stefania croci radiation oncology department university ......esmo preceptorship programme a long...

ESMO Preceptorship Programme

A long term history of Primary Brain Lymphoma

Stefania Croci

Radiation Oncology Department

University Hospital of Siena, Italy

Preceptorship on Lymphoma, Lugano, November 03-04, 2017


FemaleBorn VI/1953Smoker (20 cigarettes/die)Idiopathic ThrombocytopeniaNo significant medical history

VIII/2013: Neurological deficit (leg stiffness, myoclonus).MRI: temporal lesion (metastasis?).Total Body CT: negative. Markers: negative.


The patient underwent stereotactic biopsy.Histology: Diffuse large B cells cerebral lymphoma (DLBCL).The patient was arruolated in the Phase II Trial IELSG 32 (NCT01011920), and underwent 4 cycles of Methotrexate, cytarabine, rituximab (Induction Arm 2).

MRI: partial response.


Chemo immunotherapy with methotrexate, cytarabine,thiotepa, and rituximab (MATRix regimen) in patients with primary CNS lymphoma: results of the first randomisation of the International Extranodal Lymphoma Study Group-32(IELSG32) phase 2 trial

Andrés J M Ferreri, Kate Cwynarski, Elisa Pulczynski, Maurilio Ponzoni, Martina Deckert, Letterio S Politi, Valter Torri, Christopher P Fox,Paul La Rosée, Elisabeth Schorb, Achille Ambrosetti, Alexander Roth, Claire Hemmaway, Angela Ferrari, Kim M Linton, Roberta Rudà,Mascha Binder, Tobias Pukrop, Monica Balzarotti, Alberto Fabbri, Peter Johnson, Jette Sønderskov Gørløv, Georg Hess, Jens Panse,Francesco Pisani, Alessandra Tucci, Stephan Stilgenbauer, Bernd Hertenstein, Ulrich Keller, Stefan W Krause, Alessandro Levis, Hans J Schmoll,Franco Cavalli, Jürgen Finke, Michele Reni, Emanuele Zucca, Gerald Illerhaus, for the International Extranodal Lymphoma Study Group (IELSG)*


The patient then randomized again for the Consolidation Therapy of the same trial (Phase II Trial IELSG 32, NCT01011920), and underwent Whole Brain Radiation Therapy.DTF: WBRT with 36 Gy in the case of CR to primary chemotherapy or the same WBRT dose followed by a tumor-bed boost of 9 Gy with 1-2 cm of margin surrounding enhanced residual lesion (total tumor-bed dose 45 Gy) in patients who achieved a PR or SD after primary chemotherapy. Photons of 4-10 Mev, 180 cGy per day, 5 weekly fractions.


And the results?

The patient actually is in good performance status. Her neurological exam is normal. She is in follow up, and her MRI are negative.


But……


Acute and chronic toxicity after RT

Acute Toxicity:

< 4-6 weeks after the end of treatment

Sub-acute Toxicity:

Within 6 months of the end of the RT

Chronic Toxicity:

> 6 months after the end of RT


Late Toxicity

After 6 months

Irreversible and progressive histopathic

aspects: vascular alterations, demyelination,

white necrosis substance

Possible cognitive deficits even in the

absence of anatomical damage

Radiotherapy leucoencephalopathy


The importance of irradiation volumes in RT

BECAUSE:


Widespread cerebral necrosis

Damage to the white substance

Cortical and sub-cortical atrophy


Neuroconitary deficit

Doses higher than 20 Gy in adults:

Decreased learning ability

Memory deficit at completion

Difficulty in troubleshooting

Progressive dementia

(Alzheimer-like)


Possible reduction damage in RT

Areas to save

Dose to the predictive

hippocampus of cognitive

dificit

Attention to periventricular

sites


Techniques of RT

IMRT: conformation of the

prescribed dose on the target

volume in three-dimensional

form

The intensity of the dose

complied with complex targets

(es: target volume near

important structures, target

volum of irregular shape)


TOMOTHERAPY: Linac+TC

More selective irradiation of the tumor

Saving healthy tissues

Higher doses with fewer fractional fractions

(elastic modulus of dose)


Thank you for the attention and

Sorry for my English!!

stefania croci radiation oncology department university ......esmo preceptorship programme a long...

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