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. 2021 Oct 26;5(20):4185-4197.
doi: 10.1182/bloodadvances.2021004939.

Excellent response to very-low-dose radiation (4 Gy) for indolent B-cell lymphomas: is 4 Gy suitable for curable patients?

Brandon S Imber  1 , Karen W Chau  1   2 , Jasme Lee  3 , Jisun Lee  1 , Dana L Casey  4 , Joanna C Yang  5 , N Ari Wijentunga  1 , Annemarie Shepherd  1 , Carla Hajj  1 , Shunan Qi  1   6 , Monica R Chelius  1 , Paul A Hamlin  7 , M Lia Palomba  7 , Erel Joffe  7 , Zhigang Zhang  3 , Andrew D Zelenetz  7 , Gilles A Salles  7 , Joachim Yahalom  1
Affiliations

Excellent response to very-low-dose radiation (4 Gy) for indolent B-cell lymphomas: is 4 Gy suitable for curable patients?

Brandon S Imber et al. Blood Adv. .

Abstract

Radiotherapy plays an important role in managing highly radiosensitive, indolent non-Hodgkin lymphomas, such as follicular lymphoma and marginal zone lymphoma. Although the standard of care for localized indolent non-Hodgkin lymphomas remains 24 Gy, de-escalation to very-low-dose radiotherapy (VLDRT) of 4 Gy further reduces toxicities and duration of treatment. Use of VLDRT outside palliative indications remains controversial; however, we hypothesize that it may be sufficient for most lesions. We present the largest single-institution VLDRT experience of adult patients with follicular lymphoma or marginal zone lymphoma treated between 2005 and 2018 (299 lesions; 250 patients) using modern principles including positron emission tomography staging and involved site radiotherapy. Outcomes include best clinical or radiographic response between 1.5 and 6 months after VLDRT and cumulative incidence of local progression (LP) with death as the only competing risk. After VLDRT, the overall response rate was 90% for all treated sites, with 68% achieving complete response (CR). With a median follow-up of 2.4 years, the 2-year cumulative incidence of LP was 25% for the entire cohort and 9% after first-line treatment with VLDRT for potentially curable, localized disease. Lesion size >6 cm was associated with lower odds of attaining a CR and greater risk of LP. There was no suggestion of inferior outcomes for potentially curable lesions. Given the clinical versatility of VLDRT, we propose to implement a novel, incremental, adaptive involved site radiotherapy strategy in which patients will be treated initially with VLDRT, reserving full-dose treatment for those who are unable to attain a CR.

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Figures

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Graphical abstract
Figure 1.
Figure 1.
Cumulative incidence of local progression. Cumulative incidence (CIF) of LP assuming death as competing risk after treatment with VLDRT for the (A) overall cohort and (B) stratified by treatment intent with Gray’s test P value. Comparison of analytic methods for LP: CIF vs Kaplan-Meier (KM) curve censoring for death and start of systemic therapy (1-KM) after VLDRT for (C) the entire cohort and (D) stratified by intent of VLDRT.
Figure 2.
Figure 2.
Additional post-VLDRT outcomes. Cumulative incidence of DP after VLDRT for (A) the overall cohort and (B) stratified by treatment intent and of OP after VLDRT for (C) the overall cohort and (D) stratified by treatment intent with Gray’s test P value. Kaplan-Meier estimates of OS after VLDRT for (E) the overall cohort and (F) stratified by treatment intent with log-rank test P value. Shading is 95% CI.
Figure 3.
Figure 3.
Additional same site RT. Cumulative incidence of (A) receipt of additional RT and (B) subsequent LP after additional RT to same site after VLDRT. Shading is 95% CI.
Figure 4.
Figure 4.
Schematic framework for adaptive treatment of patients with iNHL using VLDRT and early PET guidance. MSKCC, Memorial Sloan Kettering Cancer Center.
Figure 5.
Figure 5.
Cumulative incidence of DLBCL transformation or diagnosis after VLDRT.
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References

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