Bulky disease

X Bulky disease greater than 1/3 the width of the mediastinum or greater than 1 0 cm maximal dimension of nodal mass... 

Standard doses of radiotherapy for HL generally total 3600 cGy to each field in daily fractions of 180 cGy over 4 weeks. Clinically involved areas are given boost doses of 550 to 900 cGy in three to five fractions, resulting in a total dose to the involved area of upwards of 4500 cGy. Radiation maybe given as consolidation following completion of a complete course of chemotherapy in patients with advanced HL.13,14 This treatment typically is reserved for patients who have an unconfirmed response to chemotherapy or who have bulky disease on presentation. 

In patients with bulky disease or a significant tumor burden, neoadjuvant chemotherapy can be used to decrease tumor burden to increase the likelihood of optimal tumor debulking during surgery.35 Typically, three cycles of the standard combination taxane/platinum regimen is administered once every 3 weeks. After surgery, the patient will receive another three to six cycles depending on response to chemotherapy. 

Interferon-a2b has diverse mechanisms of action, including antiviral activity, impact on cellular metabolism and differentiation, and antitumor activity.42 The antitumor activity is due to a combination of direct antiproliferative effect on tumor cells and indirect immune-mediated effects.42 Interferon-a2b is currently approved by the Food and Drug Administration (FDA) as adjuvant therapy for patients who are free of disease after curative surgical resection but are at high risk of MM recurrence. This includes patients with bulky disease or regional lymph node involvement such as stage IIB, IIC, or III disease.43 It is controversial if interferon-a2b (IFN) should be offered as adjuvant therapy for every high-risk MM patient. The reason is because clinical trials with different doses of IFN have not proved definitively that IFN improves overall patient survival. 

Unfavorable prognosis (CS I or II with risk factors [e.g., B symptoms, extranodal disease, bulky disease, three or more sites of nodal involvement, or an erythrocyte sedimentation rate >50]) Advanced-stage disease... 

Nonminimal, bulky disease Bulky N2 on CT scan or chest X-ray T4 (no effusion) N3... 

Radiation can control the bulky disease earlier with chemotherapy eradicating the micrometastatic disease outside of the radiation field. 

Spatial cooperation Radiation is more effective at controlling the primary bulky disease but is unable to affect distant micrometastases. Chemotherapy, on the other hand, can deal with micrometastases but is unable to affect the large primary tumor. The combination of both local (radiation) and systemic (chemotherapy) approaches then maximizes therapeutic impact. 

A large multicenter pivotal phase II study was performed to evaluate the efficacy of rituximab in the treatment of relapsed low-grade or follicular CD20(+) B-cell NHL (171). A total of 166 patients with small lymphocytic (n= 33), follicular small cleaved (n = 67), follicular mixed (n= 53), follicular large-cell (n = 10), or low-grade variant (n = 3) NHL were enrolled at 31 centers. Patients with bulky disease (>10 cm), pleural or peritoneal involvement, CNS lymphoma, AIDS-related lymphoma, CLL or leukemic component (more than 5,000 lymphocytes/pl) were excluded. Rituximab was again administered intravenously at 375 mg/m2 weekly for four doses. The overall response rate, which was the primary study end point, was... 

Therapeutic approaches to NHL include radiation therapy, chemotherapy, and biologic agents. The role of radiation therapy in the treatment of NHL dEfers from its role in the treatment of Hodgkin s disease. Although the disease is responsive to radiation therapy, only a small percentage of patients with NHL present with truly localized disease that can be treated with local or regional radiation therapy. Radiation therapy is used more commonly in advanced disease, primarily as a palliative measure to control local bulky disease. 

FoUicular lymphomas tend to occur in older adults, with a sUght female predominance (see Table 129-8). Most patients have advanced disease at diagnosis, but about 25% to 33% of patients have locaUzed disease (clinical stage I or II) at diagnosis." Extranodal disease, bulky disease, and B symptoms (constitutional symptoms) are... 

Chemotherapy is not usuaUy given in most patients with localized foUicular lymphoma, but it may be helpful in some patients with high-risk stage II disease (e.g., multiple sites of involvement or bulky disease). ... 

Phase II clinical trials performed during development included three single-agent trials a study in patients with bulky disease, an eight-infusion study, and a re-treatment study (Table 4). Additionally, three combination studies were conducted a study in combination with chemotherapy, a study in combination... 

Okada et al. (2000) demonstrated in his series of 51 patients an advantage in survival for all NSCLC patients with bulky nodal involvement after induction therapy and resection. These results could be confirmed by Stathopulos et al. (1999) in a larger trial with 359 patients, but their resectability rate was very low, at 6.2%. This stands in contrast to other studies reaching resectability rates of up to 88% after induction chemotherapy in patients with NSCLC stage III-A bulky disease. 

Fig.6.2.10a,b. Gastric lymphoma, a Coronal reformation demonstrates biopsy-proved early gastric lymphoma with focal thickening of the antral wall (arrows), b Sagittal reformation shows bulky disease from a biopsy-proven advanced B-cell lymphoma... 

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