Hematological recovery after central lymphatic irradiation (CLI) for stage I–III follicular lymphoma

330

I. J. Radiation

Oncology

0 Biology

0 Physics

Volume 48. Number 3, 2000

Results: With median follow-up of 64 months and a range of 6 to 204 months, 27 patients have died, 20 of them from lymphoma. The lOyear actuarial overall (OS) and disease specific (DSS) survivals were 67% and 78%, respectively. The DSS for the elderly group was only 33%. Univariate analysis for DSS showed a significantly superior outcome for patients with the following prognostic factors: Age 5 SO years (p = 0.03) hemoglobin > 1 10 g/L (p = 0.03) Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (p = 0.04), presenting mass size < 10 cm (p = 0.002) and the absence of a residual mass after treatment (p = 0.012). IJse of mediastinal consolidation irradiation conferred a trend to improved DSS and a reduced relapse rate in patients with a residual mediastinal mass. Sixty patients had post-treatment gallium scans. The DSS was X7% for patients with negative scan and 75% for positive one. Eight of 47 patients (17%) with negative scans subsequently developed local disease recurrence compared to 4 out of 13 (31%) in whom the scan was positive. Adding involved field radiation to patients with a positive scan reduced the relapse rate to 11%(I out of 9) from 75% (3 out of 4) with no irradiation. Conclusions: Primary mediastinal large B-cell lymphoma is a clinically distinct type of large cell lymphoma seen predominantly in younger patients. It has a favorable prognosis with good response to conventional treatment. Mediastinal irradiation conferred a trend to reduce the local relapse rate and improve DSS, and should be considered for all patients, especially those with positive post-chemotherapy gallium scan. Multi-institutional large prospective studies would be required to evaluate and dehne the role of radiation further.

2 133

Long-term outcome of radiotherapy ocular adnexa

Y. Kagami, Natmml

H. Ikeda, S. Murayama,

K. Tokuuye,

for mucosa-associated

lymphoid

M. Sumi, K. Tobinai,

Y. Kobayashi,

tissue (MALT) lymphoma

of the

Y. Matsuno

Cancrr Center Hospital, Tokyo, Jqatt

Purpose: Mucosa-associated lymphoid tissue (MALT) of the ocular adnexa is a very rare disorder. There are few reports on the outcome of radiotherapy for MALT lymphoma of the ocular adnexa. The purpose of this report is to evaluate long-term outcome of efficacy and feasibility of radiotherapy for MALT lymphoma of the ocular adnexa. Material and Methods: Thirty-three patients with MALT lymphoma of the ocular adnexa treated with radiation therapy were analyzed retrospectively. There were 24 males and 9 females. The age at diagnosis ranged from 22 to 89 years with a median of 56 years old. The most frequently involved site was eyelid and/or conjunctiva. There were 11patients with eyelid and/or conjunctiva involvement, 9 patients with ocular space involvement alone, 1 patient with lacrimal gland involvement alone, 7 patients with eyelid/conjunctiva and orbital space, 2 patients with eyelid/conjunctiva and lacrimal gland involvement, 2 patients with lacrimal gland and orbital space involvement. and 1 patient with eyelidlconjunctiva, orbital space, and lacrimal gland involvement, In 32 patients, their diseases were localized in unilateral ocular adnexa, and they were diagnosed as having stage I disease. In one patient, bilateral ocular adnexas was involved simultaneously without other involvement. We categorized it as having stage I Therefore. all patients had stage I disease. Two patients were treated radiotherapy following chemotherapy. 31 patients were treated with radiotherapy alone. Irradiated targets were entire ocular regions. Radiation was delivered by various techniques including 3-D conformal therapy. lateral opposed fields treatment, or single anterior held treatment vvith or without lens sparing. Total dose ranging 20 to 50 Gy with a median dose of 40 Gy was delivered by 6 MV X-ray. 4 MV X-ray or electron beams. Most of the fraction size was 2 Gy with ranging from I8 Gy to 2.2 Gy. The median follow-up was 44 months with a range of 4-224 months. Results: No patient had relapse disease in the irradiated region. Causes of death were MALT lymphoma at 1 patient, and other causes without MALT lymphoma at 4 patients, The five-year and ten-year survival rates were 919 % and 919 Or,, respectively. The five-year and ten-year relapse free rates were 90.9 % and 90.9 %. respectively. The five-year cause-specihc survival rate was 100 %. Radiation-induced cataracts developed in 11 patients (33.3 8). According to RTOG/EORTC late radiation morbidity scoring scheme, Grade 0 was in 22 patients, Grade 1 was in 3 patients, Grade 2 was in 7 patients. and Grade 3 was in I patient. Severe late eye (grade 3 or more) injury occurred in only one patient (3.0 0). Conclusion: complication

2 134

For MALT rate.

lymphoma

Hematological

recovery

of the ocular

adnexa,

radiotherapy

after central lymphatic

irradiation

C. S. Ha, S. L. Tucker. A. 1. Blanco, R. B. Wilder, F. Cabanillas,

was effective

treatment

method

(CLI) for stage I-III follicular

with low late

lymphoma

J. D. Cox

Background: We have previously reported that CL1 can induce molecular remission in stage I-111 follicular lymphoma as measured by polymerase chain reaction for t(l4;18) (q32:q21). Hematological toxicity has been considered a major consequence of CLI. This study was undertaken to analyze the patterns of hematological recovery after CLI. Methods and Materials: Thirty-three patients with stage I-111 follicular lymphoma were treated with CL1 between January 1993 and February 1998. CLI consisted of irradiation to mantle, upper two thirds of abdomen and pelvic tields. Each field was treated to 30-30.6 Gy at 15-l 8 Gy per fraction, with a boost to 39.6-40 Gy to sites of gross disease. A break of approximately 4 weeks was given after treatment of each field. Twenty-four patients who were followed for a minimum of 1 year from the end of CL1 form the basis of this analysis. Fifteen patients were male. Three patients had Stage I disease, 6 had Stage 11. and I5 had Stage III. The median values for their pretreatment characteristics were; age-60 years (range 34-73). height-173 cm (range 15S-l93), weight-79kg (range 57-107), body surface area (BSA)- 195m”(range 161-2.31), bone marrow cellurarity27%(range 2-75) platelet count-233,00O/mm’ (range 139,000-339,000) white blood cell (WBC) counts-6. 400/mmz (range 4,200-10,900), hemoglobin-14.5 mg/dl (range 118-16.6). The median duration of CL1 was 159 days (range 137-345). Ten patients had cardiovascular disease. The number of sites receiving ~39.6 Gy was 0 in 3 patients, 1 in 7 patients. 2 in 6 patients and 3 in 8 patients.

Proceedings of the 42nd Annual ASTRO Meeting

The platelet, hemoglobin, and WBC counts were tkqlowed every three months after completion of CLI. These counts were normalized to the pretreatment counts for statistical analyses. Univariate and multivariate analyses were performed to investigate the relationship between patient factors and hematological status at I year posttreatment. Pearson correlation analysis was used for the continuous factors (patients" age, height, weight, BSA, bone marrow cellularity, and duration of CL1) and the Mann-Whitney test was used for categorical factnrs (gender, perfnrmance status, stage, number of sites receiving -> 39.6 Gy, and presence or absence of cardiovascular disease).

Results: There was a continued recovery, essentially reaching the pretreatlnent levels, over 3 years for platelet cuunts, WBC and hemoglobin. Factors significantly associated with normalized platelet counts at 1 year by univariate analyses were age (P = 0.015) and cardiovascular disease (P - 0.(141). Age was the only significant factor by multivariate analyses, with older patients having lower platelet counts at 1 year post-treatment. No factnrs were found to be significantly associated with I-year normalized WBC or hemoglobin levels by either univariate or multivariate analyses.

Conclusion: All three of the hematological components (platelets, WBC, and hemoglobin) essentially recover after CLI over a 3 year period though the process appears to be slowest for platelets. Older age was the only significant adverse factor affecting the platelet recovery detected by nmltivariate analysis.

2135

Involved field radiotherapy after chop-based chemotherapy improves local control and freedom from progression in patients with bulky, clinical stage Ill-IV, intermediate grade of large-cell immunoblastic lymphomas

P. J. Schlembach, R. B. Wilder, S. L. Tucker, C. S. Ha, M. A. Hess, M. A. Rodriguez, F. F. Cabanillas, J. D. Cox The Universi O' (~/ Texas M. D. Andcrso, Cancer Center, Houston. TX

Purpose: To analyze the impact of inw)lved field radiotherapy on local control, freedom frmn progression and overall survival in patients with clinical stage III-IV, intermediate grade or large-cell immunoblastic lymphomas that have responded to induction cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP)-based chemotherapy.

Materials and Methods: From July 1989 through October 1996, 32 patients with clinical stage llI and 27 patients with clinical stage IV, intermediate grade or large-cell immunoblastic lymphomas were prospectively enrolled on 2 protocols (DM 88-087 and DM 93-003) at The University of Texas M. D. Anderson Cancer Center (UTMDACC). There were a total of 172 involved sites of disease at presentation. All 59 patients received CHOP-based chemotherapy. At least 6 cycles of chemotherapy were delivered to 92% of the patients. Invulved field radiotherapy (39.6-40.0 Gy in 20 22 fractions in 74% of cases) was adlninistered to the initially-involved sites of disease in 28/59 t47%1 patients following CHOP-based chemotherapy. Sites were irradiated at the discretion of the treating physicians. Two patients with bulky disease did not receive radiotherapy because their lymphoma progressed during induction chelnotherapy: consequently, these 2 patients were excluded from the analysis. The Cox proportional hazards model was used to assess the prognostic significance of radiotherapy, international prognostic index/IPI) and UTMDACC tulnor score. Twenty-six patients had an 1P1 1 and 33 patients had an IPI - 2-4. Kaplan-Meier estimates of outcomes lor the irradiated and non-irradiated groups were calculated as a function of IPI, and these results were compared using the log-rank test. Groups were analyzed according to the treatment delivered.

Results: The median length of tbllow-up was 52 months tk)r survivors (range: 9-96 months). The median tumor size at the start of chemotherapy in the irradiated patients was 4.5 cm (range: 0 15 cm) versus 3 cm (range: 0-7 cm) in the non-irradiated patients (p = 0.004, Mann-Whitney test). Radiotherapy resulted in a statistically significant improvement (p = 0.001 ) in local control (5-year rates: 89% versus 52%). This benefit was due to the marked improvement (p - 0.0009) in local control for patients with lymphomas measuring >-- 4 cm at the start of chemotherapy (5-year rates: 89% versus 33%). Radiotherapy also improved (p = 0.003) freedom from progression (5-year rates: 85% versus 51%), regardless of the size of the lymphoma at the start of chemotherapy. On multivariate analysis, radiotherapy was the most significant factor affecting local control and freedom from progression. The improved overall survival (5-year rates: 87% versus 81%) in irradiated patients was not statistically significant (p - 0.6).

Conclusion: The results suggest that involved field radiotherapy may benefit patients with bulky, clinical stage III-IV, intermediate grade or large-cell immunoblastic lymphomas who have received 6 cycles of CHOP-based, induction chemotherapy.

2136

The impact of chest wall involvement on the outcome of clinical stage UII Hodgkin's disease treated with combined modality therapy

D. C. Hodgson, R. W. Tsang, W. Wells, M. Pintitie, M. K. Gospodarowicz Princess Margaret Hospital, Toronto, ON. Canada

Purpose: I ) To determine whether patients with extrauodal (particularly chest wall and lung) involvement of Hodgkin's disease have worse outcomes after adjusting for cun'ently known prognostic factors. 2) To analyze the failure patterns in patients with extranodal disease to determine whether local failure is more common in these patients.

Materials and Methods: We analyzed the outcome of 340 patients with clinical stage I-II HD treated with combined modality therapy from 1981-1996. There were 170 females and 170 males. Median age was 29 (range 15-78). 242 patients received adriamycin-containing chemotherapy; 89 received MOPP; 9 received other chemotherapy. Median RT dose was 35Gy. 44 patients had clinical stage 1 disease; 296 had clinical stage I1. Cox modeling of overall survival lOS), cause-specific survival (CSS), disease-free survival (DFS), relapse-free rate (RFR) and local control (LC) was performed, using the following

331