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Radiation Oncology |
1 Departments of Radiation Oncology (Y.K.O., C.S.H., J.D.C.)
2 Diagnostic Radiology (B.I.S.)
3 Hematology (F.C., M.A.H.), University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030.
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: A total of 328 patients with previously untreated stage I, II, or III follicular lymphoma were treated between 1978 and 1994. Two hundred fifty-seven patients achieved complete response; 78 who relapsed form the basis of this study. Fifteen patients had stage I; 28, stage II; and 35, stage III disease. Fifteen patients underwent radiation therapy; 12, chemotherapy; and 51, radiation and chemotherapy. Medical records were reviewed to analyze the yield of abdominal and pelvic CT in detecting recurrence relative to the yield of standard clinical, hematologic, and imaging studies. A positive study was defined as one that led to or was abnormal at the diagnosis of recurrence.
RESULTS: The median follow-up was 101 months. Eleven relapses were detected only at abdominal, pelvic, or both abdominal and pelvic CT.
CONCLUSION: Fourteen percent (11 of 78) of the relapses were detected solely at abdominal and/or pelvic CT. Eleven (4.3%) of the 257 patients who achieved complete response benefited from abdominal and pelvic CT. The yield of the routine use of abdominal and pelvic CT in follow-up studies appears to be low for stages I–III follicular lymphoma.
Index terms: Lymphography, 99.125 • Lymphoma, 99.30, 99.8, 99.83 • Lymphoma, CT, 99.1291 • Lymphoma, diagnosis, 70.11, 80.11, 99.125, 99.1261, 99.1262, 99.1291
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Treatment
The initial treatments for these 78 patients at the time of the diagnosis were combined modality with chemotherapy and radiation therapy in 51 patients, radiation therapy alone in 15, and chemotherapy alone in 12. Two of the 12 patients treated with chemotherapy alone were treated with single-agent chemotherapy. Radiation therapy consisted of involved fields for every patient, except for one who was treated with central lymphatic irradiation (11). The doses were 30–40 Gy at 1.5–2 Gy per fraction. Doxorubicin-containing regimens were used in 51 patients. The number of cycles of the chemotherapy ranged from one to 16, with a median of nine.
Follow-up
The routine follow-up after complete response included history, physical examination, complete blood count, serum chemistry, chest radiography, KUB-LAG (plain radiography of the abdomen and pelvis to visualize the residual lymphographic dye), and CT of the abdomen and pelvis. Some patients underwent either abdominal or pelvic CT, but not both, at follow-up visits. The typical follow-up interval was 3–6 months for the first 5 years and yearly thereafter. A positive study was defined as one that led to the diagnosis of recurrence or was abnormal at the time of the diagnosis of recurrence. We counted the total numbers of each test done between complete response and relapse and calculated the probability of relapse detection by using each test.
Data Analysis
Survival rates were calculated by using the Kaplan-Meier method (14). The overall survival was measured from the first date of initial therapy to the time of death of any cause. The relapse-free survival was measured from the first date of initial therapy to the time of relapse.
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Survival Data
The median follow-up for the patients who were alive at the time of analysis, among the 257 patients who achieved complete response, was 80 months (range, 13–209 months). The actuarial overall survival rates at 5, 10, and 15 years were 88%, 71%, and 51%, respectively (Fig 1). The actuarial relapse-free survival rates at 5, 10, and 15 years were 74%, 62%, and 53%, respectively (Fig 1). The median follow-up for the 41 survivors with relapse was 101 months (range, 16–209 months).
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Positive Studies at Relapse
Relapses were detected with history and physical examination in 55 patients (71%), with complete blood count in one (1%), with serum chemistry in five (6%), with chest radiography in six (8%), with KUB-LAG examinations in 13 (17%), with abdominal CT in 29 (37%), with pelvic CT in 19 (24%), and with bone marrow biopsy and/or aspiration in 12 (15%). The relapses were detected by using more than one method in some patients.
Probabilities of Relapse Detection
The probabilities of relapse detection by each method during routine follow-up were as follows: history and physical examination, 55 (10%) of 568 tests; complete blood count, one (0.2%) of 534; serum chemistry, five (1%) of 517; chest radiography, six (1%) of 488; KUB-LAG examination, 13 (7%) of 190; abdominal CT, 29 (11%) of 259; pelvic CT, 19 (8%) of 242; and bone marrow biopsy and/or aspiration, 12 (13%) of 91.
Relapses Detected at Abdominal or Pelvic CT Alone
Twenty-nine patients had abnormal findings on the abdominal CT scans. Of these 29 patients, nine patients had relapses detected by using abdominal CT with normal findings of history and physical examination, complete blood count, serum chemistry, chest radiography, and KUB-LAG (when performed). Nineteen patients had abnormal findings on their pelvic CT scans. Of these, four patients had relapses detected by using pelvic CT with normal findings of history and physical examination, complete blood count, serum chemistry, chest radiography, and KUB-LAG (when performed). In two patients, both abdominal and pelvic CT scans were abnormal. Therefore, 11 additional relapses of a total of 78 relapses were detected with abdominal and/or pelvic CT scans during the 16-year study. Of interest, four additional patients had positive KUB-LAG findings, as well as positive CT findings of the abdomen and/or pelvis with normal findings of history and physical examination, complete blood count, serum chemistry, and chest radiography. If lymphangiography had not been performed at all, 15 recurrences would have been detected at CT of the abdomen and/or pelvis. If CT of the abdomen and/or pelvis had not been performed at all, five recurrences would have been detected only at KUB-LAG. However, a caution should be exercised in interpreting the efficiency of KUB-LAG since its usefulness is limited to the first 1 or 2 years, as mentioned earlier.
Of note, the recurrences detected solely at CT of the abdomen and/or pelvis commonly involved paraaortic nodes (six patients), inguinal nodes (four patients), or iliac nodes (two patients). Liver, mesentery, or spleen was the only site of failure detected solely at CT of the abdomen and/or pelvis in three patients.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In our analysis, the probabilities of relapse detection by each method during follow-up were 55 of 568 examinations for history and physical examination, one of 534 examinations for complete blood count, five of 517 examinations for serum chemistry, six of 488 examinations for chest radiography, 13 of 190 examinations for KUB-LAG, 29 of 259 examinations for abdominal CT, 19 of 242 examinations for pelvic CT, and 12 of 91 examinations for bone marrow biopsy and/or aspiration. After we excluded the relapses that were also detected with other follow-up methods besides bone marrow biopsy and/or aspiration, 11 additional relapses of a total 78 relapses were detected by performing 541 follow-up abdominal and pelvic CT examinations.
Test selection biases need to be kept in mind, given the retrospective nature of this study. It is possible that CT has been ordered more frequently for the patients suspected to have recurrence, and bone marrow biopsy and/or aspiration was usually performed for patients with a high index of suspicion for recurrence. However, we do not believe the effect of these biases, especially with CT, was substantial, given the much larger pool of 257 patients and the fact that most of the tests were scheduled routinely before the clinic visits for history and physical examination. The above probabilities were calculated only for the patients with relapse. The overall yield of each test in detecting the relapses would be much lower if the patients who never relapsed were to be included.
It should be kept in mind that the effectiveness of any follow-up strategy also depends on the pattern of the failure, including the sites and timing of failure. The pattern of failure in turn may depend on multiple factors, such as histology, sites of presentation, prognostic factors, and treatments. These issues are being addressed as part of on-going projects at our institution. However, the ultimate effect of the different follow-up strategies on patients' overall survival will need to be addressed in prospective randomized studies.
In conclusion, 14% (11 of 78) of the relapses were detected solely with CT of the abdomen and/or pelvis. Eleven (4.3%) of the 257 patients who achieved complete response benefitted from CT of the abdomen and pelvis for recurrence detection. If LAG had not been performed at all, 19% (15 of 78) of the relapses would have been detected solely at CT of the abdomen and/or pelvis. This would imply that 5.8% (15 of 257) instead of 4.3% of the patients who achieved complete response would have benefitted from CT of the abdomen and pelvis. The yield of the routine use of CT of the abdomen and pelvis in follow-up studies appears to be low for stages I–III follicular lymphoma. However, in research situations, where the time setting of recurrence is important, CT may be used more frequently. Further study is needed to define more selective use of CT.
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Footnotes |
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Address reprint requests to C.S.H.
Author contributions: Guarantors of integrity of entire study, Y.K.O., C.S.H., J.D.C.; study concepts and design, Y.K.O., C.S.H., J.D.C.; definition of intellectual content, Y.K.O., C.S.H., B.I.S., F.C., J.D.C.; literature research, Y.K.O., C.S.H., J.D.C.; clinical studies, C.S.H., B.I.S., F.C., J.D.C.; data acquisition, Y.K.O., C.S.H.; data analysis, Y.K.O., C.S.H., F.C., M.A.H., J.D.C.; statistical analysis, Y.K.O., C.S.H., F.C., M.A.H., J.D.C.; manuscript preparation, editing, and review, Y.K.O., C.S.H., B.I.S., F.C., M.A.H., J.D.C.
Received March 18, 1998;
revision requested April 27, 1998; revision received July 15, 1998;
accepted September 28, 1998.
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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