Would you offer scrotal radiation to a patient with a stage IIE bilateral testicular DLBCL treated with a bilateral orchiectomy and chemotherapy?

Bilateral orchiectomy is considered an alternative for those who refuse ISRT to the testicles, so I agree with you that there does not appear to have strong indication for RT in this case. However, there may be a lot of other nuances to this case. I would talk to the surgeon to make sure there was no spillage and the pathologist to make sure there was not positive margin or other concerning pathological features that would suggest high likelihood of microscopic disease.

Assuming that is all negative, I would also talk to the medical oncologist regarding whether they have any good salvage options left, ie is transplant an option should the tumor recur. If that's not an option, then I think it's reasonable to do all you can now to minimize the risk of relapse, as you may only have 1 shot for this case. Irradiation of the scrotum without intact testicles is not very morbid and there is limited clinical data on these cases who were treated without RT (at least to my knowledge), so I would also discuss that with the patient.

On a totally separate point, if those nodes were not bulky, not sure if there is strong data that consolidative RT is indicated after early PET-CR and especially after 6c of RCHOP. In fact, there is level I evidence showing that is not beneficial, eg Lamy et al (Blood. 2018;131(2):174-181). However, if those nodes were bulky, then I would favor adding RT.

Jiayi Huang

Washington University

I don’t see any benefit for scrotal RT as it is not sanctuary site nor has any blood scrotal barrier where chemo would not reach and take care of microscopic disease