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Radiotherapy in stage I–III follicular non-Hodgkin lymphoma

Retrospective analysis of a series of 50 patients

Strahlentherapie des follikulären Non-Hodgkin-Lymphoms im Stadium I–III

Eine retrospektive Analyse von 50 Patienten

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An Erratum to this article was published on 20 December 2012

Abstract

Purpose

The goal of this work was to analyze the response rate and outcome of patients with stage I–III follicular lymphoma (FL) treated with radiotherapy (RT) alone.

Patients and methods

The records of 50 consecutive patients with stage I–III FL treated with RT alone at our department from 1988–2009 were analyzed. The median age was 60 years (range 32–80 years) with a median follow-up duration of 8 years (range 4–11 years). Clinical staging was performed according to the Ann Arbor system. Stage I: 30 patients (60%), stage II: 15 patients (30%), stage III: 5 patients (10%). Thirty-two patients (64%) presented with nodal disease, 14 patients (28%) presented with disease in extranodal sites, and 4 patients (8%) had nodal and extranodal involvement. The RT field encompassed only the involved Ann Arbor nodal regions (involved-field RT) in 26 patients (52%), mantle and whole abdominopelvic fields in 6 patients (12%), mantle field in 10 patients (20%), whole abdominopelvic fields in 5 patients (10%), and a so-called mini-mantle in 3 patients (6%). The total RT dose ranged from 26–56 Gy (median 40 Gy) in daily fractions of 1.2–2.5 Gy.

Results

Complete remission (CR) and partial remission (PR) were observed in 39 (76%) and 9 (20%) patients, respectively. Only 2 of 8 patients (25%) with tumor bulk > 5 cm reached CR, whereas 37 of 42 patients (88%) with a maximum lymphoma diameter < 5 cm achieved CR (p = 0.0001). The median overall survival (OS) and median event-free survival (EFS) were 18 years (CI 95% 10–26 years) and 7 years (6–8 years), respectively. The 2-, 5-, and 10-year OS were 96 ± 3%, 90 ± 5%, and 70 ± 9%, respectively. The 2-, 5-, and 10-year EFS were 90 ± 5%, 70 ± 7%, and 38 ± 9%, respectively. Fifteen patients developed a recurrence outside the radiation field (30%) and 4 patients developed an in-field recurrence (8%). All in-field recurrences were observed in regions without clinical (macroscopic) involvement, which were irradiated with a dose of ≤ 26 Gy. Pretreatment maximum lymphoma diameter < 5 cm (p = 0.039) and complete remission after RT (p = 0.021) were significantly associated with a better OS in the univariate analysis.

Conclusion

RT is a curative option in the treatment of limited stage FL. If RT of microscopically uninvolved area is necessary, a reduction in the radiation dose should be carefully weighed against the risk of in-field recurrences.

Zusammenfassung

Ziel

Retrospektive Analyse der Therapieergebnisse nach Strahlentherapie von Patienten mit follikulärem Non-Hodgkin-Lymphom im Stadium I–III.

Patienten und Methoden

50 Patienten mit follikulärem Non-Hodgkin-Lymphom wurden zwischen 1988–2009 an der Klinik für Strahlentherapie und Radiologische Onkologie (Klinikum rechts der Isar, Technische Universität München) behandelt. Das mediane Alter betrug 60 Jahre (32–80 Jahre). Das mediane Follow-Up betrug 8 Jahre (4–11 Jahre). Die klinische Stadieneinteilung erfolgte nach der „Ann Arbor“-Klassifikation: Stadium I: 30 Patienten (60%), Stadium II: 15 Patienten (30%), Stadium III:5 Patienten (10%). 32 Patienten (64%) hatten einen nodalen Befall, 14 Patienten (28%) einen extranodalen Befall und 4 Patienten (8%) zeigten sowohl einen nodalen, als auch einen extranodalen Befall. 26 Patienten (52%) erhielten eine „involved-field“-Strahlentherapie, 6 Patienten (12%) eine Mantelfeldbestrahlung plus Behandlung der abdominopelvinen und inguinalen Lymphabflusswege, 10 Patienten (20%) wurden über ein Mantelfeld bestrahlt. 5 Patienten (10%) erhielten eine abdominopelvine Bestrahlung und 3 Patienten (6%) wurden mit einem modifiziertem Mantelfeld (Mini-Mantel) behandelt. Die mediane Gesamtdosis betrug 40 Gy (26–56 Gy) mit einer Einzeldosis von 1,2–2,5 Gy.

Ergebnisse

Eine komplette Remission (CR) wurde bei 39 Patienten (76%) und eine partielle Remission (PR) bei 9 Patienten (20%) erreicht. Nur 2 der 8 Patienten (25%) mit einem Bulk (Lymphommanifestation ≥ 5 cm) erreichten eine CR, während bei 37 der 42 Patienten (88%) ohne Bulk (Lymphommanifestation < 5 cm) eine CR beobachtet wurde (p = 0,0001). Das mediane Gesamtüberleben (OS) und das mediane ereignisfreie Überleben (EFS) betrugen 18 Jahre (95% CI  10–26 Jahre) bzw. 7 Jahre (6–8 Jahre). Das 2-, 5- und 10-Jahres-OS betrug 96 ± 3%, 90 ± 5% und 70 ± 9%. Das 2-, 5- und 10-Jahres-EFS lag bei 90 ± 5%, 70 ± 7% und 38 ± 9%. Insgesamt kam es bei 19 Patienten zu einem Rezidiv, nur 4 (8%) davon wurden innerhalb des bestrahlten Volumens beobachtet. Alle „in field“-Rezidive fanden sich in einer Region, in der vor der Therapie kein klinisch makroskopischer Befall sichtbar war und die hauptsächlich als potentiell mikroskopischer Befall mit einer Dosis von ≤ 26 Gy bestrahlt wurden. In der univariaten Analyse waren eine Lymphommanifestation < 5 cm (p = 0,039) und eine CR nach Strahlentherapie (p = 0,021) signifikant mit einem längeren Überleben assoziiert.

Schlussfolgerung

Die alleinige Strahlentherapie bietet eine kurative Behandlungsoption bei follikulärem Non-Hodgkin-Lymphom im limitierten Stadium. Bei Bestrahlung potentiell mikroskopisch befallener Areale sollte bei Dosisreduktion das erhöhte Risiko eines „in field“-Rezidivs beachtet werden.

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Acknowledgments

We thank Dr. Tibor Schuster for supporting us during the statistical analysis.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany

    K. Fakhrian MD, S. Klemm, C. Bayer, W. Riedl, M. Molls & H. Geinitz

  2. III. Medical Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany

    U. Keller

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  1. K. Fakhrian MD
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Fakhrian, K., Klemm, S., Keller, U. et al. Radiotherapy in stage I–III follicular non-Hodgkin lymphoma. Strahlenther Onkol 188, 464–471 (2012). https://doi.org/10.1007/s00066-011-0057-0

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