The small number of patients in individual treatment groups prevented comparison of outcomes between patients treated with an abbreviated vs a full course of chemotherapy. The chemotherapy was not uniform, and patient treatments were selected by physicians based on clinical presentation and other unknown but potentially confounding considerations. There are several limitations to this retrospective study. However, there was no difference in PFS and OS, indicating that additional studies addressing the role of RT in extranodal DLBCL may be needed. The reduced EFS in patients without RT was linked to a higher rate of partial responses that triggered additional treatment. 9 The 3-year event-free survival (EFS) was superior in patients who received RT. In the UNFOLDER (unfavorable low-risk patients treated with densification of R-chemo regimens) trial, patients with an age-adjusted IPI of 0 with bulky (>7.5 cm) disease or IPI of 1 were randomly assigned to R-CHOP with or without RT to bulky and/or extranodal disease. However, RT may be beneficial in specific high-risk patients or following insufficient response to immunochemotherapy. Currently, there is a tendency to forego RT in patients with limited-stage DLBCL based on the data in low-risk patients. The authors should be commended for performing this study and addressing the prognostic significance of extranodal presentation in stage I DLBCL and demonstrating that these patients may benefit from RT, especially if PET after chemotherapy is positive. Overall, these findings suggest that PET-positive patients with extranodal presentation may benefit from RT (see figure). Further, the benefit of RT was no longer observed in patients with negative PET at the end of immunochemotherapy. In a landmark analysis of patients alive at 6 months after diagnosis who had PET imaging at the end of chemotherapy prior to RT, a positive scan was not associated with shorter PFS in the whole cohort and in patients with extranodal disease. In multivariate analyses, RT consolidation was associated with longer OS and PFS in the extranodal patients, but no such analysis could be performed in patients with nodal disease due to a small number of events. Using a multinomial propensity score weighted analyses, the authors found that patients with extranodal disease had shorter OS and PFS than patients with nodal involvement. The 5-year disease-free survival and OS of all patients were 77% and 94%, respectively. Treatment response was assessed by PET in 93% of patients. Patients were treated with R-CHOP or R-CHOP-like regimens with or without RT. Bobillo et al report the results of a retrospective analysis of 354 stage I DLBCL patients (66% extranodal and 34% nodal) without any inclusion restrictions.
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