Radiotherapy contraindicated or declined for early-stage NLPBL (nodular lymphocyte-predom...

Deterministic view of the source YAML entity. Clinical authority remains with the cited source IDs and reviewer sign-off state.

ID	`RF-NLPBL-RT-CONTRAINDICATED`
Type	Red flag
Status	reviewed 2026-05-08 \| pending_clinical_signoff
Diseases	`DIS-NLPBL`
Sources	`SRC-NCCN-BCELL-2025`

Red Flag Origin

Definition	Radiotherapy contraindicated or declined for early-stage NLPBL (nodular lymphocyte-predominant B-cell lymphoma, WHO 5th ed). Major clinical scenarios: (1) Young patient with breast or thyroid field overlap — cumulative RT dose risk of secondary malignancy and cardiac toxicity unacceptable; (2) Prior RT to the involved or adjacent region — reirradiation risks exceed benefit; (3) Patient refuses RT after informed discussion. In all scenarios rituximab monotherapy (4–8 × R weekly) achieves ~94% ORR with ≥70% CR in early-stage NLPBL (Advani 2014, IELSG-37 data) and is the accepted standard alternative. RT remains the default for eligible patients where field is safe and patient consents (stage IA-IIA, ≤2 cm).
Clinical direction	de-escalate
Category	fitness-eligibility
Shifts algorithm	ALGO-NLPBL-1L

Trigger Logic

{
  "any_of": [
    {
      "finding": "rt_contraindicated",
      "value": true
    },
    {
      "finding": "radiotherapy_contraindicated",
      "value": true
    },
    {
      "finding": "prior_rt_to_field",
      "value": true
    },
    {
      "finding": "prior_radiotherapy_adjacent_field",
      "value": true
    },
    {
      "finding": "breast_field_rt_overlap",
      "value": true
    },
    {
      "finding": "thyroid_field_rt_overlap",
      "value": true
    },
    {
      "finding": "patient_refuses_radiotherapy",
      "value": true
    },
    {
      "finding": "rt_patient_preference",
      "value": "declined"
    }
  ],
  "type": "treatment_contraindication"
}

Notes

Only applies after step 1 confirms early-stage (IA-IIA) disease — advanced NLPBL routes to R-CHOP at step 1 before this RF fires. RT-field safety is a nuanced clinical judgment: 'breast field overlap' applies most to left-axillary or mediastinal-adjacent presentations in premenopausal women; thyroid overlap relevant for high cervical/upper mediastinal nodes. MDT coordination with radiation oncology to assess field feasibility is recommended before classifying RT as contraindicated. Note: NLPBL differs from classic Hodgkin lymphoma — ABVD is NOT appropriate (CD20+ B-cell; rituximab is the active backbone). IELSG-37 RCT (rituximab mono vs ISRT vs observation for very-favorable NLPBL) provides the comparative evidence base; pending mature OS data. Draft pending two-reviewer clinical co-lead signoff (CHARTER §6.1).

Used By

Algorithms

ALGO-NLPBL-1L - ALGO-NLPBL-1L