Adjuvant Scrotal Radiation Therapy As Bridging Therapy to Chimeric Antigen Receptor T-Cell Following Extramedullary Relapse in B-Cell Acute Lymphoblastic Leukemia

Chimeric antigen T-cell (CAR T) therapy is a promising emerging treatment option for patients with relapsed/refractory acute lymphoma. The role of bridging radiotherapy prior to CAR T infusion is an area of increasing interest with a sizable body of literature regarding its use in non-Hodgkin lymphoma, but reports of its use in leukemia are limited. Furthermore, available literature on bridging radiotherapy is limited to the treatment of bulky, often symptomatic disease, as opposed to its role in treating high-risk regions and sanctuary sites. Here, we present an adult male with multiply relapsed B-cell acute lymphoblastic leukemia (B-ALL) who presented with bone marrow relapse and extramedullary relapse in the right testicle. He was successfully treated with right orchiectomy followed by adjuvant bridging radiotherapy to the left testicle and scrotum, followed by CAR T infusion. Under this treatment paradigm, he tolerated the CAR T infusion with minimal toxicity and was without evidence of disease 100 days post-infusion, with normal testosterone levels. This is the first reported case of bridging radiation being used in the adjuvant setting in a patient with hematologic malignancy. This case adds to the growing body of literature that bridging radiation is well-tolerated and can potentially decrease the risk of relapse in high-risk areas following CAR T infusion.