Purpose: To develop guidelines for the work-up and radiation therapy (RT) management of patients with plasma cell neoplasms. Methods and Materials: A literature review was conducted covering staging, work-up, and RT management of plasma cell neoplasms. Guidelines were developed through consensus by an international panel of radiation oncologists with expertise in these diseases, from the International Lymphoma Radiation Oncology Group. RT volume definitions are based on the International Commission on Radiation Units and Measurements. Results: Plasma cell neoplasms account for approximately one-fifth of mature B-cell neoplasms in the United States. The majority (similar to 95%) are diagnosed as multiple myeloma, in which there has been tremendous progress in systemic therapy approaches with novel drugs over the last 2 decades, resulting in improvements in disease control and survival. In contrast, a small proportion of patients with plasma cell neoplasms present with a localized plasmacytoma in the bone, or in extramedullary (extraosseous) soft tissues, and definitive RT is the standard treatment. RT provides long-term local control in the solitary bone plasmacytomas and is potentially curative in the extramedullary cases. This guideline reviews the diagnostic work-up, principles, and indications for RT, target volume definition, treatment planning, and follow-up procedures for solitary plasmacytoma. Specifically, detailed recommendations for RT volumes and dose/fractionation are provided, illustrated with specific case scenarios. The role of palliative RT in multiple myeloma is also discussed. Conclusions: The International Lymphoma Radiation Oncology Group presents a standardized approach to the use and implementation of definitive RT in solitary plasmacytomas. The modern principles outlining the supportive role of palliative RT in multiple myeloma in an era of novel systemic therapies are also discussed. Crown Copyright (C) 2018 Published by Elsevier Inc. All rights reserved.

Approximately 30% to 40% of patients with diffuse large B-cell lymphoma (DLBCL) will have either primary refractory disease or relapse after chemotherapy. In transplant-eligible patients, those with disease sensitive to salvage chemotherapy will significantly benefit from high-dose therapy with autologous stem cell transplantation. The rationale for considering radiation therapy (RT) for selected patients with relapsed/refractory DLBCL as a part of the salvage program is based on data regarding the patterns of relapse and retrospective series showing improved local control and clinical outcomes for patients who received peritransplant RT. In transplant-ineligible patients, RT can provide effective palliation and, in selected cases, be administered with curative intent if the relapsed/refractory disease is localized. We have reviewed the indications for RT in the setting of relapsed/refractory DLBCL and provided recommendations regarding the optimal timing of RT, dose fractionation scheme, and treatment volume in the context of specific case scenarios. (C) 2017 Elsevier Inc. All rights reserved.

Purpose: To determine the effect of treatment changes over time on all-cause mortality risk in patients with early-stage Hodgkin lymphoma (HL) after radiation therapy. The long-term survivorship of those with HL necessitates quantification of the late risk of mortality from HL and other causes. Methods and Materials: An institutional review board-approved retrospective study was conducted using a multi-institutional database of 1541 stage I and II HL patients treated from 1968 to 2007 with radiation therapy alone or combined-modality treatment. The analytic methods included cumulative incidence function, Kaplan-Meier estimates and log-rank tests for overall survival (OS) differences, and Cox proportional hazards modeling. Results: The median age at diagnosis was 27 years. At a median follow-up of 15.2 years (35% of patients with >20 years of follow-up), 395 patients had died of all causes, including 85 HL, 168 second malignancy (25 hematologic and 143 nonhematologic), 70 cardiovascular, and 21 pulmonary deaths. The cumulative incidence of non-HL mortality had surpassed HL mortality at 8.3 years. For patients treated from 1968 to 1982, 1983 to 1992, and 1993 to 2007, the 15-year OS rates were 78%, 85%, and 88%, respectively (P=.0016). On Cox proportional hazards analysis, age, B symptoms, and number of disease sites were significantly associated with all-cause mortality in the first decade of follow-up, with a trend toward significance for radiation field extent. Conclusions: The all-cause mortality risk was significantly lower for patients treated in the most recent era during the first decade of follow-up, likely due to improved HL therapy resulting in a higher cure rate and lower treatment-related toxicity from smaller radiation fields. Current efforts toward radiation treatment reduction might further reduce the long-term mortality risk for these patients. (C) 2017 Elsevier Inc. All rights reserved.

Relapsed and refractory Hodgkin lymphoma (HL) challenges clinicians to devise treatment strategies that are effective and safe. This problem is particularly prominent in an era when de-escalation trials are designed to minimize therapeutic toxicities in both early-and advanced-stage disease. Radiation therapy is the single most effective treatment modality for HL, and its integration into salvage regimens, or its independent use in select patients, must be understood to maximize our success in treating these patients. The complexity of treating relapsed or refractory HL derives from the spectrum of primary treatment approaches currently in use that creates heterogeneity in both treatment exposure and the potential toxicities of salvage therapy. Patients can have relapsed or refractory disease after limited or aggressive primary therapy (with or without radiation therapy), at early or delayed time points, with limited or extensive disease volumes, and with varying degrees of residual morbidity from primary therapy. Their response to salvage systemic therapy can be partial or complete, and the use of consolidative stem cell transplantation is variably applied. New biologics and immunotherapeutic approaches have broadened but also complicated salvage treatment approaches. Through all of this, radiation therapy remains an integral component of treatment for many patients, but it must be used effectively and judiciously. The purpose of this review is to describe the different treatment scenarios and provide guidance for radiation dose, volume, and timing in patients with relapsed or refractory HL. (C) 2018 Elsevier Inc. All rights reserved.

BackgroundMantle cell lymphoma (MCL) rarely presents as early-stage disease, but clinical observations suggest that patients who present with early-stage disease may have better outcomes than those with advanced-stage disease.Patients and methodsIn this 13-institution study, we examined outcomes among 179 patients with early-stage (stage I or II) MCL in an attempt to identify prognostic factors that influence treatment selection and outcome. Variables examined included clinical characteristics, treatment modality, response to therapy, sites of failure, and survival.ResultsPatients were predominantly male (78%) with head and neck being the most common presenting sites (75%). Most failures occurred outside the original disease site (79%). Although the administration of radiation therapy, either alone or with chemotherapy, reduced the risk of local failure, it did not translate into an improved freedom from progression or overall survival (OS). The treatment outcomes were independent of treatment modality. The 10-year OS for patients treated with chemotherapy alone, chemo-radiation therapy and radiation therapy alone were 69%, 62%, and 74% (P = 0.79), and the 10-year freedom from progression were 46%, 43%, and 31% (P = 0.64), respectively.ConclusionGiven the excellent OS rates regardless of initial therapy in patients with early-stage MCL, de-intensified therapy to limit treatment-related toxicity is a reasonable approach.

Primary breast lymphoma (PBL) comprises < 1% of breast malignancies, leading to a paucity of data to guide management. We evaluated PBL recurrence patterns across two academic hospitals in the era of modern systemic-therapy and radiotherapy.

Abstract Our purpose was to assess outcome of patients with early-stage, favorable (per GHSG criteria) Hodgkin Lymphoma (HL) staged with FDG-PET/CT and treated with two cycles of adriamycin, bleomycin, vincristine, and dacarbazine (ABVD) followed by PET/CT assessment and involved-site radiotherapy (ISRT) to 20 Gy. Records of 23 patients who met eligibility criteria, treated between 2008 and 2016, were reviewed. PET response after two cycles of ABVD was independently assessed by a nuclear medicine physician. After two cycles of ABVD, 91.3% of patients had a Deauville score of 1–2; 1 patient had a score of 3. Median follow-up was 45.3 months. As of this analysis, all patients are alive without disease. One patient had an out-of-field relapse, yielding a 4-year relapse-free survival rate of 92.9% (95%CI [59.1, 99.0]). Our results showed that with careful patient selection by initial disease characteristics and FDG-PET response to chemotherapy, the use of a more restricted treatment volume of ISRT to 20 Gy following ABVD × 2 is associated with excellent outcomes.

This portion of the NCCN Guidelines for Hodgkin lymphoma (HL) focuses on the management of classical HL. Current management of classical HL involves initial treatment with chemotherapy or combined modality therapy followed by restaging with PET/CT to assess treatment response using the Deauville criteria (5-point scale). The introduction of less toxic and more effective regimens has significantly advanced HL cure rates. However, long-term follow-up after completion of treatment is essential to determine potential long-term effects. J Natl Compr Canc Netw 2017;15(5):608–638 NCCN Categories of Evidence and Consensus Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate. Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate. Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate. Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate. All recommendations are category 2A unless otherwise

Prior studies have shown a significantly reduced second-cancer risk in Hodgkin lymphoma (HL) survivors treated with more limited-field radiation therapy (RT), although the impact of RT field size reduction on long-term overall survival (OS) has been unclear. The purpose of this study is to analyze long-term OS by field size. An institutional review board-approved retrospective study was conducted using a multi-institutional database of stage I and II HL patients treated 1967-2007 with RT with or without chemotherapy. Statistical analysis was conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC) and Stata 14 (StataCorp LP, College Station, TX). Covariates included age, gender, year of treatment, histology, number of sites, B symptoms, favorable versus unfavorable prognostic group, chemotherapy regimen, RT field, and mediastinal RT dose. The Kaplan-Meier method was used for estimates of OS and the log-rank test was used to test for significance of univariate differences. A Cox proportional hazards model was constructed based on an established method to evaluate for factors associated with all-cause mortality. A total of 1,541 clinical stage I and II HL patients were included. The overall median follow-up time was 15.2 years, with 35% of patients having >20 years of follow-up. The 10-, 15- and 20-year OS rates were 89%, 83%, and 76%, respectively. There was an increasing percentage of patients treated with involved-field (IF) RT in more recent year-cohorts of treatment: 1967-1983 (2%), 1983-1993 (3%), and 1994-2007 (42.2%). On univariate analysis, younger age at diagnosis (P<0.01), favorable-prognosis disease (P<0.01), absence of B symptoms (P = 0.04), classical or lymphocyte predominant histology (P<0.01) and more recent treatment era (P<0.01) were associated with longer OS. For the regression model (Table 1), follow-up time was restricted to the first 20 years of follow-up to ensure parity between treatment-era cohorts. Although correlated with RT field size, chemotherapy regimen fell out of the model due to lack of significance. After adjusting for covariates, IFRT, as compared to extended-field (EF) RT, was associated with significantly lower all-cause mortality, with a hazard ratio of 0.59 (P = 0.038). Treatment with IFRT in early-stage Hodgkin lymphoma was associated with a 41% reduction in the risk of death compared to those treated with EFRT. These results support current efforts to reduce RT volume to involved sites and potential further volume reduction in selected patients.Abstract 297; Table 1Hazard Ratios (HR) for All-Cause MortalityHR95% Confidence IntervalP valueAge at diagnosis<21 yearsref.21-301.220.841.780.29631-401.541.022.320.041> 406.214.408.78<0.001B symptomsAbsentref.Present1.290.981.710.072Number of sites of disease≤ 3ref.≥ 41.381.011.870.041Radiation FieldEFRTref.IFRT0.590.360.970.038 Open table in a new tab

This portion of the NCCN Guidelines for Hodgkin lymphoma (HL) focuses on the management of classical HL. Current management of classical HL involves initial treatment with chemotherapy or combined modality therapy followed by restaging with PET/CT to assess treatment response using the Deauville criteria (5-point scale). The introduction of less toxic and more effective regimens has significantly advanced HL cure rates. However, long-term follow-up after completion of treatment is essential to determine potential long-term effects.

Women who received chest irradiation (RT) for Hodgkin lymphoma (HL) at a young age are at increased risk for breast cancer (BC). Treatment-related early menopause is protective against BC but limited data are available on changes in risk as survivors enter menopause. We aimed to assess the excess BC risk of HL survivors compared with a normal age-matched population as survivors pass menopause, and to compare the excess risks of premenopausal versus postmenopausal survivors. HL treatment history, subsequent invasive BC or ductal carcinoma in situ (DCIS) development, menopausal status, and hormone-replacement therapy (HRT) history were abstracted from a HL database and medical records with IRB approval. The study included 555 women who had chest RT for HL at age <35 between 1968 and 2005. Attained age >50, pelvic RT and MOPP chemotherapy exposure were used as surrogates for menopause in 109 cases of missing menopausal status data. Postmenopausal women on HRT were considered premenopausal. Median age at RT was 23 (range = 6-35) and median current attained age was 39 (range = 12-69). SEER data were used to calculate relative (RR) and absolute excess risk (AR, per 10,000 person-years). With a median follow-up time of 20.5 years (range = 0.7-42.4), 107 women developed at least one BC, including 92 with invasive BC, 21 with DCIS, and 14 with two BCs. Median time from RT to BC diagnosis was 18 years (range = 6-39). The overall RR for developing BC was 14.4 (95% CI = 11.8-17.4) with an AR of 107.8. For survivors with attained ages <50, 50-55, and 56-60, RRs were 32.1 (25.7-39.5), 6.5 (3.6-10.9), and 3.7 (1.2-8.6), respectively (P-trend < 0.001) with corresponding ARs of 134.3, 73.6, and 47.2. There was no BC observed among survivors with attained age >60. The RRs of premenopausal and postmenopausal survivors were 27.7 (22.0-34.5) and 5.8 (3.8-8.5), respectively (P < 0.001). The corresponding ARs were 136.8 and 60.9. These results showed a significant drop in BC risk as HL survivors reach menopausal age, although the risk remained elevated compared to that of women without a prior HL diagnosis. The decline in BC risk in postmenopausal survivors suggests that they may be considered for less aggressive BC screening (e.g., mammogram alone), and may have implications for broadening breast-conserving therapy options and for preserving the contralateral breast in postmenopausal survivors who develop BC. This risk may also be mitigated in the era of modern radiation therapy, with the use of smaller fields and lower doses.

Purpose: Long-term survivors of Hodgkin's lymphoma (HL) treated with mediastinal radiotherapy often have multiple subclinical cardiac abnormalities, possibly including restrictive cardiomyopathy. The clinical importance of these abnormalities has not been established, but they may eventually reduce quality of life. We sought to confirm an earlier cross-sectional correlation between maximum oxygen consumption (VO2max) and the physical component score (PCS) of the SF-36 quality of life instrument completed years later.Methods: We created a cohort of 21 survivors of HL in childhood or adolescence who had participated in both of two independent studies: a study of multiple cardiac measures in 48 survivors at a median of 14.3 years after diagnosis and a study performed about 5 years later of 511 survivors who completed the SF-36. We assessed the correlation between VO2max and left ventricular fractional shortening (LVFS) measured during the first study with PCS measured during the second.Results: Median PCS was 10.0 points lower (55.2 to 45.2) in the second study. The correlation between VO2max and PCS at a median of 5 years later was r=0.50 (P=0.021): that between LVFS in the first study and PCS in the second was r = -0.50 (P=0.021).Conclusions: In HL survivors treated with mediastinal radiotherapy, VO2max appears to be associated with future quality of life. Measures of LVFS are clearly not sufficient to address whether decreased quality of life in these survivors is associated with cardiac impairment Larger longitudinal studies are necessary to determine how much V02max explains future quality of life. (C) 2015 Published by Elsevier Ireland Ltd.

Hodgkin lymphoma (HL) is an uncommon malignancy involving lymph nodes and the lymphatic system. Classical Hodgkin lymphoma (CHL) and nodular lymphocyte-predominant Hodgkin lymphoma are the 2 main types of HL. CHL accounts for most HL diagnosed in the Western countries. Chemotherapy or combined modality therapy, followed by restaging with PET/CT to assess treatment response using the Deauville criteria (5-point scale), is the standard initial treatment for patients with newly diagnosed CHL. Brentuximab vedotin, a CD30-directed antibody-drug conjugate, has produced encouraging results in the treatment of relapsed or refractory disease. The potential long-term effects of treatment remain an important consideration, and long-term follow-up is essential after completion of treatment.

24 n APPLIED RADIATION ONCOLOGY www.appliedradiology.com March 2012 OL GY © www.appliedradiology.c m February 4 Prostate cancer (PC) is the most common non-cutaneous malignancy in the United States, with an anticipated incidence of 239,000 cases and 29,700 deaths in 2013.1 Since the advent of prostate-specific antigen (PSA) based screening, approximately 80% of PC cases are now detected because of an elevated PSA level. Although the detection of PC has increased considerably since the introduction of PSA-testing in 1989, randomized screening studies have suggested that PSA screening can lead to both over-diagnosis and overtreatment.2 Moreover, after a median follow-up of 10 years, the Prostate Cancer Intervention versus Observation Trial demonstrated no differences in prostate-cancer-specific mortality (PCSM) or all-cause mortality among men with low risk disease3 who were observed versus those treated with a radical prostatectomy (RP).4 However, given the association of increasing risk of high grade PC with advancing age and the higher likelihood of under-staging by biopsy given increasing prostate gland volume with advancing age, screening for PC in older men who are in excellent health and expected to live at least 10 years should be considered to rule out the possibility that a high-grade PC exists. If low-risk disease is confirmed (ie, PSA ≤10, Gleason score ≤6 and clinical tumor (T) category 1c or 2a), the options of active surveillance5 versus definitive treatment with either RP or dose-escalated RT6,7 should be discussed along with the potential side-effects of each treatment, with the expectation that PSA recurrence-free survival rates approximate 90% at 7 years following treatment.8 While PC is the most prevalent non-cutaneous solid malignancy in the United States, CLL/SLL represents the most common leukemia in the Western world, accounting for 30% of all leukemias.9 CLL/SLL is a chronic lymphoproliferative disorder, heralded by the monoclonal accumulation of mature, functionally-deficient B-lymphocytes. The majority of patients present with a lymphocytosis of >5000 B-lymphocytes/uL, diagnostic of CLL. A smaller number of patients present with lymphadenopathy caused by cells with an identical immunophenotype as CLL, but with <5,000 B-cells/uL in the peripheral blood, diagnostic of SLL. Patients with either SLL or CLL in the absence of splenomegaly or cytopenias are considered to have early stage disease. FISH can provide important prognostic information. Trisomy-12 occurs in ~16% of patients and is generally a favorable indicator.10 The management of early stage SLL is dependent upon the presence of disease-related symptoms, threatened end-organ dysfunction or bulky disease. Close monitoring remains an option in the absence of these indications, although locoregional radiotherapy can be curative in early stage disease.11 Concurrent management of low-risk prostate cancer and localized small lymphocytic lymphoma in a man without competing risks despite advanced age

To quantify the long-term risk of mortality from Hodgkin lymphoma (HL) and other causes, and to determine the impact of calendar-year of treatment on all-cause mortality risk in early-stage HL patients following radiation therapy. An IRB-approved retrospective study was conducted using a multi-institutional database of 1,542 Stage I and II HL patients treated 1967-2007. Patients who received chemotherapy alone were excluded. Statistical analysis was conducted. Mortality from competing causes was computed using the cumulative incidence function. Kaplan-Meier estimates and log-rank tests for overall survival (OS) differences were computed. A Cox proportional hazards model was constructed to assess factors associated with all-cause mortality. Covariates included age, gender, year of treatment, histology, number of sites, B symptoms, clinical stage, chemotherapy regimen, and mediastinal radiation dose. At a median follow-up of 14.9 years (34 % of patients with > 20 years of follow-up), there were 395 deaths from all causes, including 85 HL, 168 second malignancy (SM), 70 cardiovascular, and 21 pulmonary deaths. Lung cancer was the most common SM resulting in death, accounting for 25% of cases (42 of 168). Cumulative incidence of mortality from causes other than HL surpassed mortality from HL at 8.4 years. The 20-, 25-, and 30-year cumulative incidence rates of SM were 9.6%, 14.4%, and 20.7% for SM deaths and 4.0%, 5.6%, and 8.7% for cardiovascular deaths. The 15-year OS rate for the entire cohort was 83%. For patients treated before 1983, 1983-1992, and 1993-2007, the 15-year OS rates were 78%, 85%, and 88%, respectively (p = 0.0018). On Cox proportional hazards analysis, after adjusting for age, histology, number of sites, and B symptoms, calendar-year of treatment remained a significant predictor for all-cause mortality. The hazard ratios were 2.03 for those treated before 1983 and 1.63 for those treated 1983-1992 (ref: treatment 1993-2007, p < 0.001 and p = 0.031). In this large cohort of historically-treated HL patients, SM accounted for 43% of all deaths, with lung cancer being the most common cause. The all-cause mortality risk, however, was significantly lower in patients treated in the more recent era, likely due to improved HL therapy resulting in a higher cure rate as well as lower treatment-related toxicity. Current efforts toward radiation treatment reduction may further reduce long-term mortality risk in these patients.

To quantify the risks of acute and late ophthalmic toxicity in lymphoma patients receiving radiation therapy (RT) to ocular or periorbital structures, and to identify dosimetric factors predictive of these risks. The study population included 30 consecutive lymphoma patients who received radiation therapy to ocular or periorbital structures at our institution from 2004 to 2010. Dose-volume histograms and dosimetric data were generated for the lacrimal glands, lenses, globes and orbits bilaterally. Radiation-related toxicities including conjunctivitis, xerophthalmia and cataracts were collected from the medical record and adverse effects were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Descriptive statistics were used to characterize dosimetric factors and the distribution of toxicities. The median age at diagnosis was 65 (range, 31 to 89). Marginal zone lymphoma was the most common histology (10 cases), followed by diffuse large B-cell lymphoma (6 cases). 11 patients (37%) received treatment to the bilateral orbits. 3D conformal therapy was used in all cases, including intensity-modulated radiation therapy in 3 cases. The median prescribed dose was 2750 cGy (range, 1980 cGy to 5000 cGy). At a median follow up of 51 months, there were no local relapses. Within the first 6 months after initiating radiation therapy, 3 patients (10%) experienced grade ≥ 2 ophthalmic toxicity comprising acute conjunctivitis or xerophthalmia. Beyond 6 months, 17 patients (57%) subsequently manifested late grade ≥ 2 toxicity comprising xerophthalmia requiring intervention or cataracts requiring surgery. There was no correlation between maximum lens dose (range 7 cGy – 3967 cGy) and the development of cataracts in the study cohort (p = 0.42). Beyond 6 months, the lacrimal gland V5 and globe V10 were significantly correlated with the development of late xerophthalmia and grade ≥ 2 toxicity. V5 covering the entire (100%) lacrimal gland and V10 covering the entire globe were associated with late xerophthalmia (p = 0.03 and p = 0.006, respectively) and with the development of grade ≥ 2 toxicity (p = 0.003 and p = 0.005, respectively). The median globe V10 was 39.8% for patients without late xerophthalmia, in contrast to 100% for those who did develop late xerophthalmia (p = 0.006). In patients receiving radiation therapy for ocular adnexal or periorbital lymphoma, attempts to spare part of the lacrimal gland and limit the globe V10 to less than 40% may reduce the risk of late xeropthalmia.

Patients with Mantle cell lymphoma (MCL) often present with advanced-stage and have a poor prognosis. Stage I-II presentation is rare, and there are only limited data on treatment outcome for these patients. To assess the outcome of this group of patients, we retrospectively reviewed 160 patients seen in 13 ILROG institutions between 1990 and 2012. Of the 160 patients, 124 (77%) were males, 90 (56%) were > 60 years; 87 (54%) were stage I, 121 (76%) presented in the head and neck areas, 100 (63%) had extranodal presentation, 17 (14%) were bulky (> 5 cm). Treatment approaches consisted of combined modality (CM) with chemotherapy and consolidative radiation therapy (RT) in 95 (59%), chemotherapy alone in 37 (23%), and definitive RT alone in 28 (18%). The median radiation dose used was 35 Gy (range 12-45). Chemotherapy consisted of cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP) or CHOP-like, regimens in 106 (80%). Rituximab was added to chemotherapy in 31/52 (60%) patients with available data. The median follow-up was 60 months (range, 4-245 months). At last follow-up, 60 (37%) patients relapsed and 40 (25%) died. The 5-and 10-years overall survivals (OS) were 76% and 64%, respectively. The 5-and 10-years disease free survivals (DFS) were 65% and 44%, respectively. On univariate analysis, the following characteristics were significantly associated with DFS and OS: age > 60 (HR = 1.86, p = 0.02 for DFS; HR = 2.33, p = 0.01 for OS), bulky disease (HR = 1.93, p = 0.06 for DFS; HR = 3.28, p = 0.002 for OS). On multivariate analysis while both DFS and OS were significantly influenced by age as a continuous variable (HR = 1.06, p < 0.001; HR = 1.04, p = 0.001) only OS was influenced by the presence of bulky disease (HR = 3.4, p = 0.001; HR = 3.1). Patients, who were presented with stage I-II MCL and were treated with programs that included consolidative local radiation therapy or even radiation therapy alone, demonstrated favorable disease control and relatively long survival.Oral Scientific Abstract 335; TableAll Patients (%)Chemotherapy alone (%)Combined Modality (%)RT Alone (%)P value5-year DFS656062870.4410-year DFS444044545-year OS768271880.6810-year OS63706156 Open table in a new tab

Radiation therapy (RT) is the most effective single modality for local control of Hodgkin lymphoma (HL) and an important component of therapy for many patients. These guidelines have been developed to address the use of RT in HL in the modern era of combined modality treatment. The role of reduced volumes and doses is addressed, integrating modern imaging with 3-dimensional (3D) planning and advanced techniques of treatment delivery. The previously applied extended field (EF) and original involved field (IF) techniques, which treated larger volumes based on nodal stations, have now been replaced by the use of limited volumes, based solely on detectable nodal (and extranodal extension) involvement at presentation, using contrast-enhanced computed tomography, positron emission tomography/computed tomography, magnetic resonance imaging, or a combination of these techniques. The International Commission on Radiation Units and Measurements concepts of gross tumor volume, clinical target volume, internal target volume, and planning target volume are used for defining the targeted volumes. Newer treatment techniques, including intensity modulated radiation therapy, breath-hold, image guided radiation therapy, and 4-dimensional imaging, should be implemented when their use is expected to decrease significantly the risk for normal tissue damage while still achieving the primary goal of local tumor control. The highly conformal involved node radiation therapy (INRT), recently introduced for patients for whom optimal imaging is available, is explained. A new concept, involved site radiation therapy (ISRT), is introduced as the standard conformal therapy for the scenario, commonly encountered, wherein optimal imaging is not available. There is increasing evidence that RT doses used in the past are higher than necessary for disease control in this era of combined modality therapy. The use of INRT and of lower doses in early-stage HL is supported by available data. Although the use of ISRT has not yet been validated in a formal study, it is more conservative than INRT, accounting for suboptimal information and appropriately designed for safe local disease control. The goal of modern smaller field radiation therapy is to reduce both treatment volume and treatment dose while maintaining efficacy and minimizing acute and late sequelae. This review is a consensus of the International Lymphoma Radiation Oncology Group (ILROG) Steering Committee regarding the modern approach to RT in the treatment of HL, outlining a new concept of ISRT in which reduced treatment volumes are planned for the effective control of involved sites of HL. Nodal and extranodal non-Hodgkin lymphomas (NHL) are covered separately by ILROG guidelines.

PURPOSE:Current guidelines recommend breast magnetic resonance imaging (MRI) as an adjunct to mammography for breast cancer screening in female cancer survivors treated with chest irradiation at a young age, beginning 8 to 10 years after treatment. Prospective data evaluating its efficacy in female cancer survivors are lacking. This study sought to compare the sensitivity and specificity of breast MRI with those of mammography in women who received chest irradiation for Hodgkin lymphoma (HL).PATIENTS AND METHODS:We enrolled 148 women treated with chest irradiation for HL at age ≤ 35 years who were > 8 years beyond treatment. Yearly breast MRI and mammogram were performed over a 3-year period. Sensitivity and specificity of the two screening modalities were compared.RESULTS:With the screening, 63 biopsies were performed in 45 women; 18 (29%) showed a malignancy. All but one of the screen-detected malignancies were preinvasive or subcentimeter node-negative breast cancers. After excluding first-screen MRI and mammogram, mammogram sensitivity was 68% as compared with 67% for MRI (P = 1.0). Sensitivity increased to 94% using both screening modalities. The specificities of mammogram alone, MRI alone, and both were 93%, 94%, and 90%, respectively.CONCLUSION:In contrast to women with genetic or familial risk, in HL survivors breast MRI was not more sensitive than mammogram for breast cancer detection. However, the two screening modalities complement each other in the detection of early cases of disease. Early diagnosis is particularly important in these patients, given the breast cancer treatment challenges in patients who have received prior cancer therapy.