Stefania Croci Radiation Oncology Department University ......ESMO Preceptorship Programme A long...
Transcript of Stefania Croci Radiation Oncology Department University ......ESMO Preceptorship Programme A long...
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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
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ESMO Preceptorship Programme
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.
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ESMO Preceptorship Programme
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.
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ESMO Preceptorship Programme
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)*
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ESMO Preceptorship Programme
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.
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ESMO Preceptorship Programme
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.
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ESMO Preceptorship Programme
But……
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ESMO Preceptorship Programme
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
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ESMO Preceptorship Programme
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
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ESMO Preceptorship Programme
The importance of irradiation volumes in RT
BECAUSE:
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ESMO Preceptorship Programme
Widespread cerebral necrosis
Damage to the white substance
Cortical and sub-cortical atrophy
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ESMO Preceptorship Programme
Neuroconitary deficit
Doses higher than 20 Gy in adults:
Decreased learning ability
Memory deficit at completion
Difficulty in troubleshooting
Progressive dementia
(Alzheimer-like)
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ESMO Preceptorship Programme
Possible reduction damage in RT
Areas to save
Dose to the predictive
hippocampus of cognitive
dificit
Attention to periventricular
sites
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ESMO Preceptorship Programme
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)
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ESMO Preceptorship Programme
TOMOTHERAPY: Linac+TC
More selective irradiation of the tumor
Saving healthy tissues
Higher doses with fewer fractional fractions
(elastic modulus of dose)
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ESMO Preceptorship Programme
Thank you for the attention and
Sorry for my English!!