Radiotherapy for Bulky Disease Added to R-CHOP Improves Outcome in Elderly Patients With Aggressive B-Cell Lymphoma


Key Points

  • In intent-to-treat analysis, adding radiotherapy to R-CHOP was associated with significantly better event-free survival and trends toward improved progression-free survival and overall survival.
  • In a per-protocol analysis excluding patients in the no radiotherapy group who received unplanned radiotherapy, radiotherapy was associated with significant event-free survival, progression-free survival, and overall survival benefits.

In an analysis reported in the Journal of Clinical Oncology, Held et al studied elderly patients with aggressive B-cell non-Hodgkin lymphoma and bulky disease in the most effective treatment arm of the RICOVER-60 trial, which included radiotherapy. The investigators compared outcomes in this group with those in patients with bulky disease from a treatment arm not receiving radiotherapy that was added as a trial amendment. They found that inclusion of radiotherapy for bulky disease was associated with better outcomes.

Study Details

In the RICOVER-60 trial, patients aged 61 to 80 years with previously untreated aggressive B-cell non-Hodgkin lymphoma were randomly assigned to receive six or eight cycles of CHOP-14 (CHOP [cyclophosphamide, doxorubicin, vincristine, and prednisone] administered every 2 weeks) with or without eight administrations of rituximab (Rituxan). Involved-field radiotherapy (36 Gy) was administered to sites of initial bulky disease (≥ 7.5 cm) and extralymphatic involvement. Six cycles of R-CHOP–14 plus two additional applications of rituximab was the most effective of the four treatment arms and was associated with significantly improved event-free survival, progression-free survival, and overall survival vs six cycles of CHOP-14.

The current study compared outcome in 117 (of 306) patients with bulky disease in this group with outcomes in 47 (of 164) patients with bulky disease in a cohort receiving the same immunochemotherapy without radiotherapy in an amendment to the trial (RICOVER-noRTh).

Improved Outcomes With Radiotherapy

After median observation of 39 months, 3-year event-free survival, progression-free survival, and overall survival rates for the group receiving radiotherapy vs the group receiving no radiotherapy were 66% vs 40% (P = .001), 75% vs 61% (P = .060), and 78% vs 63% (P = .080). On multivariate analysis of the intention-to-treat population adjusting for International Prognostic Index risk factors and age, event-free survival was significantly worse without radiotherapy (hazard ratio [HR] = 2.1, P = .005), with trends toward inferior progression-free survival (HR = 1.8, P = .058) and overall survival (HR = 1.6, P = .127).

In a per-protocol analysis excluding 11 patients in the no-radiotherapy cohort who received unplanned radiotherapy, multivariate analysis showed significantly poorer event-free survival (HR = 2.7, P = .011), progression-free survival (HR = 4.4, P = .001), and overall survival (HR = 4.3, P = .002) in the no-radiotherapy cohort.

The investigators concluded,  “Additive [radiotherapy] to bulky sites abrogates bulky disease as a risk factor and improves outcome of elderly patients with aggressive B-cell lymphoma. Whether [radiotherapy] can be spared in patients with (metabolic) complete remission after immunochemotherapy must be addressed in appropriately designed prospective trials.”

Michael Pfreundschuh, MD, of Universitätsklinikum des Saarlandes, Homburg, is the corresponding author for the Journal of Clinical Oncology article.

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