2019 Modern Radiotherapy for Hematologic Malignancies

Session Content References

New Systemic Therapies in Hodgkin’s Lymphoma (Saturday, February 16, 8:30 a.m. - 9:15 a.m.)

There are several new systemic and novel, targeted therapies that have been FDA approved for the treatment of Hodgkin lymphoma. This includes for patients with relapsed/refractory disease as well as newly diagnosed disease. These novel agents have high disease activity, although there are varied toxicities that need to be noted and managed. In addition, there are a multitude of new systemic therapies being evaluated in the laboratory and clinical trials for the treatment of Hodgkin lymphoma.

This session is directed towards knowledge and competence towards discussion and examination of new systemic therapies in the treatment of Hodgkin’s lymphoma. There is initial discussion of the important biology of Hodgkin’s lymphoma, including cell-cell interactions as well as the tissue microenvironment. We review recently FDA approved systemic agents for the treatment of Hodgkin’s lymphoma and the various disease settings being used and studied (i.e., relapsed/refractory and untreated patients). Additionally, we examine new and novel systemic treatment agents being examined in the laboratory and clinical trials.

Upon completion of this live activity, attendees should be able to do the following:

  • Distinguish the basic biology of Hodgkin lymphoma, including important cell-cell interactions.
  • Recognize the currently FDA approved targeted systemic treatment options and the clinical scenarios they are currently used in for patients with Hodgkin’s lymphoma.
  • Identify new and novel systemic treatment agents being studied in Hodgkin’s lymphoma.

The care of patients with metastatic cancers is a substantial component of care in radiation oncology settings. Palliative care in radiation oncology has often been a neglected area of clinical research. Clinical research is needed – with immediate translation into clinical practice – to improve the care of this of this diverse patient population. This session will address is reviewing recent evidence to guide and improve clinical practice in the care of patients with advanced malignancies.

Session content references:

  1. https://www.ncbi.nlm.nih.gov/pubmed/29222273 
  2. https://www.ncbi.nlm.nih.gov/pubmed/29222312 
  3. https://www.ncbi.nlm.nih.gov/pubmed/27913499

ISRT: Hodgkin's Lymphoma Cases (Saturday, February 16, 9:15 a.m. - 10:00 a.m.)

Involved site radiotherapy is a relatively new concept that is not well understood by community radiation oncologists or academic radiation oncologists who specialize in other areas. Inappropriate target volumes put the patient at risk of potential higher rate of recurrence (if the target isn’t big enough) or higher rate of toxicities if the target is too big. Further education is needed. ISRT guidelines are in the top ten downloaded articles in IJROBP.

In this session, short case vignettes will be presented to the panelists from attendees and the panelists themselves. Each case will provide appropriate imaging and include three representative slices from different locations within the target volume. Each panelist will be asked to provide their contour in advance for the case and all three will be presented along with one that is incorrect. The audience will be given an opportunity to review the slices and decide which one they think is incorrect and then the answer will be revealed. The panelists will provide an explanation for why something is correct or incorrect.

Upon completion of this live activity, attendees should be able to do the following:

  • Discuss the concepts of ISRT for various different lymphoma case scenarios.
  • Apply their knowledge of ISRT and contour appropriate ISRT treatment fields for lymphoma.

Session content references:

  1. Hoppe BS, Hoppe RT. Expert radiation oncologist interpretations of ISRT guidelines in the management of Hodgkin lymphoma. IROBP 2015 May 1;92(2):40-5
  2. Piva et al. Interobserver variability in clinical target volume delineation for primary mediastinal B-cell lymphoma. PRO 2015 Nov-Dec;5(6):383-9

DIBH Mediastinal Lymphoma (Saturday, February 16, 10:30 a.m. - 11:00 a.m.)

Radiotherapy plays a necessary role in the curative management of many patients with lymphoma. The recognized late toxicity associated with the exposure of normal tissues to radiation requires radiation oncologists to be aware of when and how to implement technical innovations (such as moderate deep inspiration breath hold (mDIBH)) to limit normal tissue exposure. Failure to implement these techniques may unnecessarily increase the risk of late toxicity in lymphoma patients.

In this session attendees will learn about the use of Moderate Deep Inspiration Breath Hold (mDIBH) to limit normal tissue exposure among lymphoma patients receiving radiation therapy to the mediastinum. The session will review the rationale for mDIBH, strategies for selecting appropriate patients, different technical methods for implementing mDIBH, and how mDIBH should influence RT planning procedures (e.g., PTV expansion) compared to free-breathing techniques.

Upon completion of this live activity, attendees should be able to do the following:

  • Recognize which patients may benefit from the use of mDIBH.
  • Implement different methods of mDIBH.
  • Explain how mDIBH may influence RT planning (size of target margins, contouring of normal tissues, etc.).
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Session content references:

  1. Edvardsson A, Kügele M, Alkner S, Enmark M, Nilsson J, Kristensen I, Kjellén E, Engelholm S, Ceberg S. Comparative treatment planning study for mediastinal Hodgkin's lymphoma: impact on normal tissue dose using deep inspiration breath hold proton and photon therapy. Acta Oncol. 2018 Oct 3:1-10.
  2. Starke A, Bowden J, Lynn R, Hall K, Hudson K, Rato A, Aldridge E, Robb D, Steele P, Brady J, Mikhaeel NG. Comparison of butterfly volumetric modulated arc therapy to full arc with or without deep inspiration breath hold for the treatment of mediastinal lymphoma. Radiother Oncol. 2018 Sep 20.
  3. Baues C, Marnitz S, Engert A, Baus W, Jablonska K, Fogliata A, Vásquez-Torres A, Scorsetti M, Cozzi L. Proton versus photon deep inspiration breath hold technique in patients with hodgkin lymphoma and mediastinal radiation: A PLANNING COMPARISON OF DEEP INSPIRATION BREATH HOLD INTENSITY MODULATION RADIOTHERAPY AND INTENSITY MODULATED PROTON THERAPY. Radiat Oncol. 2018 Jul 3;13(1):122.
  4. Aristophanous M, Chi PM, Kao J, Williamson R, Tung S, Andraos T, Milgrom SA, Pinnix CC, Dabaja BS. Deep-Inspiration Breath-Hold Intensity Modulated Radiation Therapy to the Mediastinum for Lymphoma Patients: Setup Uncertainties and Margins. Int J Radiat Oncol Biol Phys. 2018 Jan 1;100(1):254-262.
  5. Petersen PM, Aznar MA, Berthelsen AK, Loft A, Schut DA, Maraldo M, Josipovic M, Klausen TL, Andersen FL, Specht L. Prospective phase II trial of image guided radiotherapy in Hodgkin lymphoma: benefit of deep inspiration breath hold. Acta Oncol 2015; 54: 60-6.
  6. Aznar MC, Maraldo MV, Schut DA, Lundeman M, Brodin NP, Vogelius IR, Berthelsen AK, Specht L, Petersen PM. Minimizing late effects for patients with mediastinal Hodgkin lymphoma: deep inspiration breath-hold and/or IMRT? Int J Radiat Oncol Biol Phys 2015; 92: 169-74.

PET/CT Response Based Treatment in Hodgkin’s Lymphoma (Saturday, February 16, 1:30 p.m. - 2:00 p.m.)

PET/CT proved to be a useful prognostic tool in Hodgkin lymphoma with the promise of selecting patients, based on response, for therapy modification using escalation or de-escalation strategies. Many studies using PET/CT response to modify treatment in Hodgkin Lymphoma have been recently completed. Some studies produced similar results but have been interpreted differently (e.g. RAPID and H10). Medical oncologists/hematologists may interpret the studies to support omitting RT. Radiation oncologists need to understand the details of these studies and how to apply the results in making optimal and individualized treatment decisions without risking increased relapse and worse outcome.

This session will review the studies that used response assessment by PET/CT to guide therapy decisions in Hodgkin’s lymphoma (HL) and, in particular, use of radiotherapy. Dr. Mikhaeel will analyze the individual studies and how the results can be applied in clinical practice to make evidence-based decisions. Dr. Mikhaeel will also draw specific conclusions on the role of PET/CT driven treatment in HL.

Upon completion of this live activity, attendees should be able to do the following:

  • Discuss the details of these studies.
  • Apply the results in making optimal and individualized treatment decisions without risking increased relapse and worse outcome.

Session content references

  1. Radford J, Illidge T, Counsell N et al. N Engl J Med 2015; 372:1598-1607. DOI: 10.1056/NEJMoa1408648
  2. Andre M, Girinsky T, Frederico M et al. DOI: 10.1200/JCO.2016.68.6394 Journal of Clinical Oncology 35, no. 16 (June 1 2017) 1786-1794

Who is a Hodgkin’s Lymphoma Expert? (Saturday, February 16, 1:30 p.m. - 2:00 p.m.)

The optimal treatment of Hodgkin's Lymphoma continues to evolve, requiring physicians to stay informed regarding randomized trials and long-term following toxicity data.

In this session, participants will be tested on their understanding of Hodgkin’s lymphoma with explanatory discussion after each question.

Upon completion of this live activity, attendees should be able to do the following:

  • Explain the differences between classical and nodular lymphocyte predominant Hodgkin’s lymphoma (NLPHL).
  • Identify what constitutes formable and unformable Hodgkin’s lymphoma.
  • Discuss the nuances of recent randomized trials.

Late Effects Among Lymphoma Survivors and Follow-up (Saturday, February 16, 3:00 p.m. - 3:45 p.m.)

Through extended follow up we are learning more about late effects from treatment and potential dose response relationships. Modern radiotherapy techniques may allow us to reduce the radiation dose to the different organs at risk and reduce the risk of late side effects. Late side effects might be identified earlier through surveillance programs, so that early intervention can help minimize effect on the survivor. Failure to minimize risk of late toxicity or recognize early signs of them lowers the quality of care by practicing clinicians.

This session will provide an overview of side effects that may develop following management of patients with lymphoma using radiation. We will discuss data on dose volume constraints that can help when assessing radiation treatment plans. Finally, we will discuss strategies for screening survivors for these late effects.

Upon completion of this live activity, attendees should be able to do the following:

  • Discuss the acute, subacute and late effects among lymphoma patients receiving radiotherapy.
  • Utilize knowledge from the session to better analyze radiation treatment plans considering risk of late effects.
  • Implement survivorship strategies for long-term follow up care based on risk of late radiation toxicity.

Session content references:

  1. Tseng et al. Evidence-based Review on the use of proton therapy in lymphoma from the PTCOG lymphoma subcommittee. IJROBP 2017 Nov 15;99(4):825-42.
  2. Ng et al. Current survivorship recommendations for patients with Hodgkin Lymphoma: focus on late effects. Hematology Am Soc Hematol Educ Program 2014 Dec 5;2014(1):488-94.

Case Study: Relapsed/Refractory HL and DLBCL (Saturday, February 16, 3:45 p.m. - 4:30 p.m.)

Limited data are available on the indications and optimal technique for incorporating radiotherapy as part of salvage in relapse/refractory lymphoma. Recent surges in promising systemic salvage options including immunotherapy raises the question on how best to integrate radiotherapy in the salvage program.

In this session, a series of relapsed/refractory Hodgkin’s and non-Hodgkin’s lymphoma cases will be presented to the audience. Radiation treatment in conjunction with salvage systemic therapy will be reviewed, including timing, optimal dose and fractionation, and target volume definition. Novel techniques to limit treatment-related side effects, taking into account potentially overlapping toxicity of salvage systemic therapy, will be shown in the case examples. The audience will also have the opportunity to ask questions and to share their experience.

Upon completion of this live activity, attendees should be able to do the following:

  • Recognize indications for radiation as part of salvage therapy in lymphoma.
  • Identify the key normal tissue dose constraints in the salvage radiotherapy setting.
  • Apply optimal radiation technique and dose and define target volumes in various relapsed or refractory lymphoma case scenarios.

Session content references:

  1. The Role of Radiation Therapy in Patients with Relapsed or Refractory Hodgkin Lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group. IJROBP 100(5): 1100–1118, 2018 
  2. Role of Radiation Therapy in Patients with Relapsed/Refractory Diffuse Large B-Cell Lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group100(3): 652-669, 2018
  3. Combined Radiation Therapy and Checkpoint Inhibition in Lymphoma: A Case Report and Brief Review Contemporary Radiation Oncology - March 2018

How to Convince the Payer to Cover IMRT/Protons (Saturday, February 16, 4:30 p.m. - 5:00 p.m.)

There are a number of great advancements in the field of modern radiation in lymphoma. Unfortunately, many utilize more expensive technology, which can be difficult to get insurance to cover. Physicians may not have access to available information to try and help fight a winning battle to get the treatments approved, resulting in lower quality care for the patients.

This session will provide an overview for expected discussions with insurance companies regarding coverage of modern radiation for treatment of lymphoma. We will discuss typical sequences of denials, appeals, and peer to peer reviews. We will discuss tips for getting providers to cover treatment.

Upon completion of this live activity, attendees should be able to do the following:

  • Discuss strategies for getting insurance approval for modern radiotherapy techniques.

Session content references:

  1. Hoppe RT. Are advanced RT technologies required for treating patients with Hodgkin lymphoma. JNCCN 2016;14:2-3
  2. Tseng et al. Evidence based review on the use of proton therapy in lymphoma from the particle therapy cooperative group (PTCOG) lymphoma subcommittee. IJROBP 2017 Nov 15;99(4):825-842.
  3. Dabaja et al. Proton therapy for adults with mediastinal lymphomas: the ILROG guidelines. Blood 2018 Oct 18;132(16):1635-46

Medical Oncology Review of Diffuse Large B-Cell Lymphoma (Sunday, February 17, 8:00 a.m. - 8:45 a.m.)

Diffuse large B-cell lymphoma represents a very heterogeneous disease both clinically and scientifically. There have been recent breakthroughs over the last several years in the molecular characterization of this cancer. Treatment of DLBCL depends on both the clinical scenario and presentation as well as the pathologic/molecular characteristics. There are also new targeted therapies recently FDA approved for the treatment DLBCL, in particular CAR T-cell. These novel agents have high anti-tumor activity, although there are varied toxicities that need to be noted and managed. In addition, there are a multitude of new systemic therapies being evaluated in the laboratory and clinical trials for the treatment of DLBCL.

This session is directed towards knowledge and competence towards diffuse large B-Cell lymphoma (DLBCL). There is initial discussion of the important biology of DLBCL, including molecular pathogenesis. We will review different clinical presentations of DLBCL and how this impacts varied treatment options. Additionally, we will examine new and novel systemic treatment agents that have been recently examined in clinical trials and new therapies being testing in clinical trials.

Upon completion of this live activity, attendees should be able to do the following:

  • Appraise the biology of DLBCL, including recent molecular classifications.
  • Articulate the treatment variability of DLBCL, which depends on clinical presentation as well as pathologic characterization.
  • Assess the efficacy and toxicities of CAR T-cell therapy.

Session content references:

  1. https://www.ncbi.nlm.nih.gov/pubmed/29666115 
  2. https://www.ncbi.nlm.nih.gov/pubmed/29222268 
  3. https://www.ncbi.nlm.nih.gov/pubmed/29914976 

Case Study: Primary Mediastinal B-Cell Lymphoma (Sunday, February 17, 8:45 a.m. - 9:30 a.m.)

Primary mediastinal large B-cell lymphoma (PMBCL) is a rare subtype of Non-Hodgkin's Lymphoma without large randomized studies to guide treatment decisions. Therefore, clinicians are required to understand the natural history of the disease and nuances of published studies.

In this session, a representative case will be presented. A discussion on how to make the diagnosis and initial treatment strategies will follow.

Upon completion of this live activity, attendees should be able to do the following:

  • Distinguish diffuse large B-Cell lymphoma (DLBCL) from primary mediastinal large B-cell lymphoma (PMBCL).
  • Discuss the nuances of the NCI prospective study.
  • Determine how to best manage PMBLL.

Case Study: DLBCL (Sunday, February 17, 10:00 a.m. - 10:45 a.m.)

There are many ongoing advances in the management of diffuse large b-cell lymphoma (DLBCL) in the context of radiation therapy delivery, clinical research on treatment options, and advanced techniques in radiotherapy delivery. Failure to stay informed leads to lower quality of care by practicing clinicians.

In this session, we will review the role of ISRT and the data that helps guide therapy decisions in DLBCL and in particular use of consolidation ISRT. We will analyze the individual studies and how the results can be applied in clinical practice to make evidence-based decisions.

Upon completion of this live activity, attendees should be able to do the following:

  • Discuss the details of these studies.
  • Apply the results in making optimal and individualized treatment decisions without risking increased relapse and worse outcome.

Who is an Expert in Miscellaneous Hematologic Malignancies? (Sunday, February 17, 2:15 p.m. - 3:00 p.m.)

In recent years, we have found that for many of the orphan lymphoma subtypes (which, in the past, were not considered for radiation), radiation is useful and can improve local control, disease-free survival and overall survival. Most of these studies shows that a lower radiation dose is needed. Radiation oncologists need to learn about new indications for radiation therapy.

This session will engage the audience to participate in a series of case-based, hematologic malignancy radiation management-related questions. Key concepts on the role of radiotherapy and its optimal delivery in a wide range of hematologic malignancies including lymphomas, myeloma, leukemia and other hematological conditions will be covered in this interactive question/answer game format.

Upon completion of this live activity, attendees should be able to do the following:

  • Recognize indications for radiation in the management of hematologic malignancies.
  • Apply optimal radiation technique and dose, and define target volumes in various hematologic malignancy case scenarios.
  • Identify the treatment outcome, anticipate the potential treatment-related toxicity and apply toxicity management.

Session content references:

  1. Dabaja et al;  Int J Radiat Oncol Biol Phys. 2018 Nov 1;102(3):508-514.
  2. Dabaja et al; Ann Oncol. 2017 Sep 1;28(9):2185-2190

ISRT: Plasmacytoma, Skin, NKT (Sunday, February 17, 3:15 p.m. - 4:00 p.m.)

Skin lymphomas are relatively rare, so most physicians have little experience treating them.

In this session, we will briefly review the recommended management, focusing on RT for cutaneous lymphomas.

Upon completion of this live activity, attendees should be able to do the following:

  • Utilize optional treatment fields for low grade B-cell lymphomas of skin.
  • Explain the differences between Lymphomatoid Papulosis (LyP) and Primary Cutaneous Anaplastic Large Cell Lymphoma (pcALCL).
  • Discuss total skin irradiation for mycosis fungoides.

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