The primary objective of ECOG 1484 was to assess the role of consolidation RT if a complete response (CR) was achieved after a full course of chemotherapy. 6,7,9 While now of historical significance, these influential studies shaped the management of DLBCL for many years and provide valuable insights that are still relevant today. Several randomized studies conducted before the use of rituximab or PET-CT evaluated whether RT provides benefit as a consolidation treatment after a full course of chemotherapy or whether RT might allow for fewer cycles of chemotherapy ( Table 1). Pre–Rituximab/PET-CT Era: Prospective Trials This article will review the evolving role of RT in DLBCL, from a consolidation modality in early-stage disease to a bridging modality prior to CAR T-cell therapy in refractory disease. The role of RT continues to evolve in the setting of improved systemic therapies and disease response assessment tools. 8 RT has always been a valuable palliative intervention to alleviate symptoms such as pain. 3-5 RT subsequently transitioned to a consolidation modality after chemotherapy 6,7 or chemoimmunotherapy. 1,2 Historically, early-stage DLBCL was managed with RT alone, which successfully controlled about 40% to 45% of cases. One of the first modalities used to treat DLBCL was radiation therapy (RT). Finally, chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment of relapsed and refractory (R/R) disease. The incorporation of rituximab into multiagent chemotherapy regimens has significantly improved survival in all stages of disease. PET-CT not only improves the accuracy of initial staging but also provides a means to more precisely assess response to therapy and provide risk-adapted treatment. Several major advances have been incorporated into the management of diffuse large B-cell lymphoma (DLBCL) over the past 2 decades. RT is also a valuable modality in any patient with symptomatic disease requiring palliation. This includes consolidation RT in patients with localized presentations or bulky disease in the setting of ASCT and bridging RT in select patients undergoing CAR T-cell therapy. RT can be used in both settings to optimize clinical outcomes. The most common salvage options include second-line chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation (ASCT) and chimeric antigen receptor (CAR) T-cell therapy. While many patients achieve sustained remissions after first-line therapy, up to 50% of patients with DLBCL will eventually relapse. Consolidation RT is also appropriate in some patients with advanced DLBCL, including those presenting with bulky disease (≥7.5 cm). Consolidation RT is most commonly recommended after an abbreviated course of systemic therapy in patients who have bulky disease or multiple risk factors, or in the setting of a partial response. While still an option for select patients who are not candidates for systemic therapy, RT is currently used most frequently as a consolidation treatment after chemoimmunotherapy. Historically, radiation therapy (RT) served as the primary treatment modality for patients with localized disease. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma.
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