This benefit persists in the setting of rituximab-based systemic therapy.

114P - Role of consolidative radiation therapy after surgery in patients with stage IV rectal cancer

114P - Role of consolidative radiation therapy after surgery in patients with stage IV rectal cancer

P-312 - Role of consolidative radiation therapy after surgery in patients with stage IV rectal cancer

P-312 - Role of consolidative radiation therapy after surgery in patients with stage IV rectal cancer

Role of consolidative radiation therapy for patients with mediastinal diffuse large B-cell lymphoma in the rituximab era.

The most common subtype of aggressive non-Hodgkin Lymphomas is diffuse large B-cell lymphoma (DLBCL). Mediastinal DLBCL is a distinct entity with unique clinical, pathologic, and genetic features and accepted as a subtype of DLBCL. The aim of this study is to evaluate the patients treated with consolidative radiotherapy (RT) after rituximab-containing chemotherapy for mediastinal DLBCL regarding treatment outcomes and relapse patterns. Forty-two patients with the diagnosis of mediastinal DLBCL who were treated at the Ege University Hospital between January 2008 and December 2014 were evaluated. All patients received 2-10 cycles of rituximab-containing chemotherapy schedule (mostly CHOP). RT was delivered to a total dose of 30.6-45 Gy with 1.8 Gy daily fractions in 4-5 weeks. The irradiation fields were designed by using involved lymphatic site technique. The median age at diagnosis was 53 years (range, 18-85 years). Ann Arbor clinical stage at diagnosis was as follows: 8 patients (19%) at Stage I, 20 patients (47.6%) at Stage II, 7 patients (16.7%) at Stage III, and 7 patients (16.7%) at Stage IV. The median follow-up period was 47 months (range, 7-96 months). Complete response was obtained in 27 patients (64.3%), partial response was obtained in 14 patients (33.3%) across all stages. Estimated 5-year overall survival (OS) and progression-free survival (PFS) rates were, respectively, 84% and 77% for all patients, 100% and 92% for the patients without residual disease after chemotherapy. The response to chemotherapy is the most important factor affecting both OS and PFS. The role of consolidative RT is not clear in the rituximab era due to the lack of phase III trial. However, available literature shows that consolidative RT may still have a role in mediastinal DBLCLs.

Management of Double/Triple Hit Early Stage Diffuse Large B-Cell Lymphoma With Radiation Therapy

The role of consolidative radiation therapy (RT) after R-CHOP in early stage Diffuse Large B-Cell Lymphoma (DLBCL) remains controversial. Further, recent research has identified double-hit (DHL) and triple-hit (THL) as aggressive subtypes of this disease, but the role of RT has not been well defined in these cases. We evaluated the outcome of patients treated with systemic therapy followed by consolidative RT vs. those treated with systemic therapy alone with a focus on DHL and THL. A total of 209 lesions treated in 188 patients with early stage DLBCL were identified for retrospective analysis. These patients were treated in a single institution, from February 1998 to December 2014. Details of clinical characteristics, treatments, outcomes, and molecular profiles were extracted from clinical chart review and radiologic examinations. A total of 141 lesions were treated with RT (67%). Outcomes including time to relapse (TTR) and overall survival (OS) were estimated with Kaplan-Meier rates. Univariate (UVA) and multivariate (MVA) Cox proportional hazard ratios (HR) were used to assess the effect of patient, tumor, and other predictive factors. The median age was 60 years (range: 20-90), the majority were male (n = 105; 56%) and white (n = 167; 89%). Stages of disease were 1A (n = 87; 46%), 1B (n = 5; 3%), 2A (n = 73; 39%), and 2B (n = 23; 12%). Seventy-five (40%) patients had germinal center B-cell subtype. 27 (14%) were identified as DHL (7 typical and 20 atypical), and 10 (5%) were identified as THL (3 typical and 7 atypical). In those treated with chemotherapy (CT) alone, the median number of CT cycles was 6 (range: 1-10), and in patients treated with CT and RT it was 4 (range: 0-8, P<0.001). Median follow-up from treatment completion was 33 months (0.3-204 months). Median RT dose was 36 Gy (20-54 Gy). A total of 40 patients (21%) were known to be dead at last analysis. The receipt of RT was significant on MVA for the TTR with a HR 0.38 (0.20 -0.71; P = 0.002) with a trend for OS on MVA (P = 0.08). TTR at 36 months was 46% and 83% in patients treated without and with RT (P<0.0001). MVA demonstrated significance for OS in THL vs. DHL with a HR 6.1 (1.6-22.8, P = 0.01), and THL vs. none with a HR 4.5 (1.4-12.9, P = 0.02). MVA demonstrated significance for TTR in THL vs. none HR 6.6 (1.4-30.7, P = 0.05). TTR and OS rates at 36 months were 80%/83%, 47%/72%, and 17%/44% in patients without analyzed genetic aberrations, DHL, and THL (P < 0.0001 and P = 0.0002), respectively. DHL and THL patients treated with R-CHOP benefited significantly from consolidative RT with a 36 month TTR rate of 64% and 11% in patients treated with and without RT, respectively (P = 0.04). The receipt of RT and DHL/THL status were the only factors that correlated with TTR on MVA. DHL and THL status correlated with worse OS, and consolidative RT may offer a significant benefit to this cohort of patients. Early identification of these patients for more aggressive treatment utilization may lead to improved outcomes.

Role of Consolidative Radiation Therapy After Autologous Hematopoietic Cell Transplantation for the Treatment of Relapsed or Refractory Hodgkin Lymphoma

PurposeTo evaluate the role of the addition of consolidative radiation therapy after high-dose chemotherapy and autologous hematopoietic cell transplantation (AHCT) for relapsed or refractory Hodgkin lymphoma (HL).Methods and MaterialsMedical records were reviewed from a total of 80 consecutive patients who underwent high-dose chemotherapy with AHCT treated under a single protocol at University of Minnesota between November 2005 and January 2014. Of these, 32 patients received radiation therapy after AHCT as planned consolidation.ResultsAt a median follow-up of 25 months, the 2-year overall survival (OS) and progression-free survival (PFS) for the entire cohort was 96% and 52%, respectively. Consolidative radiation therapy was found to significantly improve the 2-year PFS (67% vs 42%, P<.01) without a significant change in OS (100% vs 93%, P=.15). On subgroup analysis, consolidative radiation therapy was shown to improve PFS in patients with bulky disease (62% vs 39%, P=.02), B-symptoms (48% vs 28%, P=.05), primary refractory disease (47% vs 32%, P=.02), and those with a partial response on pretransplant imaging (47% vs 32%, P=.02). The improvement seen on 2-year PFS with consolidative radiation therapy remained significant on multivariate analysis (hazard ratio 4.64, 95% confidence interval 1.98–10.88). Minimal toxicity was observed among the patients receiving radiation therapy.ConclusionsThe addition of consolidative radiation therapy after high-dose chemo-therapy and AHCT demonstrated a significant improvement in 2-year PFS and no impact on OS. Radiation therapy was well tolerated, with minimal toxicity. Our study supports a role of consolidative radiation therapy in patients with HL treated with AHCT.

Combined Modality Therapy in the Upfront Treatment of Patients with Primary Central Nervous System Lymphoma: A Systematic Review

Background: The role of combined modality therapy (CMT) in previously untreated patients with primary central nervous system lymphoma (PCNSL) remains unclear. We performed a systematic review of the available evidence regarding the efficacy and long-term neurotoxicity of consolidative radiation therapy in addition to systemic chemotherapy in the upfront management of fit immunocompetent adult patients with PCNSL.Methods: Peer reviewed literature searches were conducted using the MEDLINE, EMBASE and PubMed databases from 1950 to March 26, 2015. We included all prospective clinical trials (randomized and non-randomized) published on or after January 1, 1998 with at least 20 subjects receiving frontline CMT with CNS-penetrating chemotherapy in addition to radiation therapy. We excluded trials of high-dose chemotherapy followed by autologous stem cell rescue and those involving patients with isolated intra-ocular lymphoma. The primary outcome was overall survival (OS). Secondary outcomes included progression free survival (PFS), overall response rate (ORR), complete remission (CR) rate, partial remission (PR) rate, and incidence of late radiation-induced neurotoxicity. Two reviewers independently performed title and abstract screening, full-text review and data extraction. The Cochrane Risk of Bias Tool was used to assess the quality of randomized trials included in this systematic review.Results: The literature search yielded 10,646 potentially relevant records for primary screening after de-duplication, of which 299 full-text articles were evaluated. Of the 299 full-text articles reviewed, there were 21 publications eligible for inclusion. These 21 publications represented 15 unique clinical trials (4 trials were reported in 2 publications each, and 1 trial was reported in 3 publications; Figure 1). The included studies involved a total of 1123 enrolled subjects. Of the 15 trials included, there was 1 phase III randomized controlled trial, 1 phase II randomized trial, and 2 non-randomized multi-arm trials. The remaining studies were single arm non-comparator trials. Chemotherapy backbones varied, and planned whole brain radiation therapy (WBRT) doses ranged from 23.4 to 50.4 Gy. Due to variation in follow-up time, it was difficult to compare survival endpoints between studies. In the large multicenter phase III randomized controlled trial comparing 202 patients receiving WBRT to 208 patients without WBRT, there was no difference in OS (32.4 months vs. 36.1 months, p=0.98) however WBRT improved PFS from 9.9 months to 15.4 months (p=0.034) (Korfel et al., Neurology. 2015 Mar 24;84(12):1242-8). Response rates were not consistently reported after completion of both chemotherapy and radiation therapy. Amongst those trials reporting response rates after completion of CMT, the CR rate ranged from 28-87% and the ORR ranged from 56-100%. Although there was variability in the definitions and reporting of delayed-onset neurotoxicity, this complication was common, ranging from 0-45.8%. The Cochrane Risk of Bias Tool was only applicable to the 2 randomized trials in this review. On the basis of clinical heterogeneity, we chose not to statistically pool the results of the included trials together in this systematic review.Conclusions: We identified a large body of literature assessing the use of CMT in the upfront management of PCNSL. However, only one randomized study addressed the specific role of consolidative radiation therapy with respect to survival, in which there was no benefit to OS. Consolidative WBRT may improve local disease control and PFS, though late neurotoxicity remains a concern. Our review underscores the need for ongoing collaborative efforts between treatment centers to design and conduct large randomized controlled trials. [Display omitted] DisclosuresBuckstein:Celgene: Honoraria, Research Funding.

The Role of Consolidative Radiation Therapy for Patients Over Age 60 With Diffuse Large B Cell Lymphoma (DLBCL)

Purpose/Objective(s)The role of consolidative radiation therapy (RT) in patients ≥ 60 years old with DLBCL in the rituximab era is controversial. Our objectives were to examine the impact on disease control and overall survival by the addition of consolidative RT after completion of chemotherapy, while adjusting for known adverse risk factors.Materials/MethodsUnder IRB-approved protocol, retrospective chart review of 83 consecutive patients ≥ 60 years old with DLBCL treated in the rituximab era, from 2004 to 2012 was undertaken. The goal of the study design was to compare those that received R-CHOP versus those that additionally received consolidative RT using standard statistical methods.ResultsOral Scientific Abstracts 185; Table 1Multivariate Analysis of Different Clinical Factors and Their Association With Overall SurvivalCovariateLevelHazard RatioP-ValueConsolidative RadiationYes No0.31 (0.11–0.91).033StageI/II III/IV0.09 (0.01–0.82).032B-SymptomsYes No1.83 (0.75–4.44).182BM InvolvementYes No6.90 (2.01–23.64)0.002Bulky>5 cm ≤5 cm0.51 (0.22–1.15).103IPI Score4/5 3 2 13.39 (0.24–47.68) 8.13 (0.69–96.44) 1.46 (0.35–6.12).205Number of extranodal sites2+ 1 01.23 (0.29–5.19) 2.19 (0.75–6.40).331 Open table in a new tab ConclusionThe use of consolidative RT for patients ≥60 years old with DLBCL was associated with statistically significant better disease control and overall survival outcomes. Radiation therapy was well tolerated with no severe acute or long-term toxicity. The use of consolidative radiation therapy should be considered for patients ≥60 years old independent of presenting stage. This conclusion is especially applicable to those patients whose disease achieved a complete response to systemic therapy. Purpose/Objective(s)The role of consolidative radiation therapy (RT) in patients ≥ 60 years old with DLBCL in the rituximab era is controversial. Our objectives were to examine the impact on disease control and overall survival by the addition of consolidative RT after completion of chemotherapy, while adjusting for known adverse risk factors. The role of consolidative radiation therapy (RT) in patients ≥ 60 years old with DLBCL in the rituximab era is controversial. Our objectives were to examine the impact on disease control and overall survival by the addition of consolidative RT after completion of chemotherapy, while adjusting for known adverse risk factors. Materials/MethodsUnder IRB-approved protocol, retrospective chart review of 83 consecutive patients ≥ 60 years old with DLBCL treated in the rituximab era, from 2004 to 2012 was undertaken. The goal of the study design was to compare those that received R-CHOP versus those that additionally received consolidative RT using standard statistical methods. Under IRB-approved protocol, retrospective chart review of 83 consecutive patients ≥ 60 years old with DLBCL treated in the rituximab era, from 2004 to 2012 was undertaken. The goal of the study design was to compare those that received R-CHOP versus those that additionally received consolidative RT using standard statistical methods. ResultsOral Scientific Abstracts 185; Table 1Multivariate Analysis of Different Clinical Factors and Their Association With Overall SurvivalCovariateLevelHazard RatioP-ValueConsolidative RadiationYes No0.31 (0.11–0.91).033StageI/II III/IV0.09 (0.01–0.82).032B-SymptomsYes No1.83 (0.75–4.44).182BM InvolvementYes No6.90 (2.01–23.64)0.002Bulky>5 cm ≤5 cm0.51 (0.22–1.15).103IPI Score4/5 3 2 13.39 (0.24–47.68) 8.13 (0.69–96.44) 1.46 (0.35–6.12).205Number of extranodal sites2+ 1 01.23 (0.29–5.19) 2.19 (0.75–6.40).331 Open table in a new tab ConclusionThe use of consolidative RT for patients ≥60 years old with DLBCL was associated with statistically significant better disease control and overall survival outcomes. Radiation therapy was well tolerated with no severe acute or long-term toxicity. The use of consolidative radiation therapy should be considered for patients ≥60 years old independent of presenting stage. This conclusion is especially applicable to those patients whose disease achieved a complete response to systemic therapy. The use of consolidative RT for patients ≥60 years old with DLBCL was associated with statistically significant better disease control and overall survival outcomes. Radiation therapy was well tolerated with no severe acute or long-term toxicity. The use of consolidative radiation therapy should be considered for patients ≥60 years old independent of presenting stage. This conclusion is especially applicable to those patients whose disease achieved a complete response to systemic therapy.

Single-Institution Experience in the Treatment of Primary Mediastinal B Cell Lymphoma Treated With Immunochemotherapy in the Setting of Response Assessment by 18Fluorodeoxyglucose Positron Emission Tomography

Excellent outcomes obtained after infusional dose-adjusted etoposide, doxorubicin, cyclophosphamide, vincristine, prednisone, and rituximab (R-EPOCH) alone have led some to question the role of consolidative radiation therapy (RT) in the treatment of primary mediastinal B cell lymphoma (PMBL). We reviewed the outcomes in patients treated with 1 of 3 rituximab-containing regimens (cyclophosphamide, doxorubicin, vincristine, prednisone [R-CHOP]; hyperfractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone [R-HCVAD], or R-EPOCH) with or without RT. We also evaluated the ability of positron emission tomography-computed tomography (PET-CT) to identify patients at risk of relapse. We retrospectively identified 97 patients with diagnoses of stage I/II PMBCL treated at our institution between 2001 and 2013. The clinical characteristics, treatment outcomes, and toxicity were assessed. We analyzed whether postchemotherapy PET-CT could identify patients at risk for progressive disease according to a 5 point scale (5PS) Deauville score assigned. Among 97 patients (median follow-up time, 57 months), the 5-year overall survival rate was 99%. Of patients treated with R-CHOP, 99% received RT; R-HCVAD, 82%; and R-EPOCH, 36%. Of 68 patients with evaluable end-of-chemotherapy PET-CT scans, 62% had a positive scan (avidity above that of the mediastinal blood pool [Deauville 5PS = 3]), but only 9 patients experienced relapse (n=1) or progressive disease (n=8), all with a 5PS of 4 to 5. Of the 25 patients who received R-EPOCH, 4 experienced progression, all with 5PS of 4 to 5; salvage therapy (RT and autologous stem cell transplantation) was successful in all cases. Combined modality immunochemotherapy and RT is well tolerated and effective for treatment of PMBCL. A postchemotherapy 5PS of 4 to 5, rather than 3 to 5, can identify patients at high risk of progression who should be considered for therapy beyond chemotherapy alone after R-EPOCH.

Predictors of Local Recurrence After Rituximab-Based Chemotherapy Alone in Stage III and IV Diffuse Large B-Cell Lymphoma: Guiding Decisions for Consolidative Radiation

The role of consolidative radiation therapy (RT) for stage III and IV diffuse large B-cell lymphoma (DLBCL) in the era of rituximab is not well defined. There is evidence that some patients with bulky disease may benefit, but patient selection criteria are not well established. We sought to identify a subset of patients who experienced a high local failure rate after receiving rituximab-based chemotherapy alone and hence may benefit from the addition of consolidative RT. Two hundred eleven patients with stage III and IV DLBCL treated between August 1999 and January 2012 were reviewed. Of these, 89 had a complete response to systemic therapy including rituximab and received no initial RT. Kaplan-Meier analysis and Cox proportional hazards regression were performed, with local recurrence (LR) as the primary outcome. The median follow-up time was 43.9 months. Fifty percent of patients experienced LR at 5 years. In multivariate analysis, tumor ≥ 5 cm and stage III disease were associated with increased risk of LR. The 5-year LR-free survival was 47.4% for patients with ≥ 5-cm lesions versus 74.7% for patients with <5-cm lesions (P=.01). In patients with <5-cm tumors, the maximum standardized uptake value (SUVmax) was ≥ 15 in all patients with LR. The 5-year LR-free survival was 100% in SUV<15 versus 68.8% in SUV ≥ 15 (P=.10). Advanced-stage DLBCL patients with stage III disease or with disease ≥ 5 cm appear to be at an increased risk for LR. Patients with <5-cm disease and SUVmax ≥ 15 may be at higher risk for LR. These patients may benefit from consolidative RT after chemoimmunotherapy.

Role of Consolidative Radiation Therapy Following Autologous Stem Cell Transplantation for Relapsed or Refractory Hodgkin Lymphoma

Role of Consolidative Radiation Therapy Following Autologous Stem Cell Transplantation for Relapsed or Refractory Hodgkin Lymphoma

The Role of Consolidative Radiation Therapy in Early-Stage Diffuse Large B-Cell Lymphoma Treated With R-CHOP–Based Immunochemotherapy

The Role of Consolidative Radiation Therapy in Early-Stage Diffuse Large B-Cell Lymphoma Treated With R-CHOP–Based Immunochemotherapy

Bladder cancer: ESMO Practice Guidelines for diagnosis, treatment and follow-up

Bladder cancer: ESMO Practice Guidelines for diagnosis, treatment and follow-up

Patterns of Failure in Advanced Stage Diffuse Large B-Cell Lymphoma Patients After Complete Response to R-CHOP Immunochemotherapy and the Emerging Role of Consolidative Radiation Therapy

The role of consolidative radiation therapy (RT) after complete response (CR) to rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) for stage III-IV diffuse large B-cell lymphoma (DLBCL) patients is unclear. We aimed to evaluate our institutional experience when consolidative RT is delivered to initial presenting sites or bulky sites in these patients. We identified 211 histologically confirmed stage III-IV DLBCL patients who received R-CHOP from January 2000 to May 2012 at our institution. Patterns of failure for patients who achieved CR to R-CHOP were analyzed. Local control (LC), distant control (DC), progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan-Meier method and compared between patients who received R-CHOP alone versus R-CHOP plus consolidative RT using the log-rank test. Multivariate analyses were also performed using Cox proportional hazards model. Detailed treatment records were available for 163 patients. After a median 6 cycles of R-CHOP, 110 patients (67.5%) achieved CR and were entered for analysis. Fourteen patients (12.7%) received consolidative RT. After median follow-up of 32.9 months, 43.8% of patients who received R-CHOP alone failed at the initial sites with or without distant recurrence (DR), whereas isolated DR only occurred in 3.7% of these patients. Consolidative RT was associated with significantly improved LC (91.7% vs 48.8%), DC (92.9% vs 71.9%), PFS (85.1% vs 44.2%), and OS (92.3% vs 68.5%; all Ps<.0001) at 5 years compared with patients with R-CHOP alone. On multivariate analysis, consolidative RT and nonbulky disease were predictive of increased LC and PFS, whereas bone marrow involvement was associated with increased risk of DR and worse OS. Consolidative RT was also associated with marginal improved OS. Forty-four percent of patients with advanced stage DLBCL failed at initial presenting sites after achieving CR to R-CHOP. Incorporation of consolidative RT as part of upfront treatment in these patients was associated with improved LC, PFS, and a trend towards improved OS.

Benefit of Consolidative Radiation Therapy in Patients With Diffuse Large B-Cell Lymphoma Treated With R-CHOP Chemotherapy

The current standard therapy for patients with diffuse large B-cell lymphoma (DLBCL) is rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). The role of consolidative radiation therapy (RT) in the setting of R-CHOP chemotherapy is not well reported. This retrospective analysis is an attempt to clarify this role. Subjects were 469 patients with histologically confirmed DLBCL treated between January 2001 and December 2007. Variables including age, sex, Ann Arbor disease stage, bulky disease status, standardized uptake values (SUVs) on positron emission tomography (PET), International Prognostic Index (IPI), and Ki67 staining (proliferation). Of 469 patients, 190 (40.5%) had stage I or II disease and 279 (59.5%) had stage III or IV disease, 327 (70%) had at least six cycles of R-CHOP, and 142 (30.2%) had involved-field RT (dose, 30 to 39.6 Gy) after complete response to chemotherapy. Median follow-up was 36 months (range, 8 to 85 months). Multivariate analysis showed that RT (P < .0001), IPI score (P = .001), response to therapy (P = .001), use of six to eight cycles of R-CHOP (P < .001), and combined presence (P = .006) or absence (P = .025) of high Ki67, high PET SUV, and bulky disease influenced overall survival (OS) and progression-free survival (PFS). Matched-pair analyses of patients who received six to eight cycles of R-CHOP with stage I or II disease (44 pairs) and all stages (74 pairs) indicated that RT improved OS (hazard ratio [HR], 0.52 and 0.29, respectively) and PFS (HR, 0.45 and 0.24, respectively) compared with no RT. This study showed significant improvements in OS and PFS among patients who received consolidation RT after R-CHOP chemotherapy for DLBCL.

Bladder cancer: ESMO Practice Guidelines for diagnosis, treatment and follow-up

n Europe, an estimated 151 297 new cases of bladder cancer were diagnosed in 2012, with an age-standardised incidence rate (per 100 000 persons) of 17.7 for males and 3.5 for females. Overall, the annual crude incidence rate is 20.4/100 000. In 2012, there were 52 395 deaths from bladder cancer with an annual crude mortality rate of 7.1/100 000 [1]. Approximately 70% of patients with bladder cancer are >65 years of age. The most common presenting symptom is painless haematuria, seen in >80% of patients. Others may also present with irritative symptoms such as dysuria, frequency or urgency. Symptoms of metastases such as bone or flank pain are rare. Most diagnosed cases of muscle-invasive bladder cancer (MIBC; 80%–90%) present as primary invasive bladder cancer. However, up to 15% of patients have a history of non-muscle-invasive bladder cancer (NMIBC), mainly high-risk cases.

Radiation therapy for consolidation of metastatic or recurrent sarcomas in children treated with intensive chemotherapy and stem cell rescue. A feasibility study

Purpose: To assess the role of consolidative radiation therapy (CRT) in conjunction with myeloablative therapy with or without total body irradiation (TBI) in children and young adults with metastatic or recurrent sarcoma.Methods and Materials: Twenty-one pediatric sarcoma patients with metastatic (10) or recurrent (11) disease were entered on a prospective feasibility study of intensive myeloablative therapy with or without TBI. Median patient age was 17.8 years (range, 9.4–24.7 years). Primary histologies included Ewing’s (12), PNET (3), and other soft tissue sarcomas (6). Twenty patients received induction chemotherapy. Myeloablative therapy consisted of TBI in 11 patients with either high dose melphalan/etoposide (9) or high dose cytoxan/thiotepa (2). TBI consisted of 12 Gy in 2 Gy fractions delivered twice daily over 3 days. Ten patients received high dose chemotherapy alone, either with thiotepa/carboplatinum/etoposide (8) or cytoxan/carboplatinum (2). Myeloablative therapy was followed by autologous stem cell rescue (ASCR) 24 to 48 hours after completing chemotherapy. Fourteen patients (67%) received CRT either prior to (5) or following (9) myeloablative therapy. Median CRT dose was 37.2 Gy (range, 20–60). Fifty-one disease sites were present prior to myeloablative therapy. Twelve (24%) were bulky (> 8 cm) and 18 (35%) underwent surgical debulking. The median follow-up of surviving patients was 15 months (range, 8–20) with 25% of patients having been followed for more than 20 months.Results: The 3-year actuarial disease-free (DFS) and overall survival (OS) rates for the entire group were 36% and 27%, respectively. Following myeloablative treatment, responses were: 11 complete, 6 partial, 1 stable, and 3 progressive disease. Sixteen patients (71%) have relapsed. The most common site of relapse was the lung (13). Of the 51 disease sites present prior to myeloablative therapy, 36 sites (71%) were amenable to CRT. Non-amenable sites were: multiple lung metastases (13) and bone marrow (2). Twenty-six amenable sites (51%) received CRT either prior to (14) or following (12) ASCR. Amenable sites treated with CRT had a better 3-year actuarial local control (80 vs 37%) (p = 0.0065) than amenable sites not treated with CRT. Factors associated with improved disease-free survival (DFS) in univariate analysis were induction chemotherapy response (p = 0.002) and extent of surgical resection (p = 0.045). There was a trend toward improved DFS on univariate analysis with the use of TBI as part of myeloablative therapy (p = 0.07). The one factor associated with improved OS on univariate analysis was induction chemotherapy response (p = 0.007). Multivariate analysis revealed that induction chemotherapy response is the only factor that remains significant for DFS (p = 0.032) as well as for OS (p = 0.017). Patients with complete response to induction therapy had 40% probability of survival versus all other patients who had 10% survival (p = 0.05).Conclusion: Consolidative radiotherapy is feasible in primary metastatic or recurrent pediatric sarcoma patients treated with myeloablative therapy with or without TBI. CRT to sites amenable to irradiation provided an improved 3-year actuarial local control than that seen in sites amenable to CRT that did not undergo radiotherapy. There was a trend for improved DFS with the use of TBI. Improved DFS and OS can be predicted by response to induction therapy. This intensive regimen may improve the cure rate of advanced pediatric sarcomas in select patients.