Seminars in Radiation Oncology
Volume 17, Issue 3 , Page 157, July 2007

Introduction

Article Outline

 

Radiation oncology of lymphomas has markedly transformed over the last decade. A profound shift in indications, field concept, and dose prescription evolved as radiation oncology adapted to the availability of more effective and safer chemotherapy. The change was also influenced by the new lymphoma classification and better understanding of the various subtypes that led to identification of “new” lymphomas such as the mucosa-associated lymphoid tissue (MALT) lymphomas that are mostly cured by radiation alone.

In contrast to past practice, radiation therapy as the primary treatment (often without chemotherapy) is nowadays only used in selected lymphoma subcategories, such as lymphocyte predominance Hodgkin lymphoma, extranodal marginal zone lymphoma (MALT lymphoma), and early-stage follicular lymphoma. Yet, in most other, more common histologies, such as classic Hodgkin lymphoma, diffuse large B-cell lymphoma, and primary CNS lymphoma, the role of radiation is complementary to chemotherapy and is often limited to patients with early-stages and/or bulky sites.

Although the complementary role of radiation is relevant to a large number of patients, it is also the most controversial. Many medical oncologists often prefer to use more chemotherapy to compensate for excluding radiation. The generously used (or abused) argument is that radiation therapy harbors increased risk of long-term side effects, particularly second tumors and heart disease.1, 2

Indeed, radiation when given unselectively to multiple normal organs at full doses increases the risk of second solid tumors and cardiovascular disease. In recent years, many radiation oncologists analyzed past data and reported extensively on those complications in patients treated 20 to 50 years ago with “radical radiotherapy. Unfortunately, what many of our colleagues in medical oncology fail to recognize is that radiation fields and doses used today are drastically different from past practices and new data are indicating that future risks will be significantly lower. At the same time, very little is known about long-term side effects of chemotherapy for lymphoma, and data that are emerging are quite alarming.3, 4 Adding more and more chemotherapy while deleting radiation has not (in multiple studies) compensated for the absence of the ”most effective single agent for many lymphomas” (radiation) but resulted in higher toxicity.5

It is quite obvious that the number of lymphoma patients referred for consideration of radiotherapy has dropped significantly, and many are sent only after multiple standard and experimental systemic agents have failed. How many of those patients could have benefited from incorporating radiotherapy earlier can only be speculated.

As a byproduct of the change in referral pattern in many institutions, radiation oncologists in training and in practice are less involved in the care of lymphoma patients, and the interest and expertise of our professionals in this category of patients is of concern.

I hope that this issue of Seminars in Radiation Oncology will help radiation oncologists update their expertise in this fast changing field. The topics were selected to assist in identifying the scenarios in which radiation makes an important contribution to disease control. The information in many chapters will help to make the arguments in favor of incorporating radiation therapy into a balanced treatment program and design fields and dose that will result in an improved outcome and reduced side effects. Educating ourselves and our colleagues on the appropriate use of the effective modality that we have for patients with lymphoma will improve their chances for cure or palliation. It will hopefully restore the balance of optimal management, improve communication, and reduce the bias against radiation therapy in this disease.

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References 

  1. DeVita VT. Hodgkin’s disease—Clinical trials and travails. N Engl J Med. 2003;348:2375–2376
  2. Longo DL. Radiation therapy in Hodgkin disease: Why risk a Pyrrhic victory?. J Natl Cancer Inst. 2005;97:1394–1395
  3. Aviles A, Neri N, Nambo JM, et al. Late cardiac toxicity secondary to treatment in Hodgkin’s disease (A study comparing doxorubicin, epirubicin and mitoxantrone in combined therapy). Leuk Lymphoma. 2005;46:1023–1028
  4. Martin WG, Ristow KM, Habermann TM, et al. Bleomycin pulmonary toxicity has a negative impact on the outcome of patients with Hodgkin’s lymphoma. J Clin Oncol. 2005;23:7614–7620
  5. Yahalom J. Don’t throw out the baby with the bathwater: On optimizing cure and reducing toxicity in Hodgkin’s lymphoma. J Clin Oncol. 2006;24:544–548

PII: S1053-4296(07)00021-5

doi:10.1016/j.semradonc.2007.03.001

Seminars in Radiation Oncology
Volume 17, Issue 3 , Page 157, July 2007

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