Cahan 2015

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Volume 93  Number 2  2015 Comments 471

3. Dignam JJ, Kocherginsky MN. Choice and interpretation of statistical


tests used when competing risks are present. J Clin Oncol 2008;26:4027-
4034.
4. King AD, Tse GM, Ahuja AT, et al. Necrosis in metastatic neck nodes:
Diagnostic accuracy of CT, MR imaging, and US. Radiology 2004;
230:720-726.
5. Lee KC, Lee SH, Lee Y, et al. Prospective pilot study of consolidation
chemotherapy with docetaxel and cisplatin after concurrent
chemoradiotherapy for advanced head and neck cancer. Int J Radiat
Oncol Biol Phys 2008;71:187-191.

Modern Radiation Therapy for Extranodal


Lymphomas: Field and Dose Guidelines From
the International Lymphoma Radiation
Oncology Group
Fig. 1. Whole-brain radiation therapy field for con-
In Regard to Yahalom et al solidative primary central nervous system lymphoma ther-
apy. Field includes the optic nerves (orange) and retinas
To the Editor: We read with great interest the International (green) while blocking the lenses (magenta) with anteriorly
Lymphoma Radiation Oncology Group’s recent field and placed isocenter. A color version of this figure is available
dose guidelines for extranodal lymphoma (1). We appre- at www.redjournal.org.
ciate this comprehensive review of an important and under-
studied disease. results should give us pause, particularly after a CR to in-
We were particularly interested in the guidelines for duction therapy. Observation alone with WBRT reserved
primary central nervous system lymphoma (PCNSL). As for salvage therapy should also be considered as part of the
the authors rightly noted, neurotoxicity can be a significant treatment algorithm. This may be especially relevant in
burden on patients who received whole-brain radiation elderly patients who are at greatest risk of significant
therapy (WBRT) for PCNSL (2-5). The concern over neurotoxicity after WBRT.
WBRT-induced neurotoxicity has led to efforts to reduce Finally, we agree with the text of the article that recom-
the dose of radiation therapy, especially after complete or mends radiation fields to include the posterior orbit because
partial response to induction chemotherapy or immu- of risk of disease in the retina and optic nerve. Figure 1,
nochemotherapy modeled after dose reduction strategies in panels C and D of the article by Yahalom et al (1) demonstrate
nodal Hodgkin’s and non-Hodgkin’s lymphoma (6-8). We a WBRT field for a patient with PCNSL. However, this image
agree with the recommendations of the article, that dose does not seem to include these structures. Figure 1 above
reduction remains an appealing option for patients with demonstrates a lateral radiation field which includes the
response to induction chemotherapy. posterior orbit. The bilateral retinas and optic nerves are
It must be noted that the reported studies use data from included, whereas the lenses are blocked.
either a small, single-institution, single-armed study or
from retrospective reviews. The German PCNSL Study
Benjamin Cahan, MD
Group, however, randomized 410 patients who completed
Yi-Jen Chen, MD, PhD
induction high-dose methotrextate to receive consolidative Department of Radiation Oncology
WBRT (dose of 45 Gy in 1.5-Gy fractions) or observation City of Hope
(9). Whole-brain RT improved progression-free survival National Medical Center
(PFS; 15.4 vs 9.9 months, PZ.034). However, there was no Duarte, California
improvement in overall survival (OS; 32.4 vs 36.1 months,
PZ.98). For the primary endpoint of noninferiority of OS, http://dx.doi.org/10.1016/j.ijrobp.2015.06.007
this study did not reach statistical significance. Subgroup
analysis demonstrated no significant benefit in terms of PFS
or OS in patients with a complete response (CR) to in-
duction methotrexate. Patients without CR did have a sig- References
nificant improvement in PFS (hazard ratio 0.6, PZ.002),
without significant improvement in OS. 1. Yahalom J, Illidge T, Specht L, et al. Modern radiation therapy for
We believe these randomized results should inform de- extranodal lymphomas: Field and dose guidelines from the Interna-
cision making when approaching a patient with PCNSL. As tional Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol
Phys 2015;92:11-31.
the authors note, consolidative, dose-reduced WBRT 2. Omuro AM, Ben-Porat LS, Panageas KS, et al. Delayed neurotoxicity
(23.4-24 Gy after CR, 36-45 Gy after partial response) may in primary central nervous system lymphoma. Arch Neurol 2005;62:
play a role in PCNSL. The German PCNSL Study Group 1595-1600.
472 Comments International Journal of Radiation Oncology  Biology  Physics

3. Shah GD, DeAngelis LM. Treatment of primary central nervous upfront chemotherapy. Int J Radiat Oncol Biol Phys 2011;80:
system lymphoma. Hematol Oncol Clin North Am 2005;19. 611-27, v. 169-175.
4. DeAngelis LM, Seiferheld W, Schold SC, et al. Combination 7. Reni M, Ferreri AJ, Guha-Thakurta N, et al. Clinical relevance of
chemotherapy and radiotherapy for primary central nervous system consolidation radiotherapy and other main therapeutic issues in
lymphoma: Radiation Therapy Oncology Group Study 93-10. J Clin primary central nervous system lymphomas treated with upfront
Oncol 2002;20:4643-4648. high-dose methotrexate. Int J Radiat Oncol Biol Phys 2001;51:
5. Gavrilovic IT, Hormigo A, Yahalom J, et al. Long-term follow-up of 419-425.
high-dose methotrexate-based therapy with and without whole brain 8. Shah GD, Yahalom J, Correa DD, et al. Combined immunochemo-
irradiation for newly diagnosed primary CNS lymphoma. J Clin Oncol therapy with reduced whole-brain radiotherapy for newly diagnosed
2006;24:4570-4574. primary CNS lymphoma. J Clin Oncol 2007;25:4730-4735.
6. Ferreri AJ, Verona C, Politi LS, et al. Consolidation radiotherapy in 9. Korfel A, Thiel E, Martus P, et al. Randomized phase III study of
primary central nervous system lymphomas: Impact on outcome of whole-brain radiotherapy for primary CNS lymphoma. Neurology
different fields and doses in patients in complete remission after 2015;84:1242-1248.

ERRATUM

Erratum to: Jabbari S, Fitzmaurice T, Munoz F, et al. Cross-Border Collaboration


in Oncology: A Model for United StatesdMexico Border Health. Int J Radiat
Oncol Biol Phys 2015;92:509-511.

In the article referenced above, the affiliation for authors Fatima Munoz, MD, MPH, and Connie Lafuente, BA, should have
appeared as follows:
U.S.-Mexico Border Health Commission
The authors regret the error.

http://dx.doi.org/10.1016/j.ijrobp.2015.06.030

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