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Lymphoma in pregnancy is a rare and challenging diagnosis that complicates ∼1:6000 pregnancies; posing a series of unique therapeutic, social, and ethical challenges to the patient, her family, and the medical professionals involved. These difficulties are compounded by the paucity of real-world data on the management of LIP, and a lack of relevant support systems for women in this setting. We conducted a retrospective multicenter qualitative study, interviewing women aged ≥18 years of age diagnosed with Hodgkin (HL) or non-Hodgkin lymphoma (NHL) during pregnancy or within 12 months postpartum, between 1 January 2009 and 31 December 2020 from 13 Australasian sites. Semi-structured telephone interviews were conducted, recorded, and analyzed using QSR Int NVivo 12 Pro (March 2020, USA) to quantify salient themes. Of the 32 women interviewed, 20 (63%) were diagnosed during pregnancy (16, 34, and 13% in the 1st, 2nd, and 3rd trimesters, respectively), while 12 (37%) were diagnosed post-partum. Women recalled that their chief concerns at diagnosis were the welfare of their child (

Peripheral T-cell lymphomas (PTCLs) represent a heterogeneous disease group accounting for 10% of non-Hodgkin lymphomas. PTCL patients have typically poorer outcomes compared to aggressive B-cell lymphomas. However, such outcomes are heavily dependent upon subtype. Although anthracycline-based regimens such as cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) remain the standard first-line treatment for most aggressive PTCLs, there are important variations including incorporation of novel agents, use of radiotherapy and judicious consideration of stem cell transplantation. Relapsed or refractory disease represents a significant area of unmet need where chemotherapy intensification has limited efficacy and novel agents such as brentuximab vedotin and pralatrexate provide additional opportunities for attainment of remission and potential stem cell transplant. In the future, pre-therapy prognostic biomarkers including genomic characterisation, may aid in risk stratification and help guide initial patient management to improve survival. There is an urgent need to better understand the pathogenesis of PTCLs to facilitate novel drug combinatorial approaches to improve survival. This position statement represents an evidence-based synthesis of the literature for application in Australian and New Zealand practice. This article is protected by copyright. All rights reserved.

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype, accounting for 30-40% of lymphoma diagnoses. Though aggressive, cure is achievable in approximately 60% of cases with primary chemo-immunotherapy, and in a further substantial minority by salvage therapy and autologous stem cell transplantation. Despite promising activity in early phase clinical trials, no intensified or novel treatment regimen has improved outcomes over R-CHOP21 in randomised studies. However, there remain several areas of controversy including the most appropriate prognostic markers, CNS prophylaxis and the optimal treatment for patients with high-risk disease. This position statement presents an evidence-based synthesis of the literature for application in Australasian practice. This article is protected by copyright. All rights reserved.

The game of cricket is played at various times of the day and no studies have investigated the time of day effects on perceptual, physical and performance measures of cricketers. Therefore, the purpose of this study was to focus on adolescent fast bowlers and their responses when bowling at different times of the day. First team, adolescent male fast bowlers (N = 5, Mean age 17.00 ± 0.55 years; stature 185.2 ± 6.5 cm and mass 86.06 ± 17.56 kg) were required to complete a fast-bowling simulation protocol whereby perceptual, physical and bowling-specific performance measures were tested at three different times of day (10:30, 14:30, 18:30). Over all the spells over one was significantly slower than all the other overs. There were no significant changes in bowling speed between the time intervals. However, there was a large increase in bowling speed at 14:30 compared to 10:30 (ES – 1.25) and a moderate increase in bowling speed (ES = 0.67) between 10:30 and 18:30. There was no significant change in accuracy at the different time intervals although it was best at 10:30 followed by 18:30 although the latter had a greater variance. In conclusion, this investigation found time of day did not significantly impact the responses, but the effects sizes show that bowling accuracy was worst at 14:30 despite the other parameters, such as speed of delivery, being best at this time, which may suggest a speed-accuracy trade-off. Additionally, both 10:30 and 18:30 were found to be times conducive to bowling performance with regards to accuracy.

The management of Hodgkin Lymphoma (HL) has undergone significant changes in recent years. Due to the predilection of HL to affect younger patients, balancing cure and treatment related morbidity is a constant source of concern, for physicians and patients alike. PET adapted therapy has been developed for both early and advanced stage HL to try and improve the outcome of treatment, whilst minimising toxicities. The aim of this review is to digest the plethora of studies recently conducted and provide some clear, evidence-based practice statements to simplify the management HL. This article is protected by copyright. All rights reserved.

Primary cutaneous CD4 + small/medium T-cell lymphoproliferative disorder (PCSMLPD) is a benign behaving condition, typically manifesting as solitary head or neck papules, frequently creating cosmetic concerns. Optimal management of this rare disease is unclear. Herein, patterns of care and treatment outcomes are described, with particular focus on low-dose RT.Eligibility required biopsy-proven PCSMLPD on central review, diagnosed between 2007-2022. Patterns of care, treatment responses and relapse patterns were assessed. Freedom-from-progression (FFP) was compared between RT and surgery.41 patients were eligible. First-line treatments were: RT, 19 (46.3 %); surgery, 17 (41.5 %) (3 received adjuvant RT); watchful waiting, 5 (12.2 %). Median follow-up was 37.7 months. Overall, 24 patients received RT (19 definitive first-line, 3 adjuvant, 2 second-line). 10 (42 %) received 4 Gy in 2 fractions (with no acute toxicities); 14 (58 %) received 20-40 Gy. Complete response rate was 100 %. No post-RT relapses observed. After first-line surgery alone (n = 14, 3 with positive margins), 4 (28.5 %) experienced relapse (2 local, 2 distant). Watchful-waiting (n = 5) led to partial resolution post-biopsy in 4 patients; no complete resolution seen. 3-year FFP for RT alone was 100 % vs 61 % for surgery alone (p = 0.12).RT is a successful, non-invasive option for PCSMLPD: 100 % achieved complete response, with no relapses, and FFP appearing numerically superior to surgery in this cohort. In this first series of low-dose RT for PCSMLPD, 4 Gy in 2 fractions appears an excellent treatment option, offering durable disease control, no acute toxicities and convenient treatment time of only 2 days.

PURPOSE: Patients with abscopal regressions of lymphoma after palliative involved-site radiation therapy (ISRT), detected on sequential 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), were identified by audit. A retrospective analysis was subsequently conducted to estimate the frequency of abscopal regression in follicular lymphoma (FL). METHODS AND MATERIALS: Potential cases were identified at multidisciplinary lymphoma meetings and fulfilled these criteria: (1) palliative ISRT given for histologically confirmed lymphoma, (2) >2 lesions visualized on FDG-PET, (3) >1 unirradiated lesion(s) outside ISRT volume, (4) no systemic therapy delivered

With a median follow-up of 16.6 years, Lo and colleagues report excellent long-term outcomes with primary radiotherapy for limited-stage follicular lymphoma in this month’s CME article.

F-Fluorothymidine-positron emission tomography with CT fusion ([F]FLT-PET/CT) offers a unique and non-invasive method for three-dimensional localization and quantification of functional bone marrow. [F]FLT-PET/CT has potential application in radiotherapy planning when risk of marrow toxicity is a significant clinical concern. In this patient with chemo-refractory, transformed lymphoma and treatment-induced cytopenias, [F]FLT-PET/CT was a novel and useful adjunct to (1) image the distribution of functional bone marrow reserve, (2) guide "marrow-sparing" radiotherapy planning, and (3) quantify the effects of radiotherapy-induced bone marrow suppression both in-field and out-of-field.

Primary cutaneous lymphomas represent a heterogeneous group of T- and B-cell lymphomas with distinct clinical presentations, histopathologic features, treatment approaches and outcomes. The cutaneous T-cell lymphomas, which include mycosis fungoides and Sézary syndrome, account for the majority of the cutaneous lymphomas. This Clinical Practice Statement is reflective of the current clinical practice in Australia. An expanded form of the Clinical Practice Statement (and updates), along with helpful patient resources and access to support groups, can be found at the following (http://www.australasianlymphomaalliance.org.au).

At diagnosis,1% of patients with non-small cell lung cancer (NSCLC) have synchronous solitary brain metastasis (SSBM). In prior cohorts without 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) staging, definitive treatment to intracranial and intrathoracic disease showed a 5-year overall survival (OS) of 11-21%. We investigated the long-term survival outcomes for patients with SSBM NSCLC, diagnosed in the FDG-PET/CT era and treated definitively with local therapies to both intracranial and intrathoracic sites of disease.This retrospective study assessed patients staged with FDG-PET/CT who received definitive lung and SSBM treatment from February 1999 to December 2017. A lung-molecular graded prognostic assessment (lung-molGPA) score was assigned for each patient using age, performance status score, and, where carried out, molecular status. Overall survival and progression-free survival (PFS) were calculated using Kaplan-Meier methods. Cox proportional hazard models determined OS and PFS prognostic factors.Forty-nine patients newly diagnosed with NSCLC and SSBM had a median age of 63 years (range 34-76). The median follow-up of all patients was 3.9 years. Thirty-three patients (67%) had ≥T2 disease, 23 (47%) had ≥N2. At 2 years, 45% of first failures were intracranial only (95% confidence interval 30-59). At 3 and 5 years, OS was 45% (95% confidence interval 32-63) and 30% (95% confidence interval 18-51), respectively. In ≥N1 disease, 5-year OS was 34% (95% confidence interval 18-63). The 3- and 5-year PFS was 8% (95% confidence interval 3-22) and 0%, respectively. Higher lung-molGPA was associated with longer OS (hazard ratio 0.26, 95% confidence interval 0.11-0.61, P = 0.002). Higher lung-molGPA (hazard ratio 0.33, 95% confidence interval 0.15-0.71, P = 0.005) and lower N-stage (hazard ratio 1.56, 95% confidence interval 1.13-2.15, P = 0.007) were associated with longer PFS.Definitive treatment of patients with NSCLC and SSBM staged with FDG-PET/CT can result in 5-year survivors, including those with ≥N1 disease.

Advanced-stage follicular lymphoma (FL) is generally considered incurable with conventional systemic therapies, but historic series describe long-term disease-free survival in stage III disease treated with wide-field radiation therapy (WFRT), encompassing all known disease sites. We report outcomes for patients staged with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and treated with CT-planned WFRT, given as either comprehensive lymphatic irradiation (CLI) or total nodal irradiation (TNI). This analysis of a prospective cohort includes PET-staged patients given curative-intent WFRT as a component of initial therapy, or as sole treatment for stage III FL. Thirty-three PET-staged patients with stage III FL received WFRT to 24&ndash, 30Gy between 1999 and 2017. Fifteen patients also received planned systemic therapy (containing rituximab in 11 cases) as part of their primary treatment. At 10 years, overall survival and freedom from progression (FFP) were 100% and 75%, respectively. None of the 11 rituximab-treated patients have relapsed. Nine relapses occurred, seven patients required treatment, and all responded to salvage therapies. A single death occurred at 16 years. The principal acute toxicity was transient hematologic, one patient had residual grade two toxicity at one year. With FDG-PET staging, most patients with stage III FL experience prolonged FFP after WFRT, especially when combined with rituximab.

The COVID-19 pandemic poses a unique challenge to the care of patients with haematological malignancies. Viral pneumonia is known to cause disproportionately severe disease in patients with cancer, and patients with lymphoma, myeloma and chronic lymphocytic leukaemia are likely to be at particular risk of severe disease related to COVID-19. This statement has been developed by consensus among authors from Australia and New Zealand. We aim to provide supportive guidance to clinicians making individual patient decisions during the COVID-19 pandemic, in particular during periods that access to healthcare resources may be limited. General recommendations include those to minimise patient exposure to COVID-19, including the use of telehealth, avoidance of non-essential visits and minimisation of time spent by patients in infusion suites and other clinical areas. This statement also provides recommendations where appropriate in assessing indications for therapy, reducing therapy-associated immunosuppression and reducing healthcare utilisation in patients with specific haematological malignancies during the COVID-19 pandemic. Specific decisions regarding therapy of haematological malignancies will need to be individualised, based on disease risk, risks of immunosuppression, rates of community transmission of COVID-19 and available local healthcare resources.

Background Cancer treatment can lead to left ventricular (LV) dysfunction in female cancer survivors of reproductive age, and pregnancy-related hemodynamic stress may result in LV dysfunction or heart failure (HF). Objectives We performed a systematic review and meta-analysis to determine the incidence of LV systolic dysfunction or HF during or soon after pregnancy in cancer survivors and evaluated the impact of history of cancer therapeutics-related cardiac dysfunction (CTRCD). Methods We systematically searched electronic databases (MEDLINE and EMBASE) from inception to January 2020 to identify cohort studies that examined cardiac disease in pregnant cancer survivors. Meta-analysis was performed using the inverse-variance fixed effects method. Potential sources of heterogeneity were explored using subgroup analyses and meta-regression. Results Of 13,782 identified articles, 6 studies consisting of 2,016 pregnancies, predominantly in childhood cancer survivors, were included. Overall, there were 33 cardiac events. The total weighted incidence of LV dysfunction or HF with pregnancy was 1.7% (95% confidence interval [CI]: 0.9% to 2.7%) overall; 28.4% (95% CI: 14.6% to 43.9%) in those with a history of CTRCD and 0.24% (95% CI: 0% to 0.81%) in those without, translating into an odds ratio of 47.4 (95% CI: 17.9 to 125.8). Interstudy heterogeneity was low (I2 = 17.5%). Metaregression did not reveal significant sources of heterogeneity. Conclusions The incidence of LV dysfunction or HF during pregnancy in cancer survivors was low. Although risk estimates are limited by the small number of events, women with a history of CTRCD compared to those without had a 47.4-fold higher odds of experiencing pregnancy-related LV dysfunction or HF., Central Illustration

Mycosis fungoides (MF) and Sezary syndrome (SS) are multi-relapsing, morbid, cutaneous T-cell lymphomas. Optimal treatment sequencing remains undefined. Total skin electron therapy (TSE) is a highly technical, skin-directed treatment, uniquely producing symptom-free and treatment-free intervals. Recent publications favour low-dose TSE for reduced toxicity, but early data support conventional-dose TSE (cdTSE) for longer disease control. Patient selection requires weighing-up tolerability against response durability. We investigated duration of benefit from cdTSE in patients with poorer prognosis diseases: SS and heavily pre-treated MF. Endpoints were overall survival, and &ldquo, time to next treatment&rdquo, (TTNT) as surrogate for clinical benefit duration. Seventy patients (53 MF, 17 SS) were eligible: median prior treatments, 4, median cdTSE dose, 30 Gy, median follow-up, 5.8 years. SS patients had worse prognosis (HR = 5.0, p &lt, 0.001) and shorter TTNT (HR = 4.5, p &lt, 0.001) than MF patients, median TTNT was only 3.7 months. Heavily pre-treated MF patients had inferior prognosis (HR = 1.19 per additional line, p = 0.005), and shorter TTNT (HR = 1.13 per additional line, p = 0.031). Median TTNT for MF patients with &ge, 3 prior treatments was 7.1 months, versus 23.2 months for 0&ndash, 2 prior treatments. In conclusion, cdTSE has a limited role in SS. TTNT is reduced in heavily pre-treated MF patients, suggesting greater benefit when utilized earlier in treatment sequencing.

Background: Lymphoma in pregnancy is a rare and challenging diagnosis that complicates approximately 1:6000 pregnancies. Diagnostic delay occurs frequently, as lymphoma-related symptoms may be mistakenly attributed to the pregnancy itself, and diagnostic investigations postponed or omitted. Lymphoma in pregnancy poses a series of unique therapeutic, social, and ethical challenges to the patient, her family, and the medical professionals involved. This is largely due to a paucity of published management guidelines, with current evidence based on modest case series and expert opinion. In this study we endeavoured to understand women's lived experiences during this challenging time. We performed semi-structured interviews with women previously treated for lymphoma in pregnancy, to identify both gaps in care delivery and valued interventions with the aim of informing future models of care. Methods: We retrospectively identified patients from twelve sites in Australia and New Zealand aged ≥18 years of age diagnosed with Hodgkin (HL) or non-Hodgkin lymphoma (NHL) during pregnancy or within 12 months postpartum, between 1 January 2009 and 31 December 2020. Baseline demographic characteristics, treatment details, and outcomes were collected, and semi-structured interviews were conducted via telephone with those who provided informed consent. Thematic analysis was performed using QSR Int NVivo 12 Pro (March 2020, USA) to quantify salient themes. The initial 5 transcripts were independently coded by two investigators who then reached a consensus on pre-determined codes. These codes were applied to the rest of the transcripts by one coder. The frequency of pre-determined themes was determined via descriptive statistics. Results: A total of 29 women were interviewed. Baseline demographic characteristics are documented in Table 1. The majority were diagnosed during pregnancy (14%, 28% and 17% in the 1 st, 2 nd and 3rd trimesters respectively), while 41% were diagnosed post-partum. HL was the most frequent diagnosis (48%) followed by diffuse large B cell lymphoma and primary mediastinal lymphoma (14% each). More than 90% of women received chemotherapy with 28% receiving combined modality chemoradiotherapy. Sixty-nine percent commenced chemotherapy during pregnancy (17%, 28% and 14% in the 1 st, 2 nd and 3rd trimesters respectively) and 41% commencing postpartum. In the 28% of patients who received radiotherapy, this was administered post-partum. A summary of themes identified and their frequency across the 29 transcripts are shown in Figures 1-3. Diagnostic delay attributed to pregnancy was reported by 41%. 21% of the women reported fatigue, breathlessness, weight change and musculoskeletal pain, which they felt healthcare practitioners found difficult to interpret in the context of pregnancy/postpartum period. Women recalled that their chief concerns at diagnosis were the welfare of their unborn child (41%) and a fear of dying (27%). Over half of the women (55%) reported perceived communication breakdown between health practitioners and patients. They also felt there was a lack of sensitivity in discussions around fertility preservation (45%), teratogenicity of treatment (31%), termination of pregnancy (14%) and cessation of breast-feeding (14%). Valued interventions included financial/logistic assistance from charity organisations (48%), a personal support network (45%), clinical psychology referral (31%) and emergency childcare (10%). Patients also found shared patient experiences (31%) and support groups (17%) beneficial in their treatment journey. Conclusion: To our knowledge this is the first report capturing the lived experiences of survivors of lymphoma during pregnancy. This provides us a unique opportunity to consider our management, psychosocial supports, and delivery of care to meet the needs of these women. Areas for development in future care models include increased patient advocacy, educational materials, economic, psychosocial, and childcare supports. Above all, there is scope for improved, tailored communication between health practitioners and patients, with sensitivity around embryotoxicity, pregnancy termination and adverse outcomes to foster autonomy, build trust and improve maternal wellbeing. Figure 1 Figure 1. Disclosures Greenwood: Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding. Gangatharan: Astrazeneca: Other: Educational Conference Funding. Hamad: Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Introduction Lymphoma complicates approximately 1/6000 pregnancies (Pereg, Haematologica 2007), and presents challenges for the patient, her family, and medical professionals. This rare event raises unique therapeutic, social and ethical issues, with the welfare of both mother and unborn child to consider. There are challenges regarding symptom obfuscation, diagnosis delays and treatment delivery. In this retrospective study, we aimed to describe the experience, treatment patterns and outcomes of lymphoma in pregnancy in Australia and New Zealand. Methods We identified patients aged ≥18 diagnosed with lymphoma in pregnancy between 1 January 2009 and 31 December 2020 , across 11 institutions in Australia and New Zealand. We defined "lymphoma in pregnancy" as diagnoses occurring during pregnancy (antenatal cases) or the first 12 months after delivery (postpartum cases). Postpartum cases were included to account for the phenomenon of diagnostic delay during gestation due to deferral of diagnostic investigations and symptom obfuscation (de Haan, Lancet Oncol 2018). Overall survival was calculated by Kaplan-Meier methods from the date of diagnosis to death, with patients alive and lost to follow-up censored on the last day of follow-up. Results We identified 63 patients, 34 diagnosed antepartum and 29 diagnosed postpartum (Table 1). The most common diagnoses were classical Hodgkin lymphoma (HL) (35), followed by diffuse large B cell lymphoma (11) and primary mediastinal B cell lymphoma (6). The median age was 32 (range 23-42) years. Women diagnosed antepartum were more likely to be nulliparous (p=0.004). Of the postpartum cases, symptoms of malignancy first appeared during pregnancy in 24%. At diagnosis, 44% had advanced stage disease. 60% of women had PET as part of baseline staging, however only 8% underwent PET whilst pregnant, all during the second or third trimester. 83% of HL patients had adverse risk factors (mediastinal bulk >1/3 diameter, ESR>50mm/hr, >2 sites). ESR alone, which may be elevated physiologically in pregnancy, was the sole adverse risk factor for 9% of HL patients. Median days between diagnosis and treatment initiation were 14 (IQR 8-30) for antenatal patients and 21 (IQR 7-40) for postnatal. 19% of the antenatal cohort with aggressive lymphoma had treatment deferred/delayed explicitly due to pregnancy. The majority (89%) of antenatal patients were treated with ABVD (HL) or (R)CHOP/(R)EPOCH (NHL) whilst pregnant. 3 patients received first-line treatment divergent from standard (vinblastine for HL, interferon for indolent B-NHL and surgery for primary cutaneous ALCL). 37% received radiotherapy, although only 1 patient received it antenatally. Median follow up was 34 months. 5 year OS for HL was 83% (95%CI 54%-95%) and for DLBCL 74% (95%CI 30%-93%)(Figure 1). Seven patients died (4 from lymphoma, 2 treatment-related infection, 1 unknown). Discussion of elective termination of pregnancy was documented in 24 of 34 antenatal diagnoses, advised in 3 and performed in 2, both in the first trimester. Only 31 (49%) of 63 women had documented evidence of counselling regarding future fertility strategies. Of the 48 patients with available data, there were 45 live births, 2 elective terminations and 1 spontaneous abortion in the first trimester. The mean gestation at birth was significantly earlier and marginally preterm for antenatal diagnoses (mean 35.6wk v 38.2wk, p=0.002). 6 neonates (11%) were small for gestational age, 5 of whom were born to mothers diagnosed antenatally. 29% of neonates were admitted to neonatal intensive care or special care units. There were no cases of neonatal neutropenia, one case of sepsis of prematurity and one case of PJP infection in a term baby. Conclusion Lymphoma in pregnancy is rare and lacks a harmonised approach. We present a large multicentre cohort reflecting contemporary practice. Although standard therapy could be provided to most patients, delays in treatment and diagnosis were common, and most antenatally-diagnosed women did not receive optimal staging. Neonates in the antenatally-diagnosed group were more likely to be premature, however there are likely a number of confounders and causality cannot be presumed. There were no neonatal deaths. It is imperative to continue to report on data regarding lymphoma in pregnancy to inform optimal care in this setting. Figure 1 Figure 1. Disclosures Greenwood: Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees, Research Funding; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Gregory: Janssen: Consultancy; Novartis: Consultancy; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel fees, Speakers Bureau. Hamad: Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Background: Despite increasing availability of therapeutic agents, Sezary syndrome (SS) remains associated with a generally poor prognosis. Typically, patients endure multi-line treatment, frequently with disappointingly short durations of clinical benefit. Time to next treatment (TTNT) measures the interval from the date of commencement of one therapy to the date of initiation of the next line of therapy, and provides a simple and reliable surrogate for duration of clinical benefit outside of clinical trials [ 1 ]. In this multi-centre collaborative study, we review the clinical outcomes of patients with SS/ mycosis fungoides (MF) with B1-2 blood involvement, and compare the treatment efficacy of the currently available systemic therapies using TTNT. Methods: In this retrospective analysis, eligible patients were identified from University Hospital Birmingham, Birmingham, Peter MacCallum Cancer Centre, Melbourne, and Hopital Saint Louis, Paris. Strict eligibility required biopsy-proven MF/SS, with B1-2 blood involvement, newly diagnosed during 1/1/2012 to 31/12/2020. Studied treatment groups include monotherapy and combination therapies of interferon, methotrexate, ECP, HDAC inhibitors, retinoids, monoclonal antibodies, biologicals, chemotherapy, allogeneic stem cell transplant, and best supportive care. The primary endpoint was TTNT, with the aim to compare the efficacy of these systemic therapies. Results: 178 patients were eligible. 77 (43%) were female, median age was 66 (17–94) years. At diagnosis, 35 (20%) patients had Stage IIIB, 131 (74%) Stage IVA and 12 (7%) Stage IVB MF/SS. Large cell transformation was present in 35 (20%) patients at time of diagnosis. A total of 802 treatment lines were delivered, of which 711 were systemic therapies and were included for analysis. Of the 178 patients, 168 received systemic therapy first-line: the most commonly delivered first-line systemic treatments were ECP-containing regimens in 42 (25%) patients (ECP-monotherapy, 17, ECP-based combination therapy, 25), retinoid monotherapy in 34 (19%), interferon monotherapy in 25 (14%) and methotrexate monotherapy in 25 (14%) patients. TTNT and overall survival data will be presented. Conclusions: As a surrogate for duration of clinical benefit, TTNT is a useful endpoint to retrospectively compare the treatment efficacy of currently available systemic therapies for SS/MF with B1-2 blood involvement. Long-term disease control with durable clinical benefit remains the ultimate goal for patients with SS/MF with blood involvement.

The effects of drain maintenance on fish habitat and benthic macroinvertebrate assemblages (fish prey) were investigated for eight agricultural drains in southwestern Ontario, Canada. Our investigation employed a replicated Before-After-Control-Impact (BACI) design where each maintained section of a drain was paired with an unmaintained section downstream and an unmaintained section on a nearby reference drain of similar size and position in the watershed. Seven variables characterizing physical habitat features important to fishes and three variables characterizing the taxonomic abundance, densities, and relative densities of benthic macroinvertebrates were measured before drain maintenance and 10-12 times over 2 years following maintenance. Pulse responses were detected for three habitat variables quantifying vegetative cover: percent vegetation on the bank, percent in-stream vegetation, and percent cover. All three variables returned to pre-maintenance levels within two years of maintenance. No consistent changes were observed in the remaining habitat features or in the richness and densities of benthic invertebrate assemblages following drain maintenance. Our findings suggest that key features of fish habitat, structural properties and food availability, are resistant to drain maintenance.

A better understanding of how human activities affect biodiversity can be important for effective resource management. We tested how excavation (maintenance) of agricultural drains (ditches) altered fish assemblages. Uncertainty regarding the effects of drain maintenance on fish assemblages has been a source of tension between landowners, drain superintendents, and fishery managers. Fish assemblages in eight southwestern Ontario drains were sampled repeatedly from before to 2 years after drain maintenance using a replicated before–after, control–impact (BACI) design. Relative to reference sites, we found no evidence for short- or long-term decreases in the number of species and total abundance of fishes following drain maintenance, nor any consistent change in assemblage composition, despite clear changes in physical habitat. The fish assemblages in drains were resilient to drain maintenance and did not show changes expected to concern fishery managers. Our findings provide fishery managers with the information needed to manage drain maintenance more effectively under the Fish Protection Program of the Fisheries Act and to develop drain maintenance practices that balance the needs of agriculture with the protection of fish biodiversity.

Purpose To determine whether the risk of secondary breast cancer (SBC) is reduced in women with Hodgkin lymphoma (HL) treated with smaller field radiation therapy (SFRT) versus mantle field radiation therapy (MRT). Methods and Materials We used the BC Cancer Agency (BCCA) Lymphoid Cancer Database to identify female patients treated for HL between January 1961 and December 2009. Radiation therapy volumes were categorized as MRT or SFRT, which included involved field, involved site, or involved nodal radiation therapy. SBC risk estimates were compared using competing risk analysis and Fine and Gray multivariable model: MRT ± chemotherapy, SFRT ± chemotherapy, or chemotherapy-only. Results Of 734 eligible patients, 75% of the living patients have been followed up for more than 10 years, SBC has developed in 54, and 15 have died of breast cancer. The 20-year estimated risks (competing risk cumulative incidence) for SBC differed significantly: MRT 7.5% (95% confidence interval [CI] 4.4%-11.5%), SFRT 3.1% (95% CI 1.0%-7.7%), and chemotherapy-only 2.2% (95% CI 1.0%-4.8%) ( P =.01). Using a Fine and Gray model to control for death and patients lost to follow-up, MRT was associated with a higher risk of SBC (hazard ratio [HR] = 2.9; 95% CI 1.4%-6.0%; P =.004) compared with chemotherapy-only and with SFRT (HR = 3.3; 95% CI 1.3%-8.4%; P =.01). SFRT was not associated with a greater risk of SBC compared with chemotherapy-only (HR = 0.87; 95% CI 0.28%-2.66%; P =.80). Conclusion This study confirms that large-volume MRT is associated with a markedly increased risk of SBC; however, more modern small-volume RT is not associated with a greater risk of SBC than chemotherapy alone.

Long-term survivors of childhood, adolescent and young adult (AYA) malignancies with past exposure to potentially cardiotoxic treatments are at risk of peripartum cardiac dysfunction. Incidence and risk factors for peripartum cardiac dysfunction and maternal cardiac outcomes in this population were investigated. Eligible long-term survivors were aged &lt, 30 years at cancer diagnosis, with &ge, 1 pregnancy occurring &ge, 5 years after diagnosis. &ldquo, Peripartum&rdquo, cardiac events were defined as occurring within pregnancy or &le, 5months after delivery. Cardiac events were classified &ldquo, symptomatic&rdquo, or &ldquo, subclinical&rdquo, &ldquo, Peripartum cardiomyopathy&rdquo, (PPCM) was defined as symptomatic dysfunction without prior cardiac dysfunction. Of 64 eligible women, 5 (7.8%) had peripartum cardiac events: 3 symptomatic, 2 subclinical. Of 110 live births, 2 (1.8%, 95% CI 0.2&ndash, 6.4) were defined as PPCM: Significantly greater than the published general population incidence of 1:3000 (p &lt, 0.001), representing a 55-fold (95% CI 6.6&ndash, 192.0) increased risk. Risk factor analyses were hypothesis-generating, revealing younger age at cancer diagnosis and higher anthracycline dose. Postpartum, cardiac function of 4 women (80%) failed to return to baseline. In conclusion, peripartum cardiac dysfunction is an uncommon but potentially serious complication in long-term survivors of paediatric and AYA malignancies previously treated with cardiotoxic therapies. Peripartum cardiac assessment is strongly recommended for at-risk patients.

Extracorporeal photopheresis (ECP) has demonstrated therapeutic benefit in patients with Sezary syndrome (SS) and erythrodermic mycosis fungoides (e-MF). To examine the efficacy of ECP in the modern era of novel therapies, we conducted a retrospective analysis of 65 patients with a diagnosis of SS or e-MF with blood involvement who were treated with ECP at our institute. Overall survival (OS), time to next treatment (TTNT), and skin response rate (RR) were used as the study end points to determine patient outcome. The median follow-up from diagnosis was 48 months (range 1-225 months), with a median predicted OS of 120 months. The majority (88%) of patients commenced ECP at treatment lines 1 to 3, either as a monotherapy or in conjunction with other systemic agents. The use of ECP monotherapy resulted in a significantly longer median TTNT when compared with interferon-α (P = .0067), histone deacetylase inhibitors (P = .0003), novel immunotherapy agents (P = .028), low-dose methotrexate (P < .0001), and chemotherapy (P < .0001). In particular, early commencement of ECP at treatment lines 1 to 3 yielded a TTNT of 47 months. The results of our study support the utilization of ECP for SS/e-MF, and we recommend that ECP should be considered as early as possible in the treatment paradigm for these patients.

Introduction Where tolerated,high dose chemotherapy supported by autologous stem cell transplantation (ASCT) is the standard of care for patients with relapsed or refractory diffuse large B cell lymphoma (DLBCL). Disease recurrence post-ASCT however is common and carries an extremely poor prognosis, highlighting the need for improved pre-transplant prognostic stratification. This study investigates the prognostic utility of the PET parameters total metabolic tumour volume (TMTV) and standardised uptake value (SUV)max in the peri-transplant setting. Methods 125 patients underwent ASCT for relapsed or refractory DLBCL between 1/1/2002 and 31/1/2017 at the Peter MacCallum Cancer Centre. All patients received multi-agent salvage immuno-chemotherapy before proceeding to ASCT. 58 patients were treated with peri-transplant radiotherapy, with indications including incomplete response post-salvage therapy, and bulky and/or localised disease. 122 patients had their treatment response assessed with PET. TMTV and SUVmax were measured at time of primary disease relapse/progression prior to salvage immuno-chemotherapy (pre-salvage PET) and post-salvage immuno-chemotherapy prior to ASCT (pre-ASCT PET). 93 patients had pre-salvage and pre-ASCT PETs available for TMTV and SUVmax measurement. Results Median follow up was 5.6 years. The 5-year progression free survival (PFS) and overall survival (OS) were 52% (95% CI: 42-60) and 65% (95% CI: 56-73). In patients demonstrating complete metabolic response (CMR) and non-CMR on pre-ASCT PET the 5-year PFS was 58% (95% CI: 44-70) and 44% (95% CI: 29-57) respectively. The 5-year OS with CMR and non-CMR on pre-ASCT PET was 73% (95% CI: 59-83) and 54% (95% CI: 39-67). TMTV and SUVmax were investigated as potential prognostic factors in the peri-transplant setting. In this patient group, pre-salvage TMTV and SUVmax were not found to be of prognostic significance. Pre-salvage TMTV and SUVmax PFS hazard ratios (HR)s were 1.06 per 100ml (95% CI:0.96-1.17; p = 0.27) and 1.00 (95% CI: 0.98-1.03; p = 0.78) respectively, and OS HRs were 1.10 per 100ml (95% CI: 0.86-1.18; p = 0.07) and 1.02 (95% CI: 0.96-1.04 p = 0.24). In contrast, pre-ASCT TMTV was a significant negative prognostic factor for both PFS (HR = 1.22 per 100ml; 95%CI: 1.10-1.37; p < 0.001) and OS (HR = 1.96 per 100ml; 95% CI: 1.38-2.79; p < 0.001). Pre-ASCT SUVmax similarly demonstrated a negative association with PFS (HR = 1.07; 95% CI: 1.04-1.10; p < 0.001) and OS (HR of 1.08 ; 95% CI: 1.04-1.11; p < 0.001). In addition to the TMTV and SUVmax absolute values, the relative change from pre-salvage to pre-ASCT PET was investigated for prognostic value. No significant association with PFS or OS was demonstrated for the relative change of either parameter. The relative change in TMTV had a HRs of 1.21 (95% CI: 0.54- 2.72; p = 0.65) and 1.15 (95% CI: 0.45-2.93; p = 0.77) for PFS and OS respectively, and relative change in SUVmax had a HRs of 1.30 (95% CI: 0.68- 2.50; p = 0.43) and 1.20 (CI 95% 0.57-2.54; p = 0.64) for PFS and OS. Conclusion As prognostic tools, pre-ASCT TMTV and SUVmax were both predictors for PFS and OS. In contrast, pre-salvage TMTV and SUVmax did not demonstrate an association with PFS or OS, reinforcing the prognostic significance of the pre-ASCT PET scan. The relative change in SUVmax and TMTV were similarly not associated with PFS and OS. These findings indicate that in the context of TMTV and SUVmax measurement, residual disease on pre-ASCT PET may be of greater predictive value than degree of response to salvage immuno-chemotherapy. While TMTV and SUVmax have primarily been studied in the context of first-line therapy for DLBCL, these results suggest a promising prognostic role for these PET parameters in the peri-transplant setting. Disclosures Seymour: AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding; AstraZeneca: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Research Funding; F. Hoffmann-La Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Gilead: Consultancy; Nurix: Honoraria; Mei Pharma: Consultancy, Honoraria; Morphosys: Consultancy, Honoraria. Dickinson:Novartis: Consultancy, Honoraria, Research Funding, Speakers Bureau; Merck Sharp & Dohme: Consultancy; Gilead: Consultancy, Honoraria, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Speakers Bureau; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Malnutrition is prevalent in patients undergoing (chemo)radiotherapy (RT) for lung cancer. This pilot study tested the feasibility and acceptability of delivering an intensive nutrition intervention for lung cancer patients receiving RT. Twenty-four patients with lung cancer were randomized to receive the intervention which employed a care pathway to guide intensive dietary counseling from pretreatment until 6-wk posttreatment or usual care. Nutritional, fatigue, and functional outcomes were assessed using valid and reliable questionnaires before randomization, at the start and end of RT and 1- and 3-mo post-RT. Consent rate was 57% with an overall attrition of 37%. Subject compliance with the completion of study questionnaires was 100%. A clinically important mean difference indicated greater overall satisfaction with nutritional care in the intervention group (5.00, interquartile range [IQR] 4.50-5.00; 4.00, IQR 4.00-4.00). Clinically important differences favoring the intervention were observed for weight (3.0 kg; 95% confidence interval [CI] -0.8, 6.8), fat-free mass (0.6 kg; 95% CI -2.1, 3.3), physical well-being (2.1; 95% CI -2.3, 6.5), and functional well-being (5.1; 95% CI 1.6, 8.6), but all 95% CIs were wide and most included zero. Recruitment feasibility and acceptability of the intervention were demonstrated, which suggest larger trials using an intensive nutrition intervention would be achievable.

Background Approximately half of patients with relapsed or refractory (R/R) classical Hodgkin lymphoma (cHL) will relapse despite curative intent therapy with salvage chemotherapy (SC) and autologous stem cell transplantation (ASCT). Consolidative radiotherapy (cRT) is used to reduce the risk of local relapse in high risk patients. We aimed to examine the (i) impact of cRT on outcomes, (ii) role of positron-emission tomography computerised tomography (PET-CT) imaging in predicting outcomes, (iii) identify a subgroup most likely to benefit from cRT, (iv) assess patterns of relapse to understand the mechanisms of treatment failure and (v) propose a PET-CT based risk stratification model for relapse. Patients and Methods 104 patients with R/R cHL treated with curative intent SC and ASCT between January 2000 and May 2019 were retrospectively identified from two sites in Melbourne, Australia. Fifty-six patients (54%) received peri-transplant cRT. SC consisted of chemotherapy and/or immunotherapy of the clinician's choice followed by interim assessment by PET-CT imaging. Patients with a complete or partial metabolic response proceeded to ASCT. Disease status was routinely evaluated by physical examination and PET-CT imaging at time of disease relapse, at completion of salvage chemotherapy, and at three months following ASCT. A complete metabolic response on fluorodeoxyglucose (FDG) PET/CT was defined by Deauville Score ≤3 (uptake ≤ liver, PET negative) and compared to Deauville Score ≥4 (PET positive). Results With a median follow-up of 2.5 (range 0.2-15.2) years, the 2-year progression free survival (PFS) and overall survival (OS) rates were 68.3% and 83.6%, respectively. Inferior PFS was associated with advanced stage (III or IV) disease at relapse (AS-R) (53% vs 78%; P=0.004) and PET positivity after SC (51% vs 79%; P=0.005). Compared to PET negative patients after SC, 2-year PFS was significantly inferior in patients who were PET positive and did not receive cRT (38% vs 79%; P Conclusion One third of patients with relapsed/refractory cHL who received SC and ASCT subsequently relapsed within two years. cRT may abrogate the negative predictive value of a positive PET scan after SC, of which patients with LS-R are most likely to benefit. PET positive disease and residual mass ≥2cm after SC are associated with inferior PFS despite the use of cRT. Conversely, patients who are PET negative without residual tumor mass after SC have superior outcomes. cRT is associated with improved local disease control, yet approximately half of patients who relapse after cRT will still have in-field relapse, possibly warranting the evaluation of higher cRT doses. Therefore, we propose a PET-based model which may identify the patients at "high" risk of progressing after ASCT who are most likely to benefit from clinical trials examining different modalities of consolidative therapy (Figure 1D). Validation of this model is required in a larger independent population. Disclosures Ritchie: Amgen: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy; BMS: Research Funding; Takeda: Research Funding; Beigene: Research Funding; Imago: Research Funding; Novartis: Honoraria; Sanofi: Honoraria. MacManus:National Health and Medical Research Council Australia: Research Funding. Seymour:Janssen: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria; Roche: Consultancy, Honoraria, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Honoraria; Acerta: Consultancy, Honoraria. Dickinson:GlaxoSmithKline: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; F. Hoffmann-La Roche Ltd: Consultancy, Honoraria, Research Funding, Speakers Bureau; Merck Sharpe and Dohme: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

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.