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

Abstract

Purpose The role of consolidative radiotherapy (RT) for stage III and IV 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. Methods and Materials 211 stage III and IV DLBCL patients 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. Results Median follow-up was 43.9 months. 50% experienced LR at 5 years. In multivariate analysis tumor ≥ 5 cm and stage III disease were associated with increased risk of LR. Five year LR free survival for patients with ≥ 5 cm lesions were 47.4% versus 74.7% for patients with < 5cm lesions (p = 0.01). In patients with < 5 cm tumors, SUVmax was ≥15 in all patients with LR. Five year LR free survival was 100% in SUV < 15 versus 68.8% in SUV≥15 (p=0.10). Conclusions Advanced stage DLBCL patients who are stage III 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 following chemoimmunotherapy.

Hitting a Moving Target: Successful Management of Diffuse Large B-cell Lymphoma Involving the Mesentery With Volumetric Image-guided Intensity Modulated Radiation Therapy

“…Furthermore, prior studies have reported an association of bulky disease with worse outcomes for DLBCL patients [43]. In a previous study of 89 patients treated for DLBCL after primary immunochemotherapy, those with bulky disease (defined as > 5 cm) were approximately 7 times more likely to recur locally than those with smaller initial disease [44]. In our chemo-sensitive cohort, all patients had bulky disease at time of diagnosis (median 11.9 cm).…”

The role of radiotherapy for patients over age 60 with diffuse large B-cell lymphoma in the rituximab era

“…Prognostic factors that were included were: presence of B-symptoms, bone marrow involvement, LDH level, bulky disease as defined by greater than 5 cm per institutional practice,[20] IPI score, and the number of extranodal sites. Patients were followed with periodic physical exams and imaging.…”

Impact of salvage treatment modalities in patients with positive FDG‐PET/CT after R‐CHOP chemotherapy for aggressive B‐cell non‐Hodgkin lymphoma

“…The current standard first‐line management for patients with aggressive B‐cell non‐Hodgkin lymphoma (NHL) is R‐CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisone) chemotherapy . Indications for consolidation radiotherapy after first‐line chemotherapy include bulky or skeletal disease on initial scans at diagnosis or residual disease on imaging post‐chemotherapy . These recommendations were based on anatomical imaging and before the widespread use of positron emission tomography (PET).…”

“…1 Indications for consolidation radiotherapy after first-line chemotherapy include bulky or skeletal disease on initial scans at diagnosis or residual disease on imaging postchemotherapy. [2][3][4][5][6] These recommendations were based on anatomical imaging and before the widespread use of positron emission tomography (PET). PET, using 18 F-Fluorodeoxyglucose (FDG), is now the standard tool for assessing response to treatment, having been shown to be more accurate at defining residual and recurrent lymphoma and a better predictor of relapse than anatomical imaging.…”