A long term history of Primary Brain Lymphoma

Transcription

1 Preceptorship on Lymphoma, Lugano, November 03-04, 2017 Stefania Croci Radiation Oncology Department University Hospital of Siena, Italy A long term history of Primary Brain Lymphoma

2 Female Born VI/1953 Smoker (20 cigarettes/die) Idiopathic Thrombocytopenia No significant medical history VIII/2013: Neurological deficit (leg stiffness, myoclonus). MRI: temporal lesion (metastasis?). Total Body CT: negative. Markers: negative.

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

4 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)*

5 The patient then randomized again for the Consolidation Therapy of the same trial (Phase II Trial IELSG 32, NCT ), 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. ESMO Preceptorship Programme

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

7 But

8 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

9 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

10 The importance of irradiation volumes in RT BECAUSE:

11 Widespread cerebral necrosis Damage to the white substance Cortical and sub-cortical atrophy

12 Neuroconitary deficit Doses higher than 20 Gy in adults: Decreased learning ability Memory deficit at completion Difficulty in troubleshooting Progressive dementia (Alzheimer-like)

13 Possible reduction damage in RT Areas to save Dose to the predictive hippocampus of cognitive dificit Attention to periventricular sites

14 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)

15 TOMOTHERAPY: Linac+TC More selective irradiation of the tumor Saving healthy tissues Higher doses with fewer fractional fractions (elastic modulus of dose)

16 Thank you for the attention and Sorry for my English!!