Terry Lee, MD November 2014 Slide 2 Radiation in Lymphoma The
trend over the years has been to increase chemotherapy and decrease
radiation for treatment. Radiation volume has decrease over time
Total nodal radiation Mantle radiation Involved field radiation
Radiation dose has decrease over time 45 to 50 Gy 20 to 36 Gy Slide
3 Nodal Regions Slide 4 Radiation in Hodgkin Stage IA, IIA
Favorable Chemotherapy alone Combined Chemotherapy (ABVD or
Stadford V) Restage PET after 2 or 4 cycles If complete response on
PET Involved field radiation 20 to 30 Gy Slide 5 Radiation in
Hodgkin Stage I, II unfavorable or bulky disease Chemotherapy alone
Combined Chemotherapy Restage PET after 4 cycles If complete
response on PET Additional 2 cycles of chemotherapy Or involved
field radiation 30 Gy Slide 6 Radiation in Hodgkin Stage III, IV
Chemotherapy alone Restage PET If complete response on PET
Additional chemotherapy Optional involved field radiation to
original bulky site of disease Slide 7 Radiation in Hodgkin Stage
IA, IIA Nodular Lymphocyte predominant Hodgkins disease Involved
field radiation 30 to 36 Gy Slide 8 Hodgkins Case Example 26 year
old male with 2 months history of left lower neck mass. No B
symptoms. Excisional biopsy was positive Hodgkins lymphoma, mixed
cellularity. Bone marrow was negative. PET scan showed uptake in
the left neck, left supra and infraclavicular nodes. Stage IIA. 4
cycles of ABVD Restaging PET scan showed no uptake Slide 9
Prechemotherapy PET Slide 10 Restaging PET Slide 11 Radiation Field
Slide 12 Radiation 20 Gy in 10 fractions Mandible is out of the
field Salivary gland is out of the field Esophagus is out of the
field Possible acute side effects Fatigue Mild redness of the skin
Possible long term side effects Thyroid Secondary malinancy Slide
13 Radiation for NHL Low grade/Indolent NHL Grade 1-2 follicular
lymphoma Radiation for stage I and II Intermediate grade NHL
Diffuse Follicular grade 3 Radiation for stage I and II High grade
NHL Lymphoblastic Burkitts Radiation rarely used Slide 14 Radiation
for NHL Low grade stage I and II NHL Involved field radiation is
the preferred treatment Other options include chemotherapy or
observation 24 to 30 Gy 10 year overall survival 70% Slide 15
Radiation for NHL Intermediate grade NHL Diffuse large B cell
lymphoma Stage I, II nonbulky RCHOP followed by involved field
radiation RCHOP plus or minus involved field radiation Stage I, II
bulky RCHOP plus or minus involved field radiation 30 to 36 Gy
Slide 16 Radiation for NHL Gastric MALT Lymphoma Stage I or II and
H. pyloric negative Involved field radiation to 30 Gy Nongastric
MALT lymphoma Stage I or II Involved field radiation to 30 Gy
Mycosis Fungoides, cutaneous lymphoma 20 to 30 Gy Palliative
treatment 20 to 30 Gy Slide 17 Radiation Used for Therapy Electrons
High energy electromagnetic wave (photons) X-ray Gamma ray E
electric field M magnetic field Slide 18 Slide 19 Linear
Accelerator Slide 20 6 to 23 MeV Slide 21 Bremsstrahlung Slide 22
y1 n y2 n x1 n x2 n xA i,n Y1 X1 X2 Leaf A i xB i,n Leaf B i Varian
Tertiary MLC Beam Shaping Slide 23 Slide 24 Radiobiology DNA Slide
25 Radiation Tolerance Radiation tolerance depends on: Total dose
Dose per fractionation Volume of tissue treated TD 5/5 is 5%
probability of severe damage in 5 years TD 50/5 is 50% probability
of severe damage in 5 years Slide 26 TD 5/5 (Gy) Volume TD 50/5
(Gy) Volume Organ 1/3 2/3 3/3 1/3 2/3 3/3 End point Kidney
503023--4028 Clinical nephritis Brain 605045756560 Necrosis/
infraction Brain stem 605350-- 65 Necrosis/ infraction Ear(Mid/Ext)
30 40 Acute serious otitis Ear(Mid/Ext) 55 65 Chronic serious
otitis Esophagus 605855727068 Clinical stricture/ perforation Heart
604540705550 Pericarditis Bladder --8065--8580 Symptomatic bladder
contracture and volume loss Slide 27 TD 5/5 (Gy) Volume TD 50/5
(Gy) Volume Organ 1/3 2/3 3/3 1/3 2/3 3/3 End point Larynx 7970
9080 Cartilage necrosis Larynx --45 -- 80 Laryngeal edema Liver
503530554540 Liver failure Lung 453017.5654024.5 Pneumonitis Skin
10cm 2 70 30cm 2 60 100cm 2 55 10cm 2 -- 30cm 2 -- 100cm 2 70
Necrosis/ ulceration Small intestine 50--4060--55 Obstruction/
perforation Colon 55--4565--55 Obstruction/ perforation/
ulceration/fistula Spinal cord 5cm 50* 10cm 50 20cm 47 5cm 70* 10cm
70 20cm -- Myelitis/necrosis Slide 28 Radiation Side Effects Common
side effects Fatigue Redness of the skin Severity of the side
effects should be less than typically seen for other cancer
treatment with radiation that uses doses of 60 to 70 Gy. Slide 29
Radiation Side Effects Organ specific side effects Head and neck:
Dry mouth, decrease taste, dental problems, hypothyroid, sore
throat, hair loss Manage with fluoride treatments, magic mouth
wash, and thyroid replacement therapy Chest: Esophagitis, cough,
Lhermittes syndrome Manage with magic mouth wash and cough
medication. If severe, use steroid. Abdomen and pelvis: Nausea and
diarrhea are most common Fertility issues (move ovaries for
radiation)
