Evolution of Radiation Fields from Involved Field to Involved Site—A Summary of the Current Guidelines by the International Lymphoma Radiation Oncology Group

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The purpose of this manuscript is to summarize, and perhaps provide further direction, on published ILROG guidelines. I get the sense that in some circumstances, the authors may overreach by providing an interpretation of ILROG guidelines that may not be universally accepted (such as giving a specific PTV expansion). I suppose it would be important for the authors to specifically state if they are authorized, by ILROG, to provide this summary.

In regards to specifics of the manuscript:

1. Table 1- I would recommend collapsing the 4D and DIBH bullets into one and simply remind readers that respiratory motion management is important in thoracic and upper abdominal presentations. For example, you don't need a 4D simulation if you are doing DIBH. In regards to DIBH, in addition to mediasitnal disease, patients with upper abdominal disease often also benefit from DIBH (e.g., gastric lymphoma).

2. Line 116- I think 10 mm PTV expansion is excessive, in almost any case. Rather than list this number, it would be preferable for the authors to provide the general principles of PTV expansions and how they can be reduced (e.g., daily image guidance, doing a 4D CT to account for respiratory motion, good immobilization). It seems counter productive to talk about decreasing field sizes to reduce toxicity and then even suggest a 10 mm PTV expansion when daily imaging, good immobilization, and respiratory management should be able to reduce this significantly in almost every location.

3. Figure 2- it is very, very hard to see the contours on panel C. Further, it states that DIBH would have been preferable. I don't see why for disease in the axilla. I think that statement is unnecessary (especially since the patient wasn't even treated with DIBH. I would also state what the disease is that is being treated and the clinical circumstances, as that affects ISRT fields. 

4. Table 2 is where I have the most problems with this manuscript. I think the authors are being more proscriptive than necessary and even giving guidance that isn't universally accepted. For example;

a. First box- "For irradiation of residual mass after chemotherapy in advanced disease...." a margin of 10 mm is used. Why 10 mm? Where does that come from? Is that a uniform expansion or does it exclude normal tissues. 

b. First box- ITV expansion- Why a margin of 1.5-2 cm craniocaudal. The whole purpose of the 4D is to determine a customized margin to account for the actual patient's respiratory motion. I don't understand why specific numbers are provided (which seem excessive in most cases)

c. First box- Again, a 10 mm PTV expansion seems excessive

d. Second box (extranodal NHL)- Not all definitive RT cases require whole involved organ and not all combined modality programs will be optimally treated with partial organ (due to location, initial extent of disease). I think the authors are being too proscriptive for such a large number of disease with such a large array of presentations.

d. The CTV for primary ocular lymphoma (and PCNSL with ocular disease) does not have to include the entire globe. The anterior structures, in front of the lens, are not at risk and can be avoided. I would make th

e. Dura mater lymphoma- I would not generally advocate WBRT for a dura mater lymphoma, which is typically low-grade.

f. Doe the entire parotid need to be treated in all cases of NHL??

g. Gastric DLBCL and Gastric MALT are treated differently- with Gastric MALT, the entire stomach should be treated. For gastric DLBCL, which often just involves the pylorus, the entire stomach does not always need to be treated.

h. Most FL of the duodenum involve the 2nd portion only. I don't think you need to treat the entire 3rd and 4th portions. Again, the authors are being very proscriptive which may not reflect actual clinical practice.

 

Comments on the Quality of English Language

While the paper is readily understandable, many sentences are quite awkward with unusual usage of various words. One example is "thyroideal". I would highly recommend a native English speaker revise the entire paper to make it flow smoothly.

Author Response

We thank the reviewers for their productive input to increase the value of this manuscript.

In The attached document, we provide a detailed response to the issues raised in the review, as well as measures taken.

Yours sincerely,

the authors

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This article offers a summary of modern guidelines in lymphoma radiotherapy. It does not add much to what has already been published but, considering the importance of the topic, any review that highlights the modern radiotherapy approach in lymphomas is well appreciated. 

Author Response

We thank the reviewer for their kind report and their support in publishing this paper