Radiotherapy in lymphoma(dr fadavi)-001

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radiotherapy in lymphoma

radiotherapy in lymphoma

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  • 1. When should radiotherapy beused in lymphoma?Friday, May 24, 2013Tehran, IranPedram Fadavi MDRadiation Oncologist, IUMS
  • 2. Roentgen’s laboratory
  • 3. Until 1960s Radiotherapy was theonly non surgical treatment forlymphoma
  • 4. Current issues in lymphomaradiotherapy• Who to treat• What volume to irradiate• What dose to use
  • 5. Overview• Why use radiotherapy to treat lymphomas• Practicalities of radiotherapy delivery- Why fractionate- Treatment planning and delivery• Indications for external beam radiotherapyin:-Hodgkin lymphoma-Non Hodgkin lymphoma
  • 6. Why use radiotherapy to treatlymphomas?• Lymphoma is very radiosensitive• Relatively small doses of radiotherapy arerequired• Local relapse within an irradiated area israre• Radiotherapy fields are now smaller,reducing late toxicities
  • 7. Differential effects of irradiation ontumour and normal tissue
  • 8. Therapeutic Ratio
  • 9. Practicalities of radiotherapy• Patient must be able to lie still
  • 10. Radiotherapy Planning (1)• Identify the treatment volume-Essential to have pre-chemotherapy imaging- Need up to date diagnostic imaging- Radiotherapy planning scan• Treatment volumes- The visible tumor (GTV)- Sites of possible microscopic disease (CTV)- The area to be treated with a margin to allowfor movement and set up accuracy (PTV)
  • 11. Radiotherapy Planning (2)Considering the best way to deliver theradiotherapy• Ensure that PTV receives the intendedtreatment dose• Minimise the dose to normal surroundingtissues- Conform fields to treatment volume- Field arrangements
  • 12. Use of PET to identify the GTVTerezakis SA, Yahalom J. 2011
  • 13. what is the role for RT as part ofcombined-modality treatment inaggressive lymphoma?
  • 14. RT in indolent lymphomas
  • 15. IFRT remains the treatment of choice of for localizedstage IA and selective stage IIA patients and deliverslong-term disease-free survival and potential cure forsome patients.
  • 16. The conventional dose of curative RT used inthe early studies was considerably larger at30–40 Gy. However, a British randomized studydemonstrated equivalence of 24 Gy with 40 Gy.
  • 17. Localized LDRT appears to induce apoptosis and thisfollicular lymphoma cell death may then elicit a hostimmune response mediated by macrophages anddendritic cells.This exquisite radiation-induced apoptosis andsubsequent immune response may underlie thedurability of responses seen with both LDRT andradioimmunotherapy (RIT).
  • 18. What is the role for RT in the modernmanagement of HL?
  • 19. Identify the risksGHSG EORTC StanfordRisk Factors a- Bulky mediastinum a-Bulky mediastinum a-Bulky mediastinumb-Extranodal disease b- Age >=50 b-Age>=40ESR>=50 with noc-ESR>=50 with out B symptoms c-B symptoms c- ESR >=50Or >=30 with B symptoms Or >=30 with B symptomsd->=3 nodal sites d->=4 nodal sites D->=3 nodal sitesGHSG EORTC StanfordFavorable CS I-II CS I-II CS I-IINo risk factors No risk factors No risk factorsUnfavorable CS I- IIA with >=1 CS I- IIA with >=1 CS I- IIA with >=1risk factor risk factor risk factorCS IIB with c or dnot a+b (otherwiseadvanced)
  • 20. The use of RT also allows a shorter andsafer course of chemotherapy.
  • 21. The combination of reduced chemotherapyfollowed by mini-RT has produced diseasecontrol and even overall results that aresignificantly superior to those achieved withchemotherapy alone.
  • 22. .
  • 23. The analysis included five randomized controlledtrials involving 1245 patients. Although the completeremission rate was similar in the two groups, bothtumour control and OS were significantly better inpatients receiving combined-modality therapy.
  • 24. The authors’ conclusions were that adding RT tochemotherapy improves tumour control and OS inpatients with early-stage HL.
  • 25. The conclusion from these studies was that after fourcycles of ABVD, 30 Gy is recommended for early-stageunfavourable Hodgkin lymphoma,whereas 20 Gy isadequate for early-stage favourable Hodgkin lymphomaafter two cycles ABVD.
  • 26. Involved-site Radiotherapy
  • 27. The principal distinction between involved-noderadiotherapy and involved-site radiotherapy isthat no additional margin around the nodevolume is added in involved-node radiotherapy.Typical margins are as follows:(a) Head and neck: 0.5-1 cm, depending on local set-up.(b) Mediastinum: 1 cm transversely and 1.5 cm craniocaudally(c) All other sites: 1 cm.
  • 28. This is based on defining the site of grossdisease before chemotherapy, the GTV andusing a CT-based volume with anexpansion to form a CTV in the cranio-caudal direction. The post-chemotherapyinvolved nodal chain and residual diseaseform the CTV in all other directions.
  • 29. Involved Field(A&B) v Involved Site(C&D)RadiotherapyGrinsky, et al 2006
  • 30. Involved field v involved siteradiotherapyGrinsky, et al 2006
  • 31. Involved site radiotherapyleft neck
  • 32. Involved site radiotherapymediastinum
  • 33. Role of RT in Advanced Hodgkin DiseaseOffering RT after effective chemotherapy is not standardpractice and is still undergoing investigation.
  • 34. Although a meta-analysis and studies by the GELAand EORTC groups showed no benefit ofconsolidation RT after effective chemotherapy withsuggestions of worsened outcome when RT wasadded, more recent data have emerged from 2 largerandomized control trials (RCT) in support ofconsolidation RT.
  • 35. .
  • 36. Indications for radiotherapy inDLBC NHL• In early stage disease with short coursechemotherapy• In advanced disease- Bulky disease at the outset (MINT Study,Pfreundschuh 2008))• Risk of relapse increases with size of mass• Should irradiate masses >10cm at diagnosis- PET positive at the end of treatment (Sehn et al,2010)• Dose 30 Gy in 15 # (Hoskin et al, 2011)
  • 37. Current evidence-based recommendations for radiation doses inlymphoma are shown below:Hodgkin lymphoma1.Early-stage favourable Hodgkinlymphoma, after two cycles of ABVD,may be treated with 20 Gy.2.Early-stage unfavourable, or forresidual or refractory disease inadvanced Hodgkin lymphoma, shouldreceive 30 Gy.3.If early-stage unfavourable disease istreated using BEACOPP rather thanABVD, the dose may be reduced to20 Gy.
  • 38. Non-Hodgkin lymphoma1.Indolent lymphomas (follicular,marginal zone, small lymphocytic orchronic lymphocytic lymphoma (CLL)should be given 24 Gy in 12 fractions.2.In the palliative setting, follicularlymphoma patients will respond to 4 Gyin two fractions.3.Natural killer cell lymphoma shouldreceive at least 50 Gy in 25 fractions.4.All other non-Hodgkin lymphomasshould receive 30 Gy in 15 fractions
  • 39. The planning of radical radiotherapy for lymphomapatients, both Hodgkin and non-Hodgkin lymphoma,should be based upon contrast-enhanced 3 mmcontiguous CT imaging with three-dimensionaldefinition of volumes using the convention of GTV, CTVand PTV.
  • 40. All patients should be treated with involved-siteradiotherapy unless no pre-chemotherapyimaging is available,when involved-fieldradiotherapy is used.