Radiotherapy for solitary extramedullary plasmacytoma in the head-and-neck region: A dose greater than 45 Gy to the target volume improves the local control
01 Oct 2005-International Journal of Radiation Oncology Biology Physics (Elsevier)-Vol. 64, Iss: 4, pp 1013-1017
TL;DR: Local control of EMP in the HN seems to be improved when the dose to the CTV is > or = [DOSAGE ERROR CORRECTED] 45 Gy, and a minimum dose of 45 Gy should be recommended to theCTV.
Abstract: Purpose: Our aim was to determine the dose to the clinical target volume (CTV) required for solitary extramedullary plasmacytoma (EMP) in the head and neck (HN). Methods and Materials: Seventeen patients (15 Stage I and 2 Stage II) were treated for HN EMP at our institution between 1979 and 2003. The mean International Commission on Radiation Units (ICRU) dose prescribed to the CTV was 52.6 Gy (range, 40–65 Gy) over 24 fractions (range: 20–30). The Stage II patients received neck irradiation doses of 40 and 60 Gy. A mean dose of 36.4 Gy was used for 5 Stage I patients who received elective neck irradiation. Dose administrated to the CTV was evaluated from dosimetric data or from planning films when dosimetric data were not available. Two groups of patients were distinguished: CTV covered with a dose greater than 40 Gy and CTV covered with a dose greater than 45 Gy. Results: The 5-year local control was 72.8%. It was 100% for patients who received dose to the CTV ≤ 45 Gy vs. 50% for dose to the CTV p = 0.034). The prognostic factor for 5-year disease-specific survival (81.6%) was local control ( p = 0.058). The prognostic factors for disease-free survival (64.1%) were monoclonal immunoglobulin secretion ( p = 0.008) and a CTV dose ≤ 45 Gy ( p = 0.056) Conclusions: Local control of EMP in the HN seems to be improved when the dose to the CTV is ≤ 45 Gy. A minimum dose of 45 Gy should be recommended to the CTV.
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TL;DR: By only RT application, long-term disease-free survival (DFS) is possible for approximately 30% of patients with SBP and 65% of customers with EMP, and the choice of treatment is radiotherapy that is applied with curative intent at min. 4000 cGy.
Abstract: Solitary plasmacytoma (SP) is characterized by a mass of neoplastic monoclonal plasma cells in either bone (SBP) or soft tissue without evidence of systemic disease attributing to myeloma. Biopsy confirmation of a monoclonal plasma cell infiltration from a single site is required for diagnosis. The common presentation of SBP is in the axial skeleton, whereas the extramedullary plasmacytoma (EMP) is usually seen in the head and neck. The ratio of SP seen at males to females is 2 : 1 and the median age of patients is 55 years. The incidence rate of SP in black race is approximately 30% higher than the white race. Incidence rate increases exponentially by advancing age. SBP has a significant higher risk for progression to myeloma, and the choice of treatment is radiotherapy (RT) that is applied with curative intent at min. 4000 cGy. By only RT application, long-term disease-free survival (DFS) is possible for approximately 30% of patients with SBP and 65% of patients with EMP.
170 citations
Cites background from "Radiotherapy for solitary extramedu..."
...Even though the optimal dose of RT has not yet been established for SBP, it is recommended that a radiation dose of at least 40 Gy in four weeks is necessary to obtain local control [23, 31, 42]....
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Mayo Clinic1, University of Wisconsin-Madison2, Northwestern University3, University of Texas Southwestern Medical Center4, University of Nebraska Medical Center5, University of Michigan6, Harvard University7, University of Tennessee Health Science Center8, University of California, San Diego9, Ohio State University10, Case Western Reserve University11, University of Pennsylvania12, University of Alabama at Birmingham13, Roswell Park Cancer Institute14, Seattle Cancer Care Alliance15, City of Hope National Medical Center16, Johns Hopkins University17, Duke University18, Memorial Sloan Kettering Cancer Center19, University of California, Los Angeles20, Stanford University21, University of California, San Francisco22, University of South Florida23, University of Utah24, Washington University in St. Louis25, University of Texas MD Anderson Cancer Center26, National Comprehensive Cancer Network27
TL;DR: This manuscript discusses the management of patients with solitary plasmacytoma, smoldering multiple Myeloma, and newly diagnosed multiple myeloma.
Abstract: Multiple myeloma is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. This manuscript discusses the management of patients with solitary plasmacytoma, smoldering multiple myeloma, and newly diagnosed multiple myeloma.
159 citations
TL;DR: The objective was to review the experience with treating patients with head and neck solitary extramedullary plasmacytomas.
Abstract: Background. Head and neck solitary extramedul- lary plasmacytomas are rare plasma cell neoplasms. Literature review reveals only small numbers of reports. The objective was to review our experience with treating patients with this neo- plasm. Methods. A retrospective chart review between 1960 and 2000 was performed. Sixty-eight patients with head and neck extramedullary plasmacytomas were included. Results. The sinonasal tract was the most common site. Thirty-nine patients were treated with radiation, 8 with surgery, 14 with surgery and radiation, and 3 with chemoradiation. Me- dian follow-up was 8 years. The 5-year local recurrence-free rate (LRFR) was 81%. There was a trend toward improved LRFR in patients treated primarily with radiation. Regional recurrence at 5 years was 5%. Multiple myeloma developed in 23% of patients. The 5-year survival was 76%. Conclusions. Radiation is the treatment of choice with sur- gery reserved for large tumors and extensive bone destruction. Long-term follow-up is essential because local recurrence and disseminated disease can occur many years postdiagnosis. V C 2008 Wiley Periodicals, Inc. Head Neck 30: 1012-1019, 2008
116 citations
TL;DR: This guideline reviews the diagnostic work-up, principles, and indications for RT, target volume definition, treatment planning, and follow-up procedures for solitary plasmacytoma, and presents a standardized approach to the use and implementation of definitive RT in solitaryPlasma cell neoplasms.
Abstract: Purpose To develop guidelines for the work-up and radiation therapy (RT) management of patients with plasma cell neoplasms. Methods and Materials A literature review was conducted covering staging, work-up, and RT management of plasma cell neoplasms. Guidelines were developed through consensus by an international panel of radiation oncologists with expertise in these diseases, from the International Lymphoma Radiation Oncology Group. RT volume definitions are based on the International Commission on Radiation Units and Measurements. Results Plasma cell neoplasms account for approximately one-fifth of mature B-cell neoplasms in the United States. The majority (∼95%) are diagnosed as multiple myeloma, in which there has been tremendous progress in systemic therapy approaches with novel drugs over the last 2 decades, resulting in improvements in disease control and survival. In contrast, a small proportion of patients with plasma cell neoplasms present with a localized plasmacytoma in the bone, or in extramedullary (extraosseous) soft tissues, and definitive RT is the standard treatment. RT provides long-term local control in the solitary bone plasmacytomas and is potentially curative in the extramedullary cases. This guideline reviews the diagnostic work-up, principles, and indications for RT, target volume definition, treatment planning, and follow-up procedures for solitary plasmacytoma. Specifically, detailed recommendations for RT volumes and dose/fractionation are provided, illustrated with specific case scenarios. The role of palliative RT in multiple myeloma is also discussed. Conclusions The International Lymphoma Radiation Oncology Group presents a standardized approach to the use and implementation of definitive RT in solitary plasmacytomas. The modern principles outlining the supportive role of palliative RT in multiple myeloma in an era of novel systemic therapies are also discussed.
112 citations
TL;DR: The objective of this study was to review the outcome of patients with solitary plasmacytoma (SP) after definitive radiation therapy.
Abstract: BACKGROUND: The objective of this study was to review the outcome of patients with solitary plasmacytoma (SP) after definitive radiation therapy.
METHODS: The authors retrospectively reviewed 84 patients with SP who were diagnosed and treated at The University of Texas MD Anderson Cancer Center during 1988 to 2008. The impact of tumor anatomic site, tumor size, and the presence of serum and urinary paraprotein at diagnosis was assessed on local control, survival, and the risk of developing multiple myeloma (MM).
RESULTS: Fifty-nine patients (70%) had bone SP, and 25 patients (30%) had extramedullary SP. Serum paraprotein was present in 39 patients (46%). The median radiation dose was 45 grays (Gy) (range, 36-53.4 Gy). Local control was achieved in 77 patients (92%). Neither radiation dose nor tumor size predicted local control. The 5-year rate of progression to MM was 47% and was higher for patients with bone SP (56% vs 30% for extramedullary SP; P =.021), and patients who had serum paraprotein detected at diagnosis (60% vs 39%; P =.016). On univariate analysis, patients aged <60 years and men had higher rates of progression to MM, although the differences were not significant (P =.048 and P =.29, respectively). Multivariate analysis revealed that bone location and serum protein at diagnosis were associated statistically with progression to MM. The 5-year overall survival rate for the entire patient cohort was 78%, and no difference was observed between patients who had bone SP versus extramedullary SP (76% vs 85%, respectively; P =.274).
CONCLUSIONS: The current results indicated that definitive radiation therapy for SP can provide excellent local control. Progression to MM remains the main problem and is more common among patients with bone SP and those who have serum paraprotein detected at diagnosis.
94 citations
Cites result from "Radiotherapy for solitary extramedu..."
...This finding is in contrast to the study by Mill and Griffith, who reported better local control rates among patients who received >50 Gy,17 and the findings of Tournier-Rangeard et al, who reported that doses 45 Gy improved local control among patients with extramedullary SP.18 Similarly, Mendenhall and colleagues reported that radiation doses 40 Gy resulted in a local control rate of 94% compared with 69% in patients who received 40 Gy.19 In our series, only 2 patients received 40 Gy (39.6 Gy and 36 Gy), so we could not assess local control for doses 40 Gy....
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...This finding is in contrast to the study by Mill and Griffith, who reported better local control rates among patients who received >50 Gy,(17) and the findings of Tournier-Rangeard et al, who reported that doses 45 Gy improved local control among patients with extramedullary SP.(18) Similarly, Mendenhall and colleagues reported that radiation doses 40 Gy resulted in a local control rate of 94% compared with 69% in patients who received <40 Gy....
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...%) had extramedullary SP. Serum paraprotein was present in 39 patients (46%)....
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...%) had extramedullary SP....
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...Our institutional experience has been that MRI of the spine can detect occult disease in patients with SP.27 The current series covered the years from 1988 through 2008, and MRI of the spine was not performed uniformly in all patients during that period....
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References
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TL;DR: The principles and practice of radiation oncology are studied in detail in a systematic manner in the context of cancer diagnosis and treatment.
Abstract: Principles and practice of radiation oncology , Principles and practice of radiation oncology , کتابخانه دیجیتال جندی شاپور اهواز
2,011 citations
TL;DR: Evaluated all EMP cases published in the medical literature until now and included their own experience to obtain detailed data about the occurrence of this disease.
Abstract: Background Extramedullary plasmacytoma (EMP) is a rare entity belonging to the category of non-Hodgkin lymphoma. EMPs make up 4% of all plasma cell tumors and occur mainly in the upper aerodigestive tract (UAD). Seven patients with EMP included in this evaluation were under the authors' care and have been clinically followed since 1990. Because there are no general guidelines for the treatment of patients with EMP, the authors tried to obtain detailed data about the occurrence of this disease and also reviewed the therapies that have been used. To do so, they evaluated all EMP cases published in the medical literature until now and included their own experience. Methods Based on the clinical course and follow-up of their own EMP patients, the authors evaluated and reinvestigated all EMP cases cited in MEDLINE, Index Medicus, DIMDI (Deutsches Institut fur medizinische Dokumentation und Information, Cologne, Germany), and the reference lists of the publications found through these sources. Results In a detailed literature search, more than 400 publications between 1905 and 1997 were found, and these revealed that EMP mainly occurs between the fourth and seventh decades of life. Seven hundred fourteen cases (82.2%) were found in the UAD, and 155 cases (17.8%) were found in other body regions. The following therapeutic strategies were used to treat patients with EMP of the UAD: radiation therapy alone in 44.3%, combined therapy (surgery and radiation) in 26.9%, and surgery alone in 21.9%. The median overall survival or recurrence free survival was longer than 300 months for patients who underwent combined intervention (surgery and radiation). This result was statistically highly significant (P = 0.0027, log rank test) compared with the results for patients who underwent surgical intervention alone (median survival time, 156 months) or radiation therapy alone (median survival time, 144 months). In most cases of non-UAD EMP, surgery was performed (surgery alone, 55.6%; surgery and radiation combined, 19.8%; radiation alone, 11.1%), but there were no statistical differences in survival (P = 0.62). Overall, after treatment for EMP in the UAD, 61.1% of all patients had no recurrence or conversion to systemic involvement (i.e., multiple myeloma, MM); however, 22.0% had recurrence of EMP, and 16.1% had conversion to MM. After treatment for EMP in non-UAD areas, 64.7% of all patients had no recurrence or MM, 21.2% had recurrence, and 14.1% had conversion to MM. Conclusions The current investigation provides evidence that surgery alone gives the best results in cases of EMP of the UAD when resectability is good. However, if complete surgical tumor resection is doubtful or impossible and/or if lymph node areas are affected, then combined therapy (surgery and radiation) is recommended. These results, which were obtained from retrospective studies, should be confirmed in randomized trials comparing surgery with combined radiation therapy and surgery.
514 citations
TL;DR: Radiation therapy achieved excellent locoregional control of EMP with an approximate cure fraction of 50% and local control was achieved in 21 of 22 patients, and disease never recurred in regional nodes.
240 citations
TL;DR: A detailed analysis of the time-dose relationship required for local control is presented, based on a study of patients and a review of the literature, on patients presenting with a solitary plasmacytoma at the University of Florida.
Abstract: Between 1962 and 1978, 15 patients presenting with a solitary plasmacytoma were treated with curative intent by radiotherapy alone at the University of Florida. Criteria for admission to this study were: 1) a biopsy-proven, apparently solitary focus of plasmacytoma; 2) bone marrow biopsy showing less than 10% plasma cells; and 3) no evidence of disseminated disease. In 9 patients the primary site was osseous and in 6 patients extramedullary; 5 of the 6 extramedullary lesions were located in the upper respiratory passages. Two of the 6 extramedullary plasmacytomas progressed to multiple myeloma at 2 and 7 months. The remaining 4 patients have been disease free for periods ranging from 2 2 3 years to over 16 years. Of the 9 patients with osseous lesions, 3 developed multiple myeloma in 3–23 months and one developed a solitary second bone lesion at 9 years. One patient with a large sacral lesion developed a local recurrence following an initial radiation dose of 3000 rad. The recurrence was re-treated with radiation, and local control was obtained. No other local failures occurred. This study presents a detailed analysis of the time-dose relationship required for local control, based on a study of our own patients and a review of the literature.
232 citations
TL;DR: The clinical and pathological features and response to treatment are presented, and consideration of adjuvant chemotherapy in patients with higher grade disease is recommended.
Abstract: Extramedullary plasmacytomas (EMP) of head and neck are rare tumours. Between 1972 and 1993, 25 cases of EMP of head and neck were seen at our institute. The clinical and pathological features and response to treatment are presented. At initial presentation, 23 (92%) patients presented with disease confined to a single extramedullary site only and two patients had in addition clinical involvement of cervical lymph nodes. All except these two patients received radiotherapy to the primary site only as initial treatment. Initial primary control of local disease was obtained in 16 of 24 (67%) patients treated with radical intent. With salvage treatment of further radiotherapy and/or chemotherapy, local disease control was achieved in 21 of 24 (88%) patients. One patient was treated with palliative intent. Conversion to multiple myeloma was seen in two patients (8%). Pathologically, the tumours were classified into low, intermediate and high grade, which correlated closely with outcome. This classification has been used for the first time in extramedullary plasmacytomas and is based on the multiple myeloma grading criteria devised by Bartl et al (1987). Fifteen of eighteen (83%) low-grade tumours and only one of six (17%) intermediate- and high-grade tumours were locally controlled after primary radiotherapy. This is statistically significant for local control (P= 0.0019) but not for overall survival (P= 0.12). The median survival and 5-year overall survival is 68 months and 58.9% respectively. We recommend consideration of adjuvant chemotherapy in patients with higher grade disease.
190 citations