Whole Abdominal Radiation for a Non-Hodgkin's Lymphoma in Remission?

John D. Hainsworth, MD


August 15, 2000


Is there any role for whole abdominal radiation therapy in a 40-year-old woman with primary ovarian non-Hodgkin's lymphoma with massive abdominal disease, who received 6 cycles of CHOP and is in clinical remission?

Nabil Alsafadi

Response from John D. Hainsworth, MD

In answering this question, I will make 2 assumptions regarding this patient, because details are not included in the brief case history. First, I will assume that this patient has an aggressive-histology lymphoma (intermediate or high-grade). (If this were a low-grade histology, observation alone at this point would be the standard treatment.) Second, I will assume that this patient had a high-risk situation based on the recent IPI prognostic system -- this assumption is reasonable based on the description of "massive abdominal disease" and at least 1 extranodal site of disease (ovary).

This patient has now completed standard first-line therapy, and the first critical issue is to restage her as accurately as possible. Complete normalization of the CT scan is unusual, with initial bulky abdominal involvement, even in patients with no residual active lymphoma.[1] Recent results with PET scanning have indicated that this is a very accurate staging procedure -- a normal PET scan after treatment is highly predictive of complete remission (much better than CT scan or gallium scan). The prognosis of this patient, as well as recommendations for further treatment, would differ based on the attainment of a complete vs partial remission after first-line therapy.

The role of radiation therapy added to combination chemotherapy in the first-line treatment of aggressive NHL has long been debated. Certainly, chemotherapy is the most important therapeutic modality in these patients. For early-stage patients (ie, stages I, II), the routine addition of radiation (to include all known sites of initial disease) following short-course chemotherapy has been proven superior to chemotherapy alone.[2] However, for patients with more advanced-stage disease, the addition of radiation therapy to areas of bulky disease, or to multiple areas, has not improved results in most series. Recurrences in these patients are usually systemic and are rarely located to the single site that would be the potential target of radiation therapy.[3]

For this patient, I would base further treatment on the results of restaging. If she has attained a complete remission, I would follow her without further treatment. If she has residual lymphoma (as determined by positive PET scan or biopsy, not by residual CT abnormalities alone), she would be a candidate for further therapy immediately. Given her young age, my preference would be to proceed immediately to high-dose chemotherapy with hematopoietic support.


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