1. Hodgkin's lymphoma is a type of lymphoma that was initially described as an inflammatory disease but is now recognized and treated as a malignant lymphoma.
2. Treatment has evolved from radiation alone to a combined approach using chemotherapy and radiation or chemotherapy alone. Common chemotherapy regimens include ABVD and BEACOPP. Radiation therapy doses and fields depend on disease stage and other factors.
3. Side effects of treatment depend on factors like radiation dose, fields, and prior chemotherapy. Acute side effects are usually mild and resolve over time. Late effects can include hypothyroidism, infertility, and in rare cases pneumonitis or pericarditis. Ongoing research aims to reduce treatment
This presentation reviews the current neurosurgical management of patients with medulloblastoma, including the data on molecular subtyping; uses “medulloblastoma” as a springboard to discuss other topics / tumor cell biology in general; and formulates research questions to further advance neurosurgical basic science.
Medulloblastomas are the most common malignant brain tumors in children. They arise in the cerebellum and can spread through the CSF pathways. Complete surgical resection followed by craniospinal irradiation is the main treatment approach. CSI provides improved local and systemic tumor control compared to other radiation techniques based on early studies. Medulloblastomas are highly radiosensitive tumors, making radiation an important part of management, though younger patients and those with residual disease or metastasis have poorer outcomes.
Hodgkin’s disease was initially described as an inflammatory
disease (hence the term “disease”), but is clearly
recognized and treated as a malignant lymphoma (hence the
more accurate term Hodgkin’s lymphoma (HL) is used
synonymously with Hodgkin’s disease).
The management of Hodgkin’s lymphoma has evolved from
extended-field radiation alone as the main therapy to a
combined-modality approach with
chemotherapy and radiation, or chemotherapy alone.
Painles lymphadenopathy
Systemic symptoms- unexplained fevers, drenching night sweats, weight loss, generalize pruritus, fatigue, and alcohol-induced pain in tissues involved by HD
Mediastinal mass on a routine chest radiograph
90% of patients present with contiguous sites of involvement or Extension from adjacent lymph nodes
Hematogenous (liver or multiple bony sites) Involvement of the bones may cause blastic changes, especially in the vertebrae (creating the classic “ivory vertebra” on plain radiographs), pelvis, sternum, or ribs
Nearly all patients with hepatic or bone marrow involvement by Hodgkin lymphoma have extensive involvement of the spleen
Rare- Gut-associated lymphoid tissues such as Waldeyer ring and Peyer patches, Upper aerodigestive tract, Central nervous system, and Skin
This document summarizes a presentation on the management of primary central nervous system lymphoma. It discusses the epidemiology, pathogenesis, clinical features, investigations including imaging and pathology, prognostic factors, treatment including chemotherapy protocols and radiation therapy techniques, and a review of literature on clinical trials. The review of literature summarizes 11 key studies comparing outcomes of different chemotherapy regimens, use of whole brain radiation therapy, and impact on survival and neurotoxicity.
Dr Vandana, cranio spinal irradiation, radiotherapy, medulloblastoma, cancer, radiation, treatment, diagnosis, management, natural history of medulloblastoma, signs & symptoms of medulloblastoma,
current approach, future advancements
1) Medulloblastoma is the most common malignant brain tumor in children. It arises in the cerebellum and has a tendency to metastasize through the CSF pathways.
2) It is classified into molecular subgroups - WNT, SHH, Group 3, and Group 4 - which have different characteristics and predict survival outcomes.
3) Treatment involves maximal safe surgical resection followed by craniospinal radiation and chemotherapy based on risk stratification into standard-risk and high-risk groups. Modified radiation schedules are being studied to reduce long-term side effects.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
This document provides an overview of non-Hodgkin lymphomas (NHL). Key points include:
- NHL are a heterogeneous group of malignancies characterized by abnormal proliferation of B, T, or NK cells.
- The main subtypes seen in India are B-cell lymphomas (80-85%) and T-cell lymphomas (15-20%).
- Diagnostic workup involves clinical evaluation, laboratory/radiologic testing, and tissue biopsy for classification.
- Staging and risk stratification inform treatment selection which may include chemotherapy, immunotherapy, radiation, stem cell transplant, or observation depending on the NHL subtype and stage.
This presentation reviews the current neurosurgical management of patients with medulloblastoma, including the data on molecular subtyping; uses “medulloblastoma” as a springboard to discuss other topics / tumor cell biology in general; and formulates research questions to further advance neurosurgical basic science.
Medulloblastomas are the most common malignant brain tumors in children. They arise in the cerebellum and can spread through the CSF pathways. Complete surgical resection followed by craniospinal irradiation is the main treatment approach. CSI provides improved local and systemic tumor control compared to other radiation techniques based on early studies. Medulloblastomas are highly radiosensitive tumors, making radiation an important part of management, though younger patients and those with residual disease or metastasis have poorer outcomes.
Hodgkin’s disease was initially described as an inflammatory
disease (hence the term “disease”), but is clearly
recognized and treated as a malignant lymphoma (hence the
more accurate term Hodgkin’s lymphoma (HL) is used
synonymously with Hodgkin’s disease).
The management of Hodgkin’s lymphoma has evolved from
extended-field radiation alone as the main therapy to a
combined-modality approach with
chemotherapy and radiation, or chemotherapy alone.
Painles lymphadenopathy
Systemic symptoms- unexplained fevers, drenching night sweats, weight loss, generalize pruritus, fatigue, and alcohol-induced pain in tissues involved by HD
Mediastinal mass on a routine chest radiograph
90% of patients present with contiguous sites of involvement or Extension from adjacent lymph nodes
Hematogenous (liver or multiple bony sites) Involvement of the bones may cause blastic changes, especially in the vertebrae (creating the classic “ivory vertebra” on plain radiographs), pelvis, sternum, or ribs
Nearly all patients with hepatic or bone marrow involvement by Hodgkin lymphoma have extensive involvement of the spleen
Rare- Gut-associated lymphoid tissues such as Waldeyer ring and Peyer patches, Upper aerodigestive tract, Central nervous system, and Skin
This document summarizes a presentation on the management of primary central nervous system lymphoma. It discusses the epidemiology, pathogenesis, clinical features, investigations including imaging and pathology, prognostic factors, treatment including chemotherapy protocols and radiation therapy techniques, and a review of literature on clinical trials. The review of literature summarizes 11 key studies comparing outcomes of different chemotherapy regimens, use of whole brain radiation therapy, and impact on survival and neurotoxicity.
Dr Vandana, cranio spinal irradiation, radiotherapy, medulloblastoma, cancer, radiation, treatment, diagnosis, management, natural history of medulloblastoma, signs & symptoms of medulloblastoma,
current approach, future advancements
1) Medulloblastoma is the most common malignant brain tumor in children. It arises in the cerebellum and has a tendency to metastasize through the CSF pathways.
2) It is classified into molecular subgroups - WNT, SHH, Group 3, and Group 4 - which have different characteristics and predict survival outcomes.
3) Treatment involves maximal safe surgical resection followed by craniospinal radiation and chemotherapy based on risk stratification into standard-risk and high-risk groups. Modified radiation schedules are being studied to reduce long-term side effects.
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
This document provides an overview of non-Hodgkin lymphomas (NHL). Key points include:
- NHL are a heterogeneous group of malignancies characterized by abnormal proliferation of B, T, or NK cells.
- The main subtypes seen in India are B-cell lymphomas (80-85%) and T-cell lymphomas (15-20%).
- Diagnostic workup involves clinical evaluation, laboratory/radiologic testing, and tissue biopsy for classification.
- Staging and risk stratification inform treatment selection which may include chemotherapy, immunotherapy, radiation, stem cell transplant, or observation depending on the NHL subtype and stage.
Medulloblastoma- A primitive neuroectodermal tumors (PNETs) is the most common malignant brain tumor of childhood (WHO IV)
arising from the vermis in the inferior medullary velum.
It comprises up to 18% of all pediatric brain tumors.
WNT and Shh pathway plays major role in its pathogenesis.
c-erbB-2 (HER2/neu) oncogene expression has prognostic value. Norcantharidin, Vismodegib, Sonidegib are the future in medulloblastoma.
This document discusses the management of primary central nervous system lymphoma (PCNSL). It begins with defining PCNSL and discussing its epidemiology, which includes that it is a rare brain tumor with an increasing incidence in immunocompromised patients. The standard treatment involves high-dose methotrexate-based chemotherapy followed by whole brain radiotherapy, which provides the best outcomes compared to other regimens. Prognostic scoring systems can help determine a patient's prognosis based on factors like age, performance status, lactate dehydrogenase levels, and tumor location. Ongoing research is evaluating adding agents like cytarabine, thiotepa, and rituximab to standard chemotherapy regimens to improve survival further
Principles of medical_oncology dr. varunVarun Goel
- The document discusses several key principles of medical oncology including that cancer treatment is multidisciplinary, early stage cancers are more curable than late stage, and the best treatment is often found in clinical trials.
- It describes the basic tenets of chemotherapy including that it can be used for induction treatment of advanced cancers or as adjuvant treatment after local therapy to treat high risk of recurrence. The intent of chemotherapy can be curative or palliative.
- Several models of tumor growth and response to chemotherapy are explained including the Skipper-Wilcox model, concepts of combination chemotherapy, and the Goldie-Coldman model regarding emergence of drug resistance with increased tumor size.
1) Brain tumors are the 20th most common malignancy worldwide and their incidence varies based on factors like age, sex, and race.
2) Diagnostic workup involves imaging like MRI and CT scans, cerebrospinal fluid examination, and biopsy when needed. Molecular testing helps classify tumors.
3) Treatment depends on tumor type and grade but generally involves surgery, radiation, chemotherapy, and targeted therapies. Management of symptoms is also important.
4) Prognosis depends on tumor specific factors and can range from months to over 10 years depending on the tumor characteristics.
Molecular pathogenesis of CNS tumors lecture covers the following key points in 3 sentences:
The lecture discusses the molecular underpinnings and classification of various CNS tumors including gliomas, medulloblastoma, and meningiomas. It covers important molecular markers and genetic alterations that drive tumor pathogenesis, such as IDH1/2 mutations and 1p/19q codeletion in gliomas, and WNT and Sonic Hedgehog pathways in medulloblastoma classification. The lecture also reviews diagnostic techniques like FISH, IHC, and gene sequencing that are used to detect these molecular alterations and inform tumor grading and targeted therapy approaches.
Ewing sarcoma is the second most common bone tumor in children. Radiotherapy plays an important role in the treatment of both localized and metastatic Ewing sarcoma. For localized disease, radiotherapy is recommended for patients who cannot undergo surgery or have unresectable tumors. It is also used post-operatively if there is residual disease. For metastatic disease, radiotherapy can help control the primary tumor and reduce pulmonary metastases when combined with chemotherapy. Advances in radiotherapy planning and techniques have improved outcomes while reducing long-term side effects.
RADIOTHERAPY FOR ENDOMETRIUM AND CERVICAL CANCERSKanhu Charan
1. The document discusses radiotherapy techniques for treating gynaecological malignancies such as cancer of the cervix, endometrium, vulva, and ovaries.
2. It describes the evolution of radiotherapy from conventional 2D techniques to newer approaches like 3D conformal radiation therapy and intensity-modulated radiation therapy.
3. Key factors in treatment planning and delivery discussed include patient immobilization, imaging techniques for treatment planning like CT and PET scanning, and methods of verifying accurate patient positioning and treatment delivery such as electronic portal imaging.
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
Radiotherapy is used as primary treatment for early-stage Hodgkin lymphoma or as part of combined modality treatment with chemotherapy. Historically, large mantle fields covering lymph node regions from the skull to the pelvis were used. More modern approaches use smaller involved field radiotherapy targeting only initially involved lymph node regions after chemotherapy based on imaging. Proper delineation of clinical target volumes requires pre-chemotherapy imaging ideally with PET/CT to define original disease extent.
This document discusses the approach towards re-irradiation of common cancers. It begins by noting that local recurrence after radiation therapy and second primary tumors in irradiated areas are challenges, though re-irradiation can provide durable disease control in some cases. It then discusses key considerations for re-irradiation of head and neck cancers, gliomas, gynecological cancers, bone metastases, and brain metastases. Important factors include the initial radiation dose, interval since prior radiation, intent of re-irradiation, cumulative organ doses, and risk versus benefit. Advanced radiation techniques like IMRT can help minimize toxicity risks from re-irradiation. Careful patient selection and multidisciplinary evaluation are emphasized for meaningful survival benefits from re-
This document summarizes the management of high grade gliomas. It discusses the classification, molecular markers, diagnostic evaluation, treatment including surgery, radiation, chemotherapy, prognostic factors and response assessment for these aggressive brain tumors. Key points include the distinction between glioblastoma and anaplastic astrocytoma/oligodendroglioma, the role of maximal safe resection followed by concurrent chemoradiation using temozolomide as the standard of care, and important prognostic markers like MGMT promoter methylation status. Pseudoprogression and pseudoresponse on imaging are also reviewed.
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
1) The document discusses various radiation techniques for treating cancer of the esophagus including 2D, 3D conformal radiation therapy, IMRT, and IGRT.
2) It covers topics like target volume delineation, field design considerations for different esophageal subsites, and evolution from 2D to 3D treatment planning.
3) While there is no consensus, most contemporary trials use margins of 3-5cm cranially and caudally on the gross tumor with approximately a 2cm radial margin.
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
Lymphoma arises from mutations in cells of the lymphatic system. It is the 7th and 6th most common cancer in men and women respectively. The median age of diagnosis is 66 for non-Hodgkin lymphoma and 38 for Hodgkin lymphoma. Treatment depends on the lymphoma type and stage but may include chemotherapy, targeted therapies like rituximab, and radiation therapy. Radiation is commonly used at low doses to treat localized non-Hodgkin lymphoma and is also used in combination with chemotherapy for early stage or high risk Hodgkin lymphoma to improve outcomes. Long term risks of radiation include damage to nearby tissues and potential new cancers later in life.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
This document provides information about Hodgkin's lymphoma, including its epidemiology, risk factors, symptoms, diagnostic workup, staging, classification, treatment with chemotherapy and radiotherapy techniques. It discusses the Reed-Sternberg cells and variants that are characteristic of Hodgkin's lymphoma. It also covers risk stratification for early stage disease and modern radiotherapy techniques used to treat involved nodal regions while minimizing dose to surrounding organs at risk.
This document provides treatment recommendations for Hodgkin's lymphoma based on stage. For early stage disease, recommended treatment is chemotherapy (ABVD) followed by involved field radiation therapy (IFRT). For advanced stages III and IV, the recommended treatment is ABVD chemotherapy followed by IFRT to bulky or residual sites. Relapse is treated with chemotherapy followed by IFRT to previously untreated sites. The document also discusses definitions of radiation therapy fields and doses for different involved sites.
Hodgkin's lymphoma is a type of cancer that originates from white blood cells called lymphocytes. It is characterized by the presence of abnormal Reed-Sternberg cells in the lymph nodes and other tissues. There are two main classifications - classical Hodgkin's lymphoma, which has four subtypes based on the appearance of the lymph nodes, and nodular lymphocyte predominant Hodgkin's lymphoma. Signs and symptoms include enlarged lymph nodes, night sweats, weight loss, and fever. The cause is unknown but may involve abnormal B cells that do not die normally.
What is Lymphoma?
Malignant lymphoma is a term given to tumors of the lymphoid system and specifically of lymphocytes and their precursor cells
i.e.
Cancer of the lymphatic system.
Many lymphomas are known to be due to specific genetic mutations.
Medulloblastoma- A primitive neuroectodermal tumors (PNETs) is the most common malignant brain tumor of childhood (WHO IV)
arising from the vermis in the inferior medullary velum.
It comprises up to 18% of all pediatric brain tumors.
WNT and Shh pathway plays major role in its pathogenesis.
c-erbB-2 (HER2/neu) oncogene expression has prognostic value. Norcantharidin, Vismodegib, Sonidegib are the future in medulloblastoma.
This document discusses the management of primary central nervous system lymphoma (PCNSL). It begins with defining PCNSL and discussing its epidemiology, which includes that it is a rare brain tumor with an increasing incidence in immunocompromised patients. The standard treatment involves high-dose methotrexate-based chemotherapy followed by whole brain radiotherapy, which provides the best outcomes compared to other regimens. Prognostic scoring systems can help determine a patient's prognosis based on factors like age, performance status, lactate dehydrogenase levels, and tumor location. Ongoing research is evaluating adding agents like cytarabine, thiotepa, and rituximab to standard chemotherapy regimens to improve survival further
Principles of medical_oncology dr. varunVarun Goel
- The document discusses several key principles of medical oncology including that cancer treatment is multidisciplinary, early stage cancers are more curable than late stage, and the best treatment is often found in clinical trials.
- It describes the basic tenets of chemotherapy including that it can be used for induction treatment of advanced cancers or as adjuvant treatment after local therapy to treat high risk of recurrence. The intent of chemotherapy can be curative or palliative.
- Several models of tumor growth and response to chemotherapy are explained including the Skipper-Wilcox model, concepts of combination chemotherapy, and the Goldie-Coldman model regarding emergence of drug resistance with increased tumor size.
1) Brain tumors are the 20th most common malignancy worldwide and their incidence varies based on factors like age, sex, and race.
2) Diagnostic workup involves imaging like MRI and CT scans, cerebrospinal fluid examination, and biopsy when needed. Molecular testing helps classify tumors.
3) Treatment depends on tumor type and grade but generally involves surgery, radiation, chemotherapy, and targeted therapies. Management of symptoms is also important.
4) Prognosis depends on tumor specific factors and can range from months to over 10 years depending on the tumor characteristics.
Molecular pathogenesis of CNS tumors lecture covers the following key points in 3 sentences:
The lecture discusses the molecular underpinnings and classification of various CNS tumors including gliomas, medulloblastoma, and meningiomas. It covers important molecular markers and genetic alterations that drive tumor pathogenesis, such as IDH1/2 mutations and 1p/19q codeletion in gliomas, and WNT and Sonic Hedgehog pathways in medulloblastoma classification. The lecture also reviews diagnostic techniques like FISH, IHC, and gene sequencing that are used to detect these molecular alterations and inform tumor grading and targeted therapy approaches.
Ewing sarcoma is the second most common bone tumor in children. Radiotherapy plays an important role in the treatment of both localized and metastatic Ewing sarcoma. For localized disease, radiotherapy is recommended for patients who cannot undergo surgery or have unresectable tumors. It is also used post-operatively if there is residual disease. For metastatic disease, radiotherapy can help control the primary tumor and reduce pulmonary metastases when combined with chemotherapy. Advances in radiotherapy planning and techniques have improved outcomes while reducing long-term side effects.
RADIOTHERAPY FOR ENDOMETRIUM AND CERVICAL CANCERSKanhu Charan
1. The document discusses radiotherapy techniques for treating gynaecological malignancies such as cancer of the cervix, endometrium, vulva, and ovaries.
2. It describes the evolution of radiotherapy from conventional 2D techniques to newer approaches like 3D conformal radiation therapy and intensity-modulated radiation therapy.
3. Key factors in treatment planning and delivery discussed include patient immobilization, imaging techniques for treatment planning like CT and PET scanning, and methods of verifying accurate patient positioning and treatment delivery such as electronic portal imaging.
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
Radiotherapy is used as primary treatment for early-stage Hodgkin lymphoma or as part of combined modality treatment with chemotherapy. Historically, large mantle fields covering lymph node regions from the skull to the pelvis were used. More modern approaches use smaller involved field radiotherapy targeting only initially involved lymph node regions after chemotherapy based on imaging. Proper delineation of clinical target volumes requires pre-chemotherapy imaging ideally with PET/CT to define original disease extent.
This document discusses the approach towards re-irradiation of common cancers. It begins by noting that local recurrence after radiation therapy and second primary tumors in irradiated areas are challenges, though re-irradiation can provide durable disease control in some cases. It then discusses key considerations for re-irradiation of head and neck cancers, gliomas, gynecological cancers, bone metastases, and brain metastases. Important factors include the initial radiation dose, interval since prior radiation, intent of re-irradiation, cumulative organ doses, and risk versus benefit. Advanced radiation techniques like IMRT can help minimize toxicity risks from re-irradiation. Careful patient selection and multidisciplinary evaluation are emphasized for meaningful survival benefits from re-
This document summarizes the management of high grade gliomas. It discusses the classification, molecular markers, diagnostic evaluation, treatment including surgery, radiation, chemotherapy, prognostic factors and response assessment for these aggressive brain tumors. Key points include the distinction between glioblastoma and anaplastic astrocytoma/oligodendroglioma, the role of maximal safe resection followed by concurrent chemoradiation using temozolomide as the standard of care, and important prognostic markers like MGMT promoter methylation status. Pseudoprogression and pseudoresponse on imaging are also reviewed.
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
1) The document discusses various radiation techniques for treating cancer of the esophagus including 2D, 3D conformal radiation therapy, IMRT, and IGRT.
2) It covers topics like target volume delineation, field design considerations for different esophageal subsites, and evolution from 2D to 3D treatment planning.
3) While there is no consensus, most contemporary trials use margins of 3-5cm cranially and caudally on the gross tumor with approximately a 2cm radial margin.
This document discusses the use of radiation therapy for various benign diseases. It provides an overview of indications for radiation therapy in benign tumors and conditions of the nervous system, head and neck region, orbits, skin and soft tissues, and skeletal system. Risks of secondary malignancies from radiation are outlined. The document reviews evidence-based radiation doses and techniques for specific benign diseases.
Lymphoma arises from mutations in cells of the lymphatic system. It is the 7th and 6th most common cancer in men and women respectively. The median age of diagnosis is 66 for non-Hodgkin lymphoma and 38 for Hodgkin lymphoma. Treatment depends on the lymphoma type and stage but may include chemotherapy, targeted therapies like rituximab, and radiation therapy. Radiation is commonly used at low doses to treat localized non-Hodgkin lymphoma and is also used in combination with chemotherapy for early stage or high risk Hodgkin lymphoma to improve outcomes. Long term risks of radiation include damage to nearby tissues and potential new cancers later in life.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
This document provides information about Hodgkin's lymphoma, including its epidemiology, risk factors, symptoms, diagnostic workup, staging, classification, treatment with chemotherapy and radiotherapy techniques. It discusses the Reed-Sternberg cells and variants that are characteristic of Hodgkin's lymphoma. It also covers risk stratification for early stage disease and modern radiotherapy techniques used to treat involved nodal regions while minimizing dose to surrounding organs at risk.
This document provides treatment recommendations for Hodgkin's lymphoma based on stage. For early stage disease, recommended treatment is chemotherapy (ABVD) followed by involved field radiation therapy (IFRT). For advanced stages III and IV, the recommended treatment is ABVD chemotherapy followed by IFRT to bulky or residual sites. Relapse is treated with chemotherapy followed by IFRT to previously untreated sites. The document also discusses definitions of radiation therapy fields and doses for different involved sites.
Hodgkin's lymphoma is a type of cancer that originates from white blood cells called lymphocytes. It is characterized by the presence of abnormal Reed-Sternberg cells in the lymph nodes and other tissues. There are two main classifications - classical Hodgkin's lymphoma, which has four subtypes based on the appearance of the lymph nodes, and nodular lymphocyte predominant Hodgkin's lymphoma. Signs and symptoms include enlarged lymph nodes, night sweats, weight loss, and fever. The cause is unknown but may involve abnormal B cells that do not die normally.
What is Lymphoma?
Malignant lymphoma is a term given to tumors of the lymphoid system and specifically of lymphocytes and their precursor cells
i.e.
Cancer of the lymphatic system.
Many lymphomas are known to be due to specific genetic mutations.
This document provides information on Hodgkin's lymphoma, including its epidemiology, risk factors, clinical features, diagnostic workup, pathological classification, staging, prognostic factors, and management. It notes that Hodgkin's lymphoma accounts for a small percentage of cancers diagnosed in the US each year and has a bimodal age distribution. Diagnosis involves biopsy and staging includes CT, PET, and bone marrow exams. Treatment involves chemotherapy and involved-field radiation therapy.
Hodgkin's lymphoma, also known as Hodgkin's disease, is a cancer that originates in the lymphatic system. It is characterized by the presence of Reed-Sternberg cells in the lymph nodes and other tissues. The disease has four main subtypes - nodular sclerosis, mixed cellularity, lymphocyte depletion, and lymphocyte rich - which are distinguished based on the type of cells in the tissue around the Reed-Sternberg cells. The nodular sclerosis subtype, which involves bands of fibrosis dividing the lymph node tissue into nodules, accounts for about 40-70% of cases. Hodgkin's lymphoma most commonly presents with painless swelling of lymph nodes in the neck,
Lymphoma can be divided into two main types: Hodgkin lymphoma and non-Hodgkin lymphoma. Hodgkin lymphoma is characterized by the presence of Reed-Sternberg cells and typically presents with enlarged, painless lymph nodes. Risk factors include certain viruses and age. Treatment involves chemotherapy and/or radiation therapy depending on the stage. Non-Hodgkin lymphoma is more likely to involve extralymphatic sites and the bone marrow. It can be further divided into low-grade and high-grade subtypes depending on aggressiveness. Treatment typically involves chemotherapy regimens like CHOP.
This document provides information about lymphoma, including Hodgkin's disease and non-Hodgkin's lymphoma. It discusses the epidemiology, etiology, clinical manifestations, diagnosis, staging, treatment and prognosis of these cancers. Hodgkin's disease is characterized by Reed-Sternberg cells and is categorized using the Rye or REAL classification systems. Non-Hodgkin's lymphoma subtypes include Burkitt lymphoma, lymphoblastic lymphoma, and diffuse large B-cell lymphoma. Staging is important for determining appropriate chemotherapy regimens and radiation treatment. Outcomes depend on disease stage and subtype, with localized disease having higher survival rates.
This document summarizes information about Hodgkin's and non-Hodgkin's lymphoma, including:
- Hodgkin's lymphoma accounts for about 30% of malignant lymphomas and is typically treated initially with ABVD chemotherapy plus radiation therapy. Non-Hodgkin's lymphoma is more common and heterogeneous.
- For advanced Hodgkin's lymphoma, BEACOPP chemotherapy is more effective than COPP/ABVD but also more toxic, increasing risks of infertility, premature menopause, and leukemia.
- Long-term survivors of Hodgkin's lymphoma face elevated risks of secondary cancers decades later due to effects of treatment.
Radiotherapy contouring guideline for non-hodgkin lymphomaketan kalariya
This document provides guidelines for modern radiation therapy for nodal non-Hodgkin lymphoma. It outlines a new concept of involved-site radiation therapy using reduced treatment volumes based on imaging to define target volumes. Guidelines are provided for radiation therapy as primary treatment, as part of combined modality treatment, and for recurrent or refractory disease. Recommended doses and techniques such as IMRT are discussed depending on the clinical situation and disease stage. The goal is to restrict radiation therapy to limited involved sites to reduce normal tissue exposure while maintaining local tumor control.
The document discusses the history and evolution of chemotherapy in Hodgkin's lymphoma. It describes how early single-agent chemotherapy showed limited efficacy and tolerability. The development of MOPP chemotherapy in the 1970s, using multiple non-overlapping agents, improved response rates and long-term survival to over 50%. Subsequent refinements introduced additional regimens like COPP, ABVD and others to reduce toxicity while maintaining efficacy.
This document discusses the classification and characteristics of various types of non-Hodgkin lymphoma (NHL). It describes the historical classifications of NHL from the 1940s to the current 2008 WHO classification. It then provides details on specific NHL subtypes, including small lymphocytic lymphoma/chronic lymphocytic leukemia, follicular lymphoma, mantle cell lymphoma, and marginal zone B-cell lymphoma. For each subtype, it discusses immunophenotype, genetic abnormalities, clinical features, histopathology, immunostaining patterns, and differential diagnosis.
This document summarizes several presentations on recent developments in Hodgkin lymphoma. It begins with a discussion of a study comparing the predictive value of interim PET scans done after one or two cycles of therapy. The study found PET scans after one cycle had a higher negative predictive value. Another section summarizes a trial finding patients with low stage disease and a negative PET scan after 3 cycles of ABVD had excellent prognosis without further treatment. Later sections discuss outcomes of combining brentuximab vedotin with standard therapies for relapsed/refractory and advanced stage disease. Results showed improved survival correlated with response to brentuximab vedotin.
This document summarizes Hodgkin lymphoma (HL), including its epidemiology, histology, clinical presentation, workup, staging, prognosis, and treatment. HL is a common lymphoma that represents about 11% of all lymphomas. It predominantly affects young adults and is associated with Epstein-Barr virus. The hallmark is the Reed-Sternberg cell. Treatment involves chemotherapy such as ABVD or BEACOPP, with radiation therapy used for early or advanced stage disease. Prognosis depends on staging, with 5-year survival rates over 85% for early stage disease treated with chemotherapy and radiation.
This document discusses radiation therapy (RT) for various types of non-Hodgkin's lymphoma. It covers RT dose recommendations when used alone or as part of combined modality therapy for different lymphoma stages and histologies. It discusses techniques for total body irradiation and strategies for treating primary extranodal lymphomas in different anatomical sites. Overall, the document provides guidance on using RT to effectively treat various lymphomas based on stage, histology, and other clinical factors.
Audio and slides for this presentation are available on YouTube: http://youtu.be/pkB_mfPtjrA
Andrea K. Ng, MD, of Dana-Farber/Brigham and Women's Cancer Center Department of Radiation Oncology, gives an overview of the different types of radiation therapy, the side effects, and how it is used in the treatment of lymphoma. This presentation was given at the 2013 Lymphoma Research Foundation North American Forum on Sept. 29, 2013. http://www.dana-farber.org | http://www.lymphoma.org
The document summarizes recent advances in Hodgkin's lymphoma. It discusses the history and classification of Hodgkin's lymphoma. It covers immunophenotype markers, involvement of Epstein-Barr virus, genetic changes in Hodgkin-Reed-Sternberg cells, the tumor microenvironment, microRNAs, and mechanisms of chemoresistance. Novel therapies discussed include monoclonal antibodies targeting CD20 and CD30.
This document discusses non-Hodgkin's lymphomas, including its definition, epidemiology, classification systems, clinical features, treatment approaches, and outcomes. It defines NHL as a malignant disease of the lymphatic system that is histologically and clinically heterogeneous. Treatment outcomes depend on risk factors such as age, disease stage, organ involvement, and performance status. Standard first-line chemotherapy such as CHOP results in remission rates of 50-80% but permanent cures in only 40-60% of patients. High-risk patients may benefit from intensive chemotherapy and stem cell transplantation.
This document presents a case report of a 35-year-old man who presented with fever, night sweats, cough, pallor, fatigue, sore throat, anorexia, lymphadenopathy, hepatosplenomegaly, and bone tenderness over 4 months. Initial biopsy suggested Hodgkin's lymphoma but review suggested non-Hodgkin's lymphoma. Further workup found pancytopenia, lymphoblasts on peripheral smear, and nodular lymphoma infiltration on bone marrow biopsy, consistent with a diagnosis of both NHL and autoimmune hemolytic anemia. The diagnostic challenges and treatment considerations for NHL and its association with autoimmune diseases like AIHA are discussed.
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...Lymphoma Support Ireland
This document summarizes key information from a presentation on the treatment of lymphoma. It discusses:
1) The classification, incidence, and etiology of both Hodgkin's and non-Hodgkin's lymphomas.
2) Updates on treatment approaches for different lymphoma subtypes including chemotherapy regimens, monoclonal antibodies, and stem cell transplantation.
3) Results from clinical trials evaluating new agents and regimens for indolent non-Hodgkin's lymphoma, diffuse large B-cell lymphoma, T-cell lymphomas, and relapsed Hodgkin's lymphoma.
Sickle cell anemia is a genetic blood disorder where red blood cells become stiff and sickle-shaped. This causes blockages in blood vessels which can lead to pain, organ damage, and infections. It occurs when someone inherits two sickle cell genes, one from each parent. People with only one gene have sickle cell trait and usually do not experience symptoms. The disease varies in severity between individuals and treatments aim to manage pain and prevent complications.
Radiotherapy in lymphoma(dr fadavi)-001pedramfadavi
Radiotherapy is an important treatment for lymphomas and is often used in combination with chemotherapy. It is very effective for lymphomas due to their radiosensitivity. For Hodgkin lymphoma, 30 Gy is recommended for early-stage unfavorable disease after chemotherapy, while 20 Gy can be used for early-stage favorable disease. For non-Hodgkin lymphomas, 24 Gy is recommended for indolent types and 30 Gy for other aggressive types. Modern radiotherapy planning involves defining target volumes using CT imaging to minimize doses to normal tissues while adequately treating tumor volumes.
This document summarizes treatment approaches for early-stage Hodgkin lymphoma. It describes the evolution from radiotherapy alone to combined modality therapy with chemotherapy and radiotherapy. Key findings include:
1) Combined modality therapy is superior to radiotherapy alone in achieving high cure rates of over 90% for early-stage disease.
2) 4 cycles of ABVD chemotherapy followed by involved-field radiotherapy is as effective as subtotal nodal radiotherapy plus chemotherapy.
3) For selected early-stage favorable disease, 2 cycles of ABVD chemotherapy and 20Gy radiotherapy may be sufficient treatment.
4) For early-stage unfavorable disease, 4 cycles of ABVD chemotherapy with 30Gy
Lenalidomide maintenance compared with placebo in responding elderlyravi jaiswal
This randomized phase III trial compared lenalidomide maintenance therapy versus placebo in elderly patients with diffuse large B-cell lymphoma (DLBCL) who achieved a response to first-line R-CHOP induction therapy. The trial found that lenalidomide maintenance led to a statistically significant improvement in progression-free survival compared to placebo, with a median PFS not reached in the lenalidomide arm versus 58.9 months in the placebo arm. There was no significant difference in overall survival between the arms. Lenalidomide maintenance was associated with more grade 3-4 adverse events compared to placebo. The benefit of lenalidomide maintenance was seen across patient subgroups.
This document summarizes the use of PET-CT in staging and assessing treatment response in Hodgkin's lymphoma. It discusses that PET-CT is an important tool for initial staging, assessing response to chemotherapy, and prognostic indicator when done after partial chemotherapy. The sensitivity and specificity of PET-CT is higher than CT alone for detecting nodal and organ involvement. PET-CT may avoid the need for bone marrow biopsy in some cases. Interim PET imaging helps distinguish residual mass as viable tumor or necrosis/fibrosis. The document also reviews chemotherapy regimens like ABVD, BEACOPP and Stanford V in early and advanced Hodgkin's lymphoma.
This document discusses treatment options for indolent lymphomas. It focuses on follicular lymphoma grades I, II, and IIIa. For early stage disease, involved field radiotherapy is preferred. For advanced stages, first line therapies include R-CHOP, R-CVP, radioimmunotherapy, or single agent rituximab. For relapsed/refractory cases, second line options are chemoimmunotherapy, radioimmunotherapy, or rituximab maintenance. Consolidation with high dose chemotherapy and stem cell transplant may also be considered. Transformation to diffuse large B cell lymphoma is associated with poor prognosis but targeted treatment can provide favorable outcomes.
This document discusses treatment options for Hodgkin lymphoma based on stage. For early stage (I-II) favorable prognosis, ABVD chemotherapy for 3-4 cycles followed by radiation is most commonly used. For early stage unfavorable prognosis, ABVD plus radiation is standard. For advanced stage (III-IV) ABVD is standard but BEACOPP shows improved progression-free survival over ABVD though with greater toxicity. Radiation is often used along with chemotherapy depending on risk factors.
Chemotherapy is frequently used to treat lung cancer, especially when it has spread. For small cell lung cancer, also called oat cell cancer, chemotherapy alone or with radiation is used depending on whether the cancer is limited or extensive stage. A study compared the standard CAV/EP chemotherapy regimen to the more intensive CODE regimen for extensive stage small cell lung cancer patients. While the CODE regimen produced higher response rates, it also resulted in unacceptable toxicity with 8 patients dying from treatment-related causes, compared to no deaths for the standard regimen. The researchers concluded that standard regimens causing mild suppression are as effective with less toxicity compared to more intensive regimens for extensive stage small cell lung cancer.
Chemotherapy is frequently used to treat lung cancer, especially when it has spread. For small cell lung cancer, also called oat cell cancer, chemotherapy alone or with radiation is used depending on whether the cancer is limited or extensive stage. A study compared the standard CAV/EP chemotherapy regimen to the more intensive CODE regimen for extensive stage small cell lung cancer patients. While the CODE regimen produced higher response rates, it also resulted in unacceptable toxicity with 8 patients dying from treatment-related causes, compared to no deaths for the standard regimen. The researchers concluded that standard regimens causing mild suppression are as effective with less toxicity compared to more intensive regimens for extensive stage small cell lung cancer.
Aggressive treatment for early lymphomasGil Lederman
1) A study of 183 patients with early stage non-Hodgkin's lymphoma treated with CHOP chemotherapy and local radiation found a 98% complete response rate and 83% 5-year survival rate.
2) The chemotherapy regimen consisted of cyclophosphamide, doxorubicin, vincristine, and prednisone, followed by radiation therapy one month after the last chemotherapy treatment.
3) The authors concluded that this combined approach of short-term CHOP chemotherapy followed by local radiation should be considered the standard of care for stages I-II non-Hodgkin's lymphoma.
Radiosensitizers are agents that increase the lethal effects of radiation when administered with radiotherapy. They work through various mechanisms like increasing DNA damage, inhibiting repair, and modulating biological response. Common types include physical agents like hyperthermia, chemical agents like nitroimidazoles to target hypoxic cells, and biological modifiers like cetuximab. Effective radiosensitizers improve the therapeutic ratio by increasing tumor cell killing while minimizing harm to normal tissues. Combining radiosensitizers with radiotherapy can improve outcomes for many cancer types.
This document summarizes a randomized clinical trial that compared four treatment regimens for patients with early-stage Hodgkin's lymphoma. The trial investigated whether reducing the intensity of chemotherapy from 4 to 2 cycles of ABVD and reducing radiation therapy from 30Gy to 20Gy could maintain disease control while reducing toxicity. The trial found no significant differences in efficacy outcomes between treatment groups. Both 2 cycles of ABVD and 20Gy radiation were found to be non-inferior to standard treatment, with reduced acute toxicity. The study provides evidence that treatment intensity can be safely reduced for early-stage Hodgkin's lymphoma patients with favorable prognosis.
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptxrhmwt rhmwt
This document discusses hematopoietic malignancies including leukemias and malignant lymphomas. It covers the classification, epidemiology, etiology, clinical manifestations, diagnosis, staging, and treatment of non-Hodgkin's lymphoma. The types of NHL are divided into indolent, aggressive, and very aggressive. Treatment depends on the type, stage, and patient characteristics. Options include chemotherapy, immunotherapy, radiotherapy, clinical trials, observation, and stem cell transplant. The document provides details on therapeutic approaches for different stages and types of NHL.
This document discusses current concepts in chemotherapy for head and neck cancer. It begins by introducing head and neck squamous cell carcinoma (HNSCC) as the sixth most common cancer worldwide. It then reviews epidemiology and risk factors for HNSCC before defining different types of chemotherapy. The bulk of the document discusses evidence and standards of care for systemic therapy in previously untreated locally advanced HNSCC as well as recurrent/metastatic HNSCC. It covers the role of induction, concurrent, adjuvant and definitive chemotherapy combined with surgery or radiation. Overall survival benefits have been shown with platinum-based chemotherapy regimens and cetuximab combined with radiation or chemotherapy.
This document provides a comprehensive review of compounds that can prevent or treat oral mucositis in cancer patients undergoing radio-chemotherapy. It begins with an abstract that summarizes the document. The document then discusses the pathobiology of mucositis in five phases: initiation, message generation, signaling and amplification, ulceration, and healing. It also reviews risk factors for developing mucositis, including both patient-related factors and treatment-related factors. The goal of the review is to provide an updated understanding of compounds that are effective against mucositis following radiotherapy and/or chemotherapy.
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...JohnJulie1
Approaches are limited for treating advanced Non-Small-Cell Lung Cancer (NSCLC) with multidrug resistance but without ALK and EGFR mutations. Pembrolizumab (KEYTRUDA) brings on unprecedented clinical benefit in various cancer types...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...NainaAnon
Approaches are limited for treating advanced Non-Small-Cell Lung Cancer (NSCLC) with multidrug resistance but without ALK and EGFR mutations. Pembrolizumab (KEYTRUDA) brings on unprecedented clinical benefit in various cancer types..
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...EditorSara
Approaches are limited for treating advanced Non-Small-Cell Lung Cancer (NSCLC) with multidrug resistance but without ALK and EGFR mutations. Pembrolizumab (KEYTRUDA) brings on unprecedented clinical benefit in various cancer types..
This study compared the efficacy and toxicities of gemcitabine/cisplatin combination chemotherapy and paclitexal/carboplatin combination chemotherapy as first-line treatment for 53 patients with stage IIIB or IV non-small cell lung cancer. The study found that gemcitabine/cisplatin combination resulted in better response rates but not statistically significantly so. It also found that gemcitabine/cisplatin combination resulted in more hematological toxicities. Patient demographics were not significantly different between the two treatment arms. The study concluded that platinum-based combinations are effective for non-small cell lung cancer but require proper premedications.
This document discusses the diagnostic workup for mediastinal tumors. It begins by describing the different types of tumors that can occur in the anterior, middle, and posterior mediastinum. Signs and symptoms are non-specific but may include cough, chest pain, and weight loss. Chest x-ray is often the initial test, while CT scan provides more detail on location and tissue characteristics. MRI and nuclear imaging can further characterize masses. Tissue sampling methods include needle biopsy, mediastinoscopy, and thoracoscopy. Surgical procedures like mediastinotomy or thoracotomy may be needed in some cases. Laboratory tests help identify certain tumor types. A multidisciplinary approach is typically needed for diagnosis and treatment planning of
This document provides information on staging and treatment guidelines for cancers of the oropharynx and hypopharynx. It begins with an overview of AJCC 7th edition staging for these sites, including TNM classifications. It then reviews general principles of treatment, including the goals of treatment based on stage. The main treatment modalities of surgery, radiotherapy, chemotherapy, and their combinations are described. Finally, it provides more detailed site-specific guidelines for treatment of oropharynx and hypopharynx cancers.
PET imaging is useful for cancer diagnosis and management. It provides functional information about glucose metabolism in tumors that can help establish prognosis, guide treatment decisions, and assess response. PET using 18F-FDG has high sensitivity and specificity for detecting cancer. It has applications in staging, restaging, and monitoring treatment response for many cancer types including lung cancer, lymphoma, and head and neck cancers. PET can identify tumor involvement that may be missed by anatomical imaging alone.
The document discusses the interaction of radiation with matter. It explains that radiation can be electromagnetic or particulate. When electromagnetic radiation like x-rays or gamma rays pass through matter, they can undergo attenuation, absorption, scattering, or transmission. The major interactions that cause attenuation are coherent scattering, the photoelectric effect, the Compton effect, pair production, and photonuclear interactions. It describes each of these interactions in detail and how they transfer energy from the radiation to the absorbing material.
This document discusses several key concepts in radiobiology including:
1. The interaction of radiation with cells is probabilistic, with damage occurring through direct and indirect action. Indirect action involves free radicals produced by radiation interacting with water molecules within cells.
2. Different phases of the cell cycle have differing radiosensitivities, with G2/M being most sensitive. Fractionated radiation can exploit this through redistribution effects.
3. The linear quadratic model describes cell survival curves and accounts for both single-hit and double-hit damage from radiation. It is used to calculate biologically equivalent doses.
4. Mechanisms like reoxygenation between fractions can improve the therapeutic ratio by making tumor cells
The document discusses isotopic teletherapy machines, which use cobalt-60 or cesium-137 radioactive sources to produce gamma rays for external beam radiation therapy. It describes the components and operation of cobalt-60 teletherapy machines, including the radioactive cobalt-60 source, source housing, collimators, gantry, patient support assembly, and control console. Key factors in selecting radioisotopes are high gamma ray energy, long half-life, and ability to produce large quantities for clinical use.
Low-grade gliomas are a diverse group of uncommon brain tumors that typically occur in young adults. While historically graded on features like cell abnormalities and proliferation, the current WHO system grades them from I-II based on these factors and prognosis. Grade I lesions rarely recur after surgery alone, while Grade II tumors are infiltrative and tend to progress despite low proliferation. Surgery aims for maximal safe resection, and radiation therapy after surgery can delay tumor recurrence by around 2 years based on clinical trials, though does not impact overall survival or rate of malignant transformation. Observation is reasonable for very low risk lesions with total resection in young patients.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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Hiranandani Hospital in Powai, Mumbai, is a premier healthcare institution that has been serving the community with exceptional medical care since its establishment. As a part of the renowned Hiranandani Group, the hospital is committed to delivering world-class healthcare services across a wide range of specialties, including kidney transplantation. With its state-of-the-art facilities, advanced medical technology, and a team of highly skilled healthcare professionals, Hiranandani Hospital has earned a reputation as a trusted name in the healthcare industry. The hospital's patient-centric approach, coupled with its focus on innovation and excellence, ensures that patients receive the highest standard of care in a compassionate and supportive environment.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
1. HODGKIN’S LYMPHOMA
CHEMOTHERAPY
RADIOTHERAPY
DR ARNAB BOSE
Dept. of Radiotherapy
NRS Medical College, Kolkata
1
2. Introduction
Hodgkin’s disease was initially described as an inflammatory
disease (hence the term “disease”), but is clearly
recognized and treated as a malignant lymphoma (hence the
more accurate term Hodgkin’s lymphoma (HL) is used
synonymously with Hodgkin’s disease).
The management of Hodgkin’s lymphoma has evolved from
extended-field radiation alone as the main therapy to a
combined-modality approach with
chemotherapy and radiation, or chemotherapy alone.
2
6. Adverse Prognostic Factors
The International Prognostic Score (IPS) is based on seven factors:
three clinical and four laboratory values .
Patients are given a score of from 0 to 7, and disease can
be categorized as low (0–1), intermediate (2–3), or high (4–7) risk.
6
8. The current standard is the result of careful clinical
trials that demonstrated three principles:
i) ABVD is the preferred chemotherapy based on both
efficacy and safety,
ii) combined-modality therapy (chemotherapy + radiation
therapy) is superior to wide-field radiation therapy alone
iii) there is no advantage of wide-field radiation therapy
over involved-field radiation therapy when given in
combination with chemotherapy.
8
12. The Milan trial was among the first and most influential in
demonstrating the high cure rate of a brief course of ABVD
(four cycles) combined with involved-field radiation therapy
in limited-stage Hodgkin’s lymphoma.
Subsequently, multiple trials have explored the questions of
how many cycles of ABVD are needed and what radiation
dose is needed to maintain these outstanding results.
12
13. Among favorable patients without risk factors, the GHSG
evaluated two versus four cycles of ABVD and 20 versus
30 Gy involved-field irradiation.
The final results of this trial have not been published, but
multiple presentations of the data to date have shown FFP
rates in excess of 95% for all four treatment arms.
Thus, for the approximately 35% of limited-stage patients
with very favorable presentations, as few as two cycles of
chemotherapy combined with low-dose involved-field
irradiation is sufficient for cure.
13
14. For patients with unfavorable, limited-stage Hodgkin’s
lymphoma the subjects of clinical trial inquiry have been
chemotherapy combination, number of cycles of
chemotherapy, and radiation dose.
The H9U trial conducted by the EORTC-GELA
demonstrated that the less toxic ABVD regimen was as
effective as the BEACOPP regimen and that four cycles of
treatment were sufficient.
Similarly, the GHSG HD11 trial has shown no differences
in outcome thus far between ABVD and BEACOPP in
limited-stage patients with risk factors. 14
17. Following the ground-breaking demonstration of cure in
advanced Hodgkin’s lymphoma with MOPP chemotherapy,
a series of clinical trials was set in motion to identify the
best chemotherapy regimen in advanced disease and to
evaluate the role of radiation therapy in this setting.
Based on historical development and the efficacy of ABVD
in the relapsed setting, early trials pitted MOPP against
ABVD and the alternating MOPP/ABVD regimen.
17
18. The early CALGB study determined that ABVD-containing
combinations were superior.
A second U.S. Intergroup trial comparing ABVD to the
hybrid MOPP/ABV combination, concluded that the
treatments were similarly efficacious but ABVD was less
toxic.
On the basis of these trials, ABVD was widely adopted as
the standard chemotherapy for advanced Hodgkin’s
lymphoma with an expected cure rate of about 70%.
18
19. Stanford V is a brief, 12-week chemotherapy regimen with
minimal alkylating agent and lower cumulative doses of
doxorubicin and bleomycin that was devised to explicitly
address late effects of Hodgkin’s lymphoma treatment.
The GHSG developed a novel chemotherapy combination,
BEACOPP, which combines elements of COPP and ABVD with
etoposide. The regimen was designed and tested in standard
and escalated forms.
19
22. Secondary Therapy of Classical H L
Fortunately, fewer patients with Hodgkin’s lymphoma
currently progress after primary treatment. Those with
advanced disease and a high IPS are at greatest risk.
High-Dose Chemotherapy with either the
CBV (cyclophosphamide, carmustine, etoposide) or
BEAM (carmustine, etoposide, cytarabine, melphalan)
regimen followed by Autologous Stem Cell Transplantation
has been the most successful approach .
22
23. To achieve maximal cytoreduction before transplantation
the approach is to treat progressive and relapsing patients
with secondary chemotherapy,
most commonly the
DHAP (cisplatin, high-dose cytarabine, dexamethasone), or
ICE (ifosfamide, carboplatin, etoposide) regimen.
Recently a new regimen,
IGEV (ifosfamide, gemcitabine,etoposide, vinorelbine),
has demonstrated excellent tolerability and efficacy in the
second-line setting.
23
24. Complications of Chemotherapy
Sterility was a major adverse effect of the MOPP regimen.
ABVD does not seem to cause more than temporary
cessation of menses in women and temporary oligospermia
in men.
In contrast, BEACOPP chemotherapy routinely sterilizes
males and many young females. Semen preservation must
take place before chemotherapy.
24
25. Early reports implicated the alkylating agents in MOPP
chemotherapy in an increased risk of secondary acute
myelocytic leukemia (AML) and myelodysplasia.
ABVD chemotherapy does not seem to increase the risk of
secondary AML above baseline.
BEACOPP chemotherapy was accompanied by an increased
risk of secondary AML. In this case, etoposide was also
implicated.
25
26. Lung cancer is emerging as a leading cause of death in
Hodgkin’s lymphoma patients. Relative risks increase with
cumulative dose of alkylating agents and with increasing
doses of radiation.
The risk after chemotherapy is immediate, whereas there is
a latency of about 5 years after radiation therapy.
Importantly, the relative risk increases 20-fold with
tobacco use, indicating that smoking cessation is absolutely
imperative among Hodgkin’s lymphoma survivors.
26
27. Pulmonary toxicity related to bleomycin has been
recognized to be both idiosyncratic and related to
cumulative exposure.
Bone toxicity in the form of osteoporosis may accompany
prednisone use, particularly in the setting of gonadal
failure. Osteonecrosis is an uncommon complication that
occurs in the hips or shoulders in individuals exposed to
high cumulative doses of prednisone, particularly with the
addition of high-dose radiation therapy.
27
32. Unilateral Cervical/Supraclavicular
Region
Arms position: Akimbo or at sides
Upper Border: 1 to 2 cm above the
lower tip of the mastoid process
and midpoint through the chin.
Lower Border: 2 cm below the
bottom of the clavicle.
Lateral Border: To include the
medial two-thirds of the
clavicle.
32
33. Medial Border:
(a) If the SCL nodes are not involved, the
border is placed at the ipsilateral transverse processes
except when medial nodes close to the vertebral bodies are
seen on the initial staging neck CT scan. For medial nodes
the entire vertebral body is included.
(b) When the SCL nodes are involved, the
border should be placed at the contralateral transverse
processes
33
34. Blocks:
A posterior cervical cord block is required only if
cord dose exceeds 40 Gy.
Mid-neck calculations should be performed to
determine the maximum cord dose, especially
when the central axis is in the mediastinum.
A laryngeal block should be used unless lymph nodes
were present in that location. In that case the block should
be added at 20 Gy.
34
35. Bilateral Cervical/Supraclavicular
Region
Both cervical and SCL regions should
be treated as described in the
preceding slide regardless of the
extent of disease on each side.
Posterior cervical cord and larynx
blocks should be used.
35
36. Mediastinum
Arms position: Akimbo or at sides. The arms-up position is
optional if the axillary nodes are involved.
Upper Border: C5-6 interspace. If SCL nodes are also
involved, the upper border should be placed
at the top of the larynx.
36
37. Lower Border: The lower of: (a) 5 cm below the carina
or (b) 2 cm below the pre-chemotherapy
inferior border.
Lateral Border: The post-chemotherapy volume with
1.5 cm margin.
Hilar Area: To be included with 1 cm margin unless
initially involved, in which case the margin
should be 1.5 cm.
37
38. Axillary Region
Arms position: Arms akimbo or arms up.
Upper Border: C5-6 interspace.
Lower Border: The lower of the two: (a) the tip of the
scapula or (b) 2 cm below the lowest axillary node.
Medial Border: Ipsilateral cervical transverse process.
Include the vertebral bodies only if the SCL are involved.
Lateral Border: Flash axilla.
38
40. Abdomen (Para-Aortic Nodes)
Upper Border: Top of T11 and at least 2 cm above
pre-chemotherapy volume.
Lower Border: Bottom of L4 and at least 2 cm below
pre-chemotherapy volume.
Lateral Borders: The edge of the transverse processes and
at least 2 cm from the
post-chemotherapy volume.
40
41. Inguinal/Femoral/External Iliac
Region
Upper Border: Middle of the sacroiliac joint.
Lower Border: 5 cm below the lesser trochanter.
Lateral Border: The greater trochanter and 2 cm lateral to
initially involved nodes.
41
42. Medial Border: Medial border of the obturator foramen
with at least 2 cm medial to involved nodes.
If common iliac nodes are involved the field
should extend to the L4-5 interspace and
at least 2 cm above the initially involved
nodal border.
42
46. Simulate with
Arms - up (to pull axillary LN from chest to allow for
more lung blocking) or
Arms akimbo (to shield humeral heads and minimize
tissue in SCV folds)
Head extended
this ensures the exclusion of the oral cavity and
teeth from the RT fields, and decreases the dose to the
mandible
46
47. Borders: Lateral = beyond humeral heads;
Inferior = bottom of diaphragm (T11/12);
Superior = inferior mandible
Blocks: Larynx on AP field
Humeral heads on AP and PA fields
PA cord block (if dose >40 Gy)
Lung block at top of fourth rib to cover IC LN
If pericardial or mediastinal extension, include
entire heart to 15 Gy, then block apex of heart. After
30 Gy, block heart beyond 5 cm inferior to carina
(unless residual disease)
47
50. Dose of Radiotherapy
Combined Modality RT Dose
Non-bulky disease (stage I-II)
20*-30 Gy (if treated with ABVD)
30Gy (if treated with Stanford V)
Non-bulky disease (stage IB-IIB) and
Bulky and Non-bulky disease (stage III-IV)
30-36 Gy if treated with BEACOPP
*A dose of 20Gy following ABVD x 2 is sufficient if the patient has non bulky
stage I-IIA disease with ESR <50, no extra lymphatic lesions, and only one or
two lymph node regions involved
50
51. Bulky disease sites (all stages)
30-36 Gy (if treated with ABVD)
36Gy (if treated with Stanford V)
RT Alone Doses (uncommon except for NLPHL)
Involved regions 30-36Gy
Uninvolved regions 25-30Gy
51
52. Side Effects of Radiotherapy
Side effects of RT depend on
the irradiated volume,
the dose administered, and
the technique employed.
They are also influenced by the extent and type of prior
chemotherapy, if any, and
by the patient's age.
52
53. Most of the information that we use today to estimate risk
of RT is derived from strategies that used radiation alone.
The sizes of the fields and configuration, doses and
technology have all drastically changed over the last
decade.
It is therefore probably misleading to judge
current RT for lymphomas and inform patients solely on the
basis of different past practice of using RT in treating
lymphomas.
53
54. Acute Effects
Radiation, in general, may cause fatigue and areas of the
irradiated skin may develop mild sun-exposure like
dermatitis.
The acute side effects of irradiating the full neck include
mouth dryness, change in taste, and pharyngitis. These side
effects are usually mild and transient.
The main potential side effects of sub-diaphragmatic
irradiation are loss of appetite, nausea, and increased bowel
movements. These reactions are usually mild and can be
minimized with standard antiemetic medications.
54
55. Irradiation of more than one field, particularly after
chemotherapy, can cause myelosuppression,
which may necessitate short treatment interruption and
very rarely the administration of granulocyte-colony
stimulating factor (G-CSF).
55
56. Early Side Effects
Lhermitte's sign: <5% of patients may note an electric
shock sensation radiating down the backs of both legs when
the head is flexed (Lhermitte's sign) 6 weeks to 3 months
after mantle-field RT.
Possibly secondary to transient
demyelinization of the spinal cord, Lhermitte's sign
resolves spontaneously after a few months and is not
associated with late or permanent spinal cord damage.
56
57. Pneumonitis and pericarditis: During the same period,
radiation pneumonitis and/or acute pericarditis may
occur in <5% of patients; these side effects occur more
often in those who have extensive mediastinal disease.
Both inflammatory processes have
become rare with modern radiation techniques.
57
58. Late Side Effects
Subclinical Hypothyroidism: Irradiation of the neck and/or
upper mediastinal can induce subclinical hypothyroidism in
approximately one-third of patients.
This condition is detected by the elevation of
the thyroid-stimulating hormone (TSH). Thyroid
replacement with levothyroxine (T4) is recommended, even
in asymptomatic patients, to prevent overt hypothyroidism
and decrease the risk of benign thyroid nodules.
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59. Infertility: Only irradiation of the pelvic field may have
deleterious effects on fertility.
In most patients, this problem can be avoided
by appropriate gonadal shielding.
In women, the ovaries can be moved into a
shielded area laterally or inferomedially near the uterine
cervix.
Irradiation outside of the pelvis does not
increase the risk of sterility.
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60. Secondary Malignancies: Patients with HD who were cured
with RT and/or chemotherapy, have an increased risk of
secondary solid tumors (most commonly, lung, breast, and
stomach cancers, as well as melanoma) and NHL, 10 or more
years after treatment.
Unlike MOPP and similar chemotherapy
combinations, RT for HD is not leukemogenic.
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61. Lung Cancer: Patients who are smokers should be strongly
encouraged to quit the habit because the increase in lung
cancer that occurs after irradiation or chemotherapy has
been detected mostly in smokers.
Effects on Bone and Muscle Growth: In children, high-dose
irradiation will affect bone and muscle growth and may
result in deformities. Current treatment programs for
pediatric HD are chemotherapy based; RT is limited to low
doses.
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62. Coronary Artery Disease: An increased risk of coronary
artery disease has been reported among patients
who have received mediastinal irradiation.
To reduce this hazard, patients should be
monitored and advised about other established coronary
disease risk factors, such as smoking, hyperlipidemia,
hypertension, and poor dietary and exercise habits.
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63. Breast Cancer as a long term
sequelae of Radiotherapy in HL
For women whose HL was successfully treated at a young
age, the main long-term concern is the increased risk of
breast cancer.
The increase in risk of breast cancer is inversely related to
the patient's age at HL treatment; no increased risk has
been found in women irradiated after 30 years of age.
It is also related to the radiation dose to the breast and
the volume of breast tissue exposed.
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64. Most breast exposure in the mantle era resulted from the
radiation of the axillae, and to a lesser extent from wide
mediastinal and hilar irradiation.
During the last decade, reduction in field size has been the
most important change in radiation therapy of HD.
Reduction in the volume of exposed breast tissue together
with dose reduction (from over 40 Gy to a dose in the range
of 20-30 Gy) is likely to dramatically change the long-term
risk profile of young male and female patients cured of HD.
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