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Lymphoma and Radiation


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The use of radiation therapy in the treatment of Lymphoma

The use of radiation therapy in the treatment of Lymphoma

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  • 1. Lymphoma and RadiationRobert Miller
  • 2. New Cancer Cases Per YearLymphoma is # 7 in men and # 6 in women
  • 3. Cancer Deaths Per YearLymphoma is # 9 in men and # 7 in women
  • 4. Median Age of People Diagnosed in2005- 2009All Sites: 66yHodgkins 38yNon-Hodgkins 66y
  • 5. Lymphomas in 2013Hodgkin 9,290 (12%)Non-Hodgkin’s 69,740 (88%)Thomas Hodgkin 1798-1866
  • 6. What isLymphoma?Lymphoma is a cancer that arises from a mutation by acell that is part of the lymphatic system.The lymphatic system includes the lymphocytes, lymphnodes and other parts of the lymphatic system includethe spleen, thymus, tonsils and bone marrow
  • 7. What is aLymphocyte?A lymphocyte is a type of white blood cell in theimmune system, can be divided into large lymphocytesand small lymphocytes. Large granular lymphocytesinclude natural killer cells (NK cells). Small lymphocytesconsist of T cells and B cells.
  • 8. Stem cellsdifferentiate intoseveral kinds ofblood cell within thebone marrowB cells mature into Blymphocytes in thebone marrow while Tcells migrate to andmature in thethymus.Then they enter thecirculation andperipheral lymphoidorgans (e.g. thespleen and lymphnodes) where theysurvey for invadingpathogens and/ortumor cells.
  • 9. Cluster of differentiation (cluster of designation) (oftenabbreviated as CD) is commonly used as cell markersin immunophenotyping allowing cells to be definedbased on what molecules are present on theirsurface.
  • 10. Circulating LymphocytesT lymphocytes 70%B lymphocytes 23%NK Cells 7%B cell make up only 23% of circulatinglymphocytes but account for 90% of lymphoma
  • 11. Prognosis and Treatment forLymphoma Stage Histologic type◦ Non-Hodgkin’s or Hodgkin◦ B cell or T cell◦ Indolent of aggressive Other risk factors of advanced disease
  • 12. Specific Prognosis Factors forHodgkin Wide mediastinal mass ( > .33) Bulky mass (10 cm or bigger) Multiple site, ESR > 50, B symptoms Age over 45, male gender Anemia or low albumin
  • 13. Types of LymphomaAll malignancies are based on theoriginal cell that ‘goes bad’ or mutatesSince the immune system is so complexthe number of distinct lymphomas isnow immense and growing
  • 14. Classification of NHL (Non-Hodgkins)
  • 15. Classification of NHL (Non-Hodgkins)
  • 16. Classification of NHL (Non-Hodgkins)
  • 17. Classification of HodgkinsLymphocyte Predominant (LPHL) (5%)Classical Hodgkin’s (CHL) (95%)- Nodular Sclerosis (NSHL)- Mixed Cellularity (MCCHL)- Lymphocyte-depleted (LDCHL)- Lymphoxcyte-rich (LRCHL)
  • 18.
  • 19. Treatment for NHL LymphomaMost patients are treated with drugtherapy (chemotherapy or moleculartargeted therapy).So many different types of lymphomathe options range from no initialtherapy for slow growing (low grade orindolent) lymphomas to very intensivechemotherapy and bone marrowtransplant for aggressive lymphomas
  • 20. Cluster of differentiation (cluster of designation) (oftenabbreviated as CD) is commonly used as cell markersin immunophenotyping allowing cells to be definedbased on what molecules are present on theirsurface.
  • 21. CD 20: Normal B Cells and 90% of B Cell NHLbut not on Stem Cells or Plasma CellsPluripotentStem CellLymphoidStem CellPre-B Cell B Cell ActivatedB CellPlasmacell
  • 22. Rituximab AntibodyAntibody bindingReceptorAntibodyComplexCD20B CellLymphocyte
  • 23. After Rituximab binds to the CD20 receptor on the BCell it leads to death of the cell by multiplemechanisms
  • 24. ToposomeraseinhibitorAlkylationagentsAntimetabolitesTaxanesVinka alkaloidsDividing CancerCellTraditional Chemotherapy and Mechanism of Action
  • 25. Rituxan, Zevalin, BexxarMylotargCampathVelcadeGleevacSprycelHerceptinErbituxVectibixAvastinNexavarSutentTykerbTarcevaIressaSolid TumorsHematologic MalignanciesTargetedTherapies
  • 26. Zevalin, is a monoclonalantibody radioimmunotherapy usesantibody to which a radioactiveisotope of yttrium-90Once the antibodyattached to the CD20receptor or the B cell theradioactivity form yttriumkills the cancer cell
  • 27. Bexxar is anti-CD20 monoclonal antibody bound to theradionuclide iodine-131 which emits both beta and gammaradiation
  • 28. Role for Conventional Radiationin NHL? SLL localized Follicular Lymphoma early stage Gastric MALT (H. pylori negative) Nongastirc MALT localized Mantle Cell, early stage Diffuse Large B Cell (esp bulky) Cutaneous B-Cell Peripheral T-Cell Mycosis Fungoides Extranodal NK-T
  • 29. Radiation Technique for NHL Volume is IF (involved field) just thenode involved based on original size Generally Low Dose
  • 30. Low Dose Radiation for NHL
  • 31. Is there still a role for radiation in thetreatment of Hodgkin Lymphoma?Henry Kaplan atStanford pioneered theuse of the linearaccelerator andradiation treatment ofHodgkins in the 1960and 1970’s
  • 32. Role for Radiation inHodgkin’s? Lymphocyte-predominant early stagemay need radiation only Early stages use involved site (IS)radiation combined with limitedchemoRx (usually ABVD) or moreintensive chemoRx alone with noradiation High Risk (bulky or unfavorable) addradiation to chemoRx
  • 33. Radiation Doses forHodgkin’s
  • 34. 1370 patients with newly diagnosed early-stageHodgkins lymphoma with a favorable prognosis toone of four treatment groups (German HD10 Trial)N Engl J Med 2010; 363:640-652Chemo IF XRT 8 YearSurvivalABVD X 4 30Gy 94.4%ABVD X 4 20Gy 94.7%ABVD X 2 30Gy 93.6%ABVD X 2 20Gy 95.1%
  • 35. Long Term Risks of RadiationRadiationfieldTissue damage (espthe lungs, heart orthyroid or bonemarrow) and causingnew cancers (espbreast or leukemia)
  • 36. Long Term Health Risk after chemoradiationfor early stage Hodgkin’s
  • 37. ABVD Alone versus Radiation-Based Therapy (SNI)in Limited-Stage Hodgkins LymphomaHD6 TrialN Engl J Med 2012; 366:399-408
  • 38. Lymphoma and RadiationRobert Miller