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208 The role of radiation therapy in the management of bone metastases
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1. J. Radiation Oncology*Biology*Physics
Volume 39, Number 2, Supplement, 1997
207c Non-Hodgkin’s Lymphoma - Part I: Etiology, Pathology, Diagnostic Evaluation and Principles of Management Mary K. Gospodarowicz, M.D. Simon B. Sutclifi, M.D. Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Canada Objective: To review the approach to the diagnosis, classification, assessment, treatment and continuing management of patients with non-Hodgkin’s lymphoma with an emphasis on the role of radiation therapy and the management of localized disease. Non-Hodgkin’s lymphomas are a diverse group of diseases with an age standardized incidence of approximately 17 per 100,000 population. They become more common with increasing age and frequently involve extranodal sites. A number of potential etiological causes have been defined e.g. congenital and acquired immunodeficiency states, viruses, ionizing radiation, chronic inflammatory diseases and environmental toxins, Management is most influenced by the histological type of lymphoma. Numerous classifications have derived from architectural and cytological observations (Rappaport), concepts involving morphologic and phenotypic characterization of lineage and differentiation (Lukes-Collins, Kiel), and grade in the context of cytological differentiation and prognosis (Working Formulation). The introduction of the REAL classification has characterized clinico-pathological entities within a Bcell, T-cell and Hodgkin’s disease framework, and recognized histopathologic grade as a variable within each category. The utility of this approach is likely to increase as disease entities become further defined through karyotypic and genotypic characterization. Stage is the other principal determinant of management. Whilst the Ann Arbor staging classification is employed routinely, its limitations in the context of extranodal disease, characterization of local disease extent and bulk have resulted in the incorporation of additional prognostic factors into management policies. Important prognostic factors include patient-related variables (age, performance status), disease-related attributes (bulk, number of involved nodes, B-symptoms) and biological attributes (LDH, ESR, O-2 macroglobulin, soluble CD-30, proliferation indices). The International Prognostic Index (IPI) incorporates several independent prognostic variables into risk groups as a basis for the assessment of outcome particularly useful for advanced disease. The success of curative RT is contingent upon the presence of localized disease with favorable prognostic factors, small bulk disease and delivery of a tumoricidal RT dose (30 - 35 Cy) to a field with no critical dose-limiting tissue tolerances. The current evidence indicates that locoregional RT for stage I-II low grade lymphorna results in approximately 50% prolonged (lo- 20 years) failure free rate and possible cure. The standard management for stage I-II intermediate and high grade lymphoma, both nodal and extranodal presentation, is combined modality therapy (CMT) using an anthracycline-based chemotherapy followed by involved field RT. The two recently completed trials ECOG (ASCO 95) and SWOG (ASCO 96) have confirmed the benefit of RT in CMT protocols as compared to chemotherapy alone strategies. Combination chemotherapy is the standard management of advanced intermediate and high grade lymphoma and no regimen has been proven to the superior to CHOP. Overall complete response, relapse-free and overall survival rates of approximately 75%, 50% and 40% are achievable. Patients with a worse prognosis can be identified based upon multiple adverse presentation factors (IPI index) although it is not yet clear that current intensive therapy strategies with/without stem cell/marrow support provide survival benefit. The need for additional therapy e.g. CNS prophylaxis or local RT is determined by presentation characteristics or degree of response to chemotherapy.
208 The Role of Radiation Therapy in the Management of Bone Metastases Charles W. Scarantmo, M.D., Ph.D.1 Andre A. Km&i, M.D.2 Department of Radiation Oncology, Rex Cancer Center, Raleigh, NC1 Toledo Radiological Associates, Toledo, OH2 m The purpose of this course is to discuss the current radiotherapeutic strategies in the treatment of bone metastases. Radiation therapy continues to play a central role in the relief of symptoms associated with bone metastases. The introduction of large field or hemibody and systemic or isotopic radiation techniques has expanded the role of radiation therapy to include evaluation of the impact of radiation on occult and overt yet asymptomatic disease. This course will review some of the basic mechanisms involved in the genesis of bone pain. A comparative analysis of the clinical trials of local field irradiation on bone m&stases including dose and fractionation schedules, response rates, duration and evaluation of response will be discussed. The role of large field hemibody and systemic irradiation (e.g. isotopestiontium) in the treatment of metastatic disease will be presented. The topics include the response rates and duration of response of symptomatic metastases, the effect of each technique on the delay in progression of overt symptomatic disease as well as a delay in the appearance of new disease and the morbidity associated with each treatment modality. The design of several current trials will be presented as well as concepts for an expanding role of large field and systemic radiation techniques will be presented. The current managed care climate has brought to the forefront some basic issues regarding the economic impact of palliative radiotherapy. Therefore, this course will present an analysis of radiotherapeutic and non-radiotherapeutic management of pain associated with bone metastases as well as discussion of the basic techniques of economic analyses. Techniques of costmininiization, cost-utility, cost-benefit, and cost-effective analyses and the appropriateness of each type of analyses will be presented. A discussion of which costs and benefits to include in the analyses will also be presented.
1. J. Radiation Oncology*Biology*Physics
Volume 39, Number 2, Supplement, 1997
207c Non-Hodgkin’s Lymphoma - Part I: Etiology, Pathology, Diagnostic Evaluation and Principles of Management Mary K. Gospodarowicz, M.D. Simon B. Sutclifi, M.D. Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Canada Objective: To review the approach to the diagnosis, classification, assessment, treatment and continuing management of patients with non-Hodgkin’s lymphoma with an emphasis on the role of radiation therapy and the management of localized disease. Non-Hodgkin’s lymphomas are a diverse group of diseases with an age standardized incidence of approximately 17 per 100,000 population. They become more common with increasing age and frequently involve extranodal sites. A number of potential etiological causes have been defined e.g. congenital and acquired immunodeficiency states, viruses, ionizing radiation, chronic inflammatory diseases and environmental toxins, Management is most influenced by the histological type of lymphoma. Numerous classifications have derived from architectural and cytological observations (Rappaport), concepts involving morphologic and phenotypic characterization of lineage and differentiation (Lukes-Collins, Kiel), and grade in the context of cytological differentiation and prognosis (Working Formulation). The introduction of the REAL classification has characterized clinico-pathological entities within a Bcell, T-cell and Hodgkin’s disease framework, and recognized histopathologic grade as a variable within each category. The utility of this approach is likely to increase as disease entities become further defined through karyotypic and genotypic characterization. Stage is the other principal determinant of management. Whilst the Ann Arbor staging classification is employed routinely, its limitations in the context of extranodal disease, characterization of local disease extent and bulk have resulted in the incorporation of additional prognostic factors into management policies. Important prognostic factors include patient-related variables (age, performance status), disease-related attributes (bulk, number of involved nodes, B-symptoms) and biological attributes (LDH, ESR, O-2 macroglobulin, soluble CD-30, proliferation indices). The International Prognostic Index (IPI) incorporates several independent prognostic variables into risk groups as a basis for the assessment of outcome particularly useful for advanced disease. The success of curative RT is contingent upon the presence of localized disease with favorable prognostic factors, small bulk disease and delivery of a tumoricidal RT dose (30 - 35 Cy) to a field with no critical dose-limiting tissue tolerances. The current evidence indicates that locoregional RT for stage I-II low grade lymphorna results in approximately 50% prolonged (lo- 20 years) failure free rate and possible cure. The standard management for stage I-II intermediate and high grade lymphoma, both nodal and extranodal presentation, is combined modality therapy (CMT) using an anthracycline-based chemotherapy followed by involved field RT. The two recently completed trials ECOG (ASCO 95) and SWOG (ASCO 96) have confirmed the benefit of RT in CMT protocols as compared to chemotherapy alone strategies. Combination chemotherapy is the standard management of advanced intermediate and high grade lymphoma and no regimen has been proven to the superior to CHOP. Overall complete response, relapse-free and overall survival rates of approximately 75%, 50% and 40% are achievable. Patients with a worse prognosis can be identified based upon multiple adverse presentation factors (IPI index) although it is not yet clear that current intensive therapy strategies with/without stem cell/marrow support provide survival benefit. The need for additional therapy e.g. CNS prophylaxis or local RT is determined by presentation characteristics or degree of response to chemotherapy.
208 The Role of Radiation Therapy in the Management of Bone Metastases Charles W. Scarantmo, M.D., Ph.D.1 Andre A. Km&i, M.D.2 Department of Radiation Oncology, Rex Cancer Center, Raleigh, NC1 Toledo Radiological Associates, Toledo, OH2 m The purpose of this course is to discuss the current radiotherapeutic strategies in the treatment of bone metastases. Radiation therapy continues to play a central role in the relief of symptoms associated with bone metastases. The introduction of large field or hemibody and systemic or isotopic radiation techniques has expanded the role of radiation therapy to include evaluation of the impact of radiation on occult and overt yet asymptomatic disease. This course will review some of the basic mechanisms involved in the genesis of bone pain. A comparative analysis of the clinical trials of local field irradiation on bone m&stases including dose and fractionation schedules, response rates, duration and evaluation of response will be discussed. The role of large field hemibody and systemic irradiation (e.g. isotopestiontium) in the treatment of metastatic disease will be presented. The topics include the response rates and duration of response of symptomatic metastases, the effect of each technique on the delay in progression of overt symptomatic disease as well as a delay in the appearance of new disease and the morbidity associated with each treatment modality. The design of several current trials will be presented as well as concepts for an expanding role of large field and systemic radiation techniques will be presented. The current managed care climate has brought to the forefront some basic issues regarding the economic impact of palliative radiotherapy. Therefore, this course will present an analysis of radiotherapeutic and non-radiotherapeutic management of pain associated with bone metastases as well as discussion of the basic techniques of economic analyses. Techniques of costmininiization, cost-utility, cost-benefit, and cost-effective analyses and the appropriateness of each type of analyses will be presented. A discussion of which costs and benefits to include in the analyses will also be presented.