Hodgkin's with no chemo

[Haybrant]

78 yo man with significant comorbidites (vasculopath, DMII with left BKA, cad, worsening dementia) has a distant history 15 years ago of treatment for dlbcl in remission now found to have growing supraclav node biopsied positive for nodular sclerosing Hodgkin's Lymphoma. Very poor chemo candidate per med onc. Asking if we can give RT alone. PET shows right cervical/supraclav nodal conglomerate and a Right IMN. What would you do here, has anyone done STLI? Just treat involved field and follow?

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[CaesarRO]

I'd probably do involved field and follow. If the guy is such a poor chemo candidate, no reason to put him through STLI. "Palliative Plus" and odds are he'll do just fine with involved field. Wouldn't be surprised if with modern era diagnostics involved field RT would be curative.

 

[gmsquid]

I think strictly have to do stli based on lit but with imrt should probably be able to spare things well.

 

[Palex80]

Brentuximab on top of RT?
It does have neurotoxicity potential, but quite a few of the contemporary regimes have replaced some chemo component with brentuximab.

 

[anonymuncule]

What dose would you give?

 

[Palex80]

What dose would you give?

IFRT 30/2, followed by INRT 10/2?

 

[Haybrant]

IFRT 30/2, followed by INRT 10/2?

this sounds pretty good.

what is included for STLI for a IIA hodgkins anyway?

 

[evilbooyaa]

Chemo induced cancer!
Would probably do involved field, 1-2cm sup/inf to extent of disease and ENI to stuff in-between.
This old NEJM paper (https://www.nejm.org/doi/full/10.1056/nejmoa1111961) did 35Gy midplane in 20Fx which is really gonna be low compared to 3-dimensional planning. I think Palex is pretty good at lymphoma and his dosing seems reasonable. For the americans - 30Gy in 15fx, then 10Gy in 5Fx boost.

I... don't even know I know how to properly look up how to do STLI. Would not put a patient like that through the cardiac and lung toxicities.

 

[sirspamalot]

What would STLI exactly include? After doing IFRT/ISRT w/chemo for so many many years...

 

[Palex80]

What would STLI exactly include? After doing IFRT/ISRT w/chemo for so many many years...

I have no idea. Something like that maybe?

 

[taserlaser]

Oh goodness. I just had someone who had in the 90s as a teen that come through my clinic not too long ago with secondary breast cancer. Reading 'we blocked the heart after 30 Gy...' is just wild.

 

[gmsquid]

I have no idea. Something like that maybe?

View attachment 370134

I think that less the iliac and inguinals in this scenario. Though I suppose if you just chase the nodal areas with imrt you could keep the heart and lung doses relatively low

 

[Haybrant]

saw the pt hes fairly poor performance status had a BKA and has pretty bad sores contralateral leg high risk of losing that leg too. Trying to limit RT timing to not lose time from rehab. Is 300 x 10 involved node ok for palliating a hodgkins or do you go lower dose. Thanks

 

[medgator]

saw the pt hes fairly poor performance status had a BKA and has pretty bad sores contralateral leg high risk of losing that leg too. Trying to limit RT timing to not lose time from rehab. Is 300 x 10 involved node ok for palliating a hodgkins or do you go lower dose. Thanks

Maybe 36/12 just to get enough dose in and call it a day?

 

[taserlaser]

Maybe 36/12 just to get enough dose in and call it a day?

ILROG Covid guidelines would agree

ILROG emergency guidelines for radiation therapy of hematological malignancies during the COVID-19 pandemic

The International Lymphoma Radiation Oncology Group provides evidence-supported options for adjusting radiation therapy timing and delivery for patients with se

ashpublications.org

 

[Palex80]

 

[Haybrant]

ILROG Covid guidelines would agree

ILROG emergency guidelines for radiation therapy of hematological malignancies during the COVID-19 pandemic

The International Lymphoma Radiation Oncology Group provides evidence-supported options for adjusting radiation therapy timing and delivery for patients with se

ashpublications.org

thanks for attaching these guidelines; not really seeing where it shows such high dose needed for HL palliation; NHL yes, but HL too, 36 in 12? Thanks

 

[NotMattSpraker]

saw the pt hes fairly poor performance status had a BKA and has pretty bad sores contralateral leg high risk of losing that leg too. Trying to limit RT timing to not lose time from rehab. Is 300 x 10 involved node ok for palliating a hodgkins or do you go lower dose. Thanks

I think before anything else you need to define the goal of treatment with the patient. If its palliative, then I think standard palliation is okay and you could just treat what is symptomatic or ISRT to 30/10 or some other palliative dose.

IMO if you do ISRT and not STLI without chemo, you might get away with it or you will be chasing frequent small out of field recurrences. Time will tell. I've been in the latter situation with metastatic small cell without chemo and it very quickly feels like you are not helping.

Tough case, good luck!

 

[taserlaser]

thanks for attaching these guidelines; not really seeing where it shows such high dose needed for HL palliation; NHL yes, but HL too, 36 in 12? Thanks

Probably not needed for palliation. I think for HL would use chemoninsensitive dose assuming not getting chemo. But I’m assuming would respond much sooner than that. not something obviously I do routinely, but it’s ‘something’ to go by perhaps

 

[TheWallnerus]

You could try and palliate this and accidentally cure it. “I’m so sorry Mr Jones. I didn’t mean to cure you. Sometimes things we never want to happen just happen, it’s nobody’s fault.”

What this means, and what I’m trying to say is, is physician intent is a meaningless and worthless topic insofar as the inner machinations, thoughts, hopes, and dreams of the physician is concerned. I am a rad onc. I intend to irradiate. I have never heard a surgeon say “To cut is to palliate.” I have cured pain, bleeding, and paralysis in a lot of cancer patients. It is just plain weird that insurance companies and our prescription forms want to know “intent.” In court they call this mens rae, and it’s notoriously difficult to pin down and prove.

 

[evilbooyaa]

saw the pt hes fairly poor performance status had a BKA and has pretty bad sores contralateral leg high risk of losing that leg too. Trying to limit RT timing to not lose time from rehab. Is 300 x 10 involved node ok for palliating a hodgkins or do you go lower dose. Thanks

If the game plan is palliation(seems reasonable given the scenario), 300 x 10 is fine, don't over think it.

 

[NotMattSpraker]

You could try and palliate this and accidentally cure it. “I’m so sorry Mr Jones. I didn’t mean to cure you. Sometimes things we never want to happen just happen, it’s nobody’s fault.”

What this means, and what I’m trying to say is, is physician intent is a meaningless and worthless topic insofar as the inner machinations, thoughts, hopes, and dreams of the physician is concerned. I am a rad onc. I intend to irradiate. I have never heard a surgeon say “To cut is to palliate.” I have cured pain, bleeding, and paralysis in a lot of cancer patients. It is just plain weird that insurance companies and our prescription forms want to know “intent.” In court they call this mens rae, and it’s notoriously difficult to pin down and prove.

I think the call to include intent in documentation is a poor solution to a real problem. I agree wtih you on the downsides. The problem is that patients are often mis-informed of the goal of treatment and are biased toward unrealistic expectations.

If you tell this particular patient, "Im going to treat you with radiation" and thats it, many will assume it is for cure. If it comes back in 3 months outside the field, they will be upset. I have seen this happen so many times with medical oncologists, particularly those enrolling patients in to phase I trials. If I can head that off in my own patients, I think its a greater good.

It is not harmful to say "I am going to treat you wtih radiation. It has a high chance of making you feel better, but a low chance of making this go away forever. Also, it's worth remembering that doctors are bad at predicting the future, so only time will tell the outcome".

It is evidence based, it gives hope, and it clearly communicates to the patient what they can expect, on average, for the future.

 

[seper]

I think the call to include intent in documentation is a poor solution to a real problem. I agree wtih you on the downsides. The problem is that patients are often mis-informed of the goal of treatment and are biased toward unrealistic expectations.

If you tell this particular patient, "Im going to treat you with radiation" and thats it, many will assume it is for cure. If it comes back in 3 months outside the field, they will be upset. I have seen this happen so many times with medical oncologists, particularly those enrolling patients in to phase I trials. If I can head that off in my own patients, I think its a greater good.

It is not harmful to say "I am going to treat you wtih radiation. It has a high chance of making you feel better, but a low chance of making this go away forever. Also, it's worth remembering that doctors are bad at predicting the future, so only time will tell the outcome".

It is evidence based, it gives hope, and it clearly communicates to the patient what they can expect, on average, for the future.

there is no such thing as "forever". That's why definitive vs palliative intent is a lousy discussion. However, oncology must have something like this concept in order to function.

 

[RadOncDoc21]

I think the call to include intent in documentation is a poor solution to a real problem. I agree wtih you on the downsides. The problem is that patients are often mis-informed of the goal of treatment and are biased toward unrealistic expectations.

If you tell this particular patient, "Im going to treat you with radiation" and thats it, many will assume it is for cure. If it comes back in 3 months outside the field, they will be upset. I have seen this happen so many times with medical oncologists, particularly those enrolling patients in to phase I trials. If I can head that off in my own patients, I think its a greater good.

It is not harmful to say "I am going to treat you wtih radiation. It has a high chance of making you feel better, but a low chance of making this go away forever. Also, it's worth remembering that doctors are bad at predicting the future, so only time will tell the outcome".

It is evidence based, it gives hope, and it clearly communicates to the patient what they can expect, on average, for the future.

Don’t forget the promises made at another place with no chance of toxicity and 100% cure rates guaranteed… I’m looking at you CTCA!

 

[medgator]

Don’t forget the promises made at another place with no chance of toxicity and 100% cure rates guaranteed… I’m looking at you CTCA!

You mean COH now, an NCI designated CC 😂

 

[NotMattSpraker]

there is no such thing as "forever". That's why definitive vs palliative intent is a lousy discussion. However, oncology must have something like this concept in order to function.

Don’t forget the promises made at another place with no chance of toxicity and 100% cure rates guaranteed… I’m looking at you CTCA!

Agreed on both counts. Biologically there is no "forever", but this is more about patient perception than biology.

All Im saying is that if we removed intent entirely from discussion, I think that it is more harm than good. Im cool with removing it from documentation, but right now I do that for compliance.

 

[sirspamalot]

Ergo, the surgical mantra "We got it all" must be the highest form of intent (to bullshyt) patients in the game

 

[Fpg1245]

Ergo, the surgical mantra "We got it all" must be the highest form of intent (to bullshyt) patients in the game

Then I get them: “I don’t understand whynim here the surgeon said they got it all”

Will someone tell them to stop saying that.

 

[taserlaser]

Then I get them: “I don’t understand whynim here the surgeon said they got it all”

Will someone tell them to stop saying that.

Seriously. Worst offenders here are s/p craniotomy for GBM

 

[sirspamalot]

 

[Fpg1245]

Seriously. Worst offenders here are s/p craniotomy for GBM

Bigtime offenders. Especially the older ones.

 

[TheWallnerus]

Then I get them: “I don’t understand whynim here the surgeon said they got it all”

Will someone tell them to stop saying that.

If there’s one thing I know for sure, surgeons listen to rad oncs when rad oncs tell the surgeons how to speak to patients.

 

[metallica81788]

Ergo, the surgical mantra "We got it all" must be the highest form of intent (to bullshyt) patients in the game

But surgeon said they got it all, why do I need radiation?

Ugh