Standard and proposed emergency fractionation schemes for curative and palliative RT for hematologic malignancies
| . | Standard . | Emergency COVID-19 crisis alternative dose fractionation . | BED calculations, Gy . | |||||
|---|---|---|---|---|---|---|---|---|
| Total dose, Gy . | No. of fractions . | Comments . | Total dose, Gy . | No. of fractions . | Dose/Fraction, Gy* . | EQD2 α/β = 3 Gy . | EQD2 α/β = 10 Gy . | |
| Curative | ||||||||
| HL favorable, chemosensitive | 20 | 10 | Consider hypo-fractionation only in a critical resource shortage situation | 18 | 6 | 3 | 22 | 20 |
| HL unfavorable, chemosensitive | 30.6 | 17 | Consider hypo-fractionation only in a critical resource shortage situation | 27 | 9 | 3 | 32 | 29 |
| NLPHL RT alone | ||||||||
| HL, chemorefractory | 40 | 20 | Consider hypo-fractionation only in a critical resource shortage situation | 36-39 | 12-13 | 3 | 43-47 | 39-42 |
| Aggressive NHL, chemosensitive | 30 | 15 | No significant cardiac and/or lung exposure and no overlapping critical organs | 25 | 5 | 5 | 40 | 32 |
| Some cardiac/lung exposure or overlapping critical organs | 27 | 9 | 3 | 32 | 29 | |||
| Aggressive NHL, chemorefractory disease | 40-50 | 20-25 | No significant cardiac and/or lung exposure and no overlapping critical organs | 30 | 6 | 5 | 48 | 38 |
| Localized aggressive NHL, primary RT alone (not chemo candidate) | Some cardiac/lung exposure or overlapping critical organs | 36-39 | 12-13 | 3 | 43-47 | 39-42 | ||
| Indolent lymphoma, limited stage | 24 | 12 | Start with 4 Gy ×1, reevaluate after 2-3 mo→ | 4 | 1 | 4 | 6 | 5 |
| If insufficient response, proceed to definitive RT | 20 | 5 | 4 | 28 | 23 | |||
| NK-/T-cell lymphoma | 45† | 25 | In patients treated with effective chemotherapy regimen‡ | 36 | 9 | 4 | 50 | 42 |
| Cutaneous T-cell lymphoma, TSEBT | 10-12 | 6-10 | Give 2-3 treatments, 1 per week, evaluate response after each | 8-12 | 2-3 | 4 | 11-17 | 9-14 |
| Solitary bone plasmacytoma or solitary extramedullary plasmacytoma | 40-45 | 20-25 | Nonspine, non-H&N sites | 30 | 6 | 5 | 48 | 38 |
| Spine or H&N sites | 36 | 12 | 3 | 43 | 39 | |||
| Palliative | ||||||||
| Symptomatic aggressive NHL (no chemo options) | 30 | 10 | Life expectancy ≥3 mo | 25 | 5 | 5 | 40 | 31 |
| Life expectancy <3 mo | 8 | 1 | 8 | 18 | 12 | |||
| Symptomatic multiple myeloma | 20 | 5 | No cord compression | 8 | 1 | 8 | 18 | 12 |
| Cord compression | 20 | 5 | 4 | 28 | 23 | |||
| Symptomatic indolent lymphoma | 4 | 2 | No cord compression | 4 | 1 | 4 | 6 | 5 |
| Cord compression | 20 | 5 | 4 | 28 | 23 | |||
| Myeloid sarcoma/leukemia | 24 | 12 | Cranial leptomeningeal disease | 8 | 2 | 4 | 11 | 9 |
| Focal leptomeningeal spine disease, and symptomatic chloroma outside the CNS | 12 | 3 | 4 | 17 | 14 | |||
| . | Standard . | Emergency COVID-19 crisis alternative dose fractionation . | BED calculations, Gy . | |||||
|---|---|---|---|---|---|---|---|---|
| Total dose, Gy . | No. of fractions . | Comments . | Total dose, Gy . | No. of fractions . | Dose/Fraction, Gy* . | EQD2 α/β = 3 Gy . | EQD2 α/β = 10 Gy . | |
| Curative | ||||||||
| HL favorable, chemosensitive | 20 | 10 | Consider hypo-fractionation only in a critical resource shortage situation | 18 | 6 | 3 | 22 | 20 |
| HL unfavorable, chemosensitive | 30.6 | 17 | Consider hypo-fractionation only in a critical resource shortage situation | 27 | 9 | 3 | 32 | 29 |
| NLPHL RT alone | ||||||||
| HL, chemorefractory | 40 | 20 | Consider hypo-fractionation only in a critical resource shortage situation | 36-39 | 12-13 | 3 | 43-47 | 39-42 |
| Aggressive NHL, chemosensitive | 30 | 15 | No significant cardiac and/or lung exposure and no overlapping critical organs | 25 | 5 | 5 | 40 | 32 |
| Some cardiac/lung exposure or overlapping critical organs | 27 | 9 | 3 | 32 | 29 | |||
| Aggressive NHL, chemorefractory disease | 40-50 | 20-25 | No significant cardiac and/or lung exposure and no overlapping critical organs | 30 | 6 | 5 | 48 | 38 |
| Localized aggressive NHL, primary RT alone (not chemo candidate) | Some cardiac/lung exposure or overlapping critical organs | 36-39 | 12-13 | 3 | 43-47 | 39-42 | ||
| Indolent lymphoma, limited stage | 24 | 12 | Start with 4 Gy ×1, reevaluate after 2-3 mo→ | 4 | 1 | 4 | 6 | 5 |
| If insufficient response, proceed to definitive RT | 20 | 5 | 4 | 28 | 23 | |||
| NK-/T-cell lymphoma | 45† | 25 | In patients treated with effective chemotherapy regimen‡ | 36 | 9 | 4 | 50 | 42 |
| Cutaneous T-cell lymphoma, TSEBT | 10-12 | 6-10 | Give 2-3 treatments, 1 per week, evaluate response after each | 8-12 | 2-3 | 4 | 11-17 | 9-14 |
| Solitary bone plasmacytoma or solitary extramedullary plasmacytoma | 40-45 | 20-25 | Nonspine, non-H&N sites | 30 | 6 | 5 | 48 | 38 |
| Spine or H&N sites | 36 | 12 | 3 | 43 | 39 | |||
| Palliative | ||||||||
| Symptomatic aggressive NHL (no chemo options) | 30 | 10 | Life expectancy ≥3 mo | 25 | 5 | 5 | 40 | 31 |
| Life expectancy <3 mo | 8 | 1 | 8 | 18 | 12 | |||
| Symptomatic multiple myeloma | 20 | 5 | No cord compression | 8 | 1 | 8 | 18 | 12 |
| Cord compression | 20 | 5 | 4 | 28 | 23 | |||
| Symptomatic indolent lymphoma | 4 | 2 | No cord compression | 4 | 1 | 4 | 6 | 5 |
| Cord compression | 20 | 5 | 4 | 28 | 23 | |||
| Myeloid sarcoma/leukemia | 24 | 12 | Cranial leptomeningeal disease | 8 | 2 | 4 | 11 | 9 |
| Focal leptomeningeal spine disease, and symptomatic chloroma outside the CNS | 12 | 3 | 4 | 17 | 14 | |||
BED, biological equivalent dose; chemo, chemotherapy; CNS, central nervous system; EQD2, equivalent dose in 2-Gy fractions; H&N, head and neck; HL, Hodgkin lymphoma; NK, natural killer; NLPHL, nodular lymphocyte-predominant Hodgkin lymphoma; TSEBT, total skin electron beam therapy.
When using 5 Gy per fraction to 25 to 30 Gy or 4 Gy per fraction to 36 Gy, we recommend keeping the maximum dose (Dmax) to ≤25 Gy for retina, optic nerves, optic chiasm, cochlea, brainstem, brachial plexus, spinal cord, and cauda; V25 (the volume of the organ receiving 25 Gy) <5 cc for stomach, duodenum, and other small bowel; mean liver dose <20 Gy; and mean dose <6 Gy for kidney (bilateral, but optimal if 1 kidney can be spared). If these dose constraints cannot be met, we recommend using 3 Gy per fraction to 27 Gy for chemosensitive disease and 36 Gy for chemorefractory disease.
With optimal chemotherapy.
In patients who are not treated with chemotherapy, or in those treated with nonoptimal regimens, a higher effective dose is needed, and use of the standard fractionation should be considered if at all possible.