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HODGKIN’S LYMPHOMA
Dr Sandip Barik
Department of
Radiotherapy,KGMU,Lucknow
INTRODUCTION
• Are group of cancers which originates from
Reticuloendothelial systems
• It was named after Thomas Hodgkin who first described it in
1832.
• Dorothy Reed and Carl Stenberg first described the malignant
cells of Hodgkin’s lymphoma called Reed Stenberg cells.
• Hodgkins lymphoma was the first cancer which could be
successfully treated by radiation therapy and also by
combination chemotherapy.
Epidemiology
• Accounts for 0.58% of all cancers diagnosed and 0.23% of all cancer deaths
in U.S each year.
• Incidence is less than 3 per 100,000
• In 2010 in U.S 8490 cases were registered (4670 males, 3820 females) and
accounted for 1320 deaths.
• It has a slightly male predominance (1.1:1)
• It is rare in children younger than 10 years
• It has Bimodal peak of distribution (25-30 yrs and >55 yrs)
Risk Factors
• First degree relatives have five fold increase in risk for Hodgkins Disease.
• Associated with EBV infection mainly with mixed cellularity type.
• Associated with Infectious Mononucleosis. Incidence is about 2.55 times
higher
• High socio economic status.
• Prolonged uses of human growth hormone
Natural History
• Hodgkins lymphoma arises in a single node or a chain of nodes and
spreads first to anatomically contiguous lymphoid tissue.
• Visceral involvement by Hodgkins lymphoma may be secondary to
extension from adjacent lymph nodes.
• Haematogenous spread occurs to liver or multiple bony sites
• It rarely involves the gut associated lymphoid tissue such as Waldeyer ring
and Peyers patches.
• Mechanism of spleen involvement is unclear but all pts with hepatic and
bone involvement are associated with splenic involvement.
Clinical features
• Most common presentation is
asymptomatic lymphnode enlargement
typically in the neck.
• Cervical lympnodes are involved in 80%
cases .
• Mediastinal involvement is seen in about
50% cases .they produce symps like
Chest pain
Cough
Dyspnoea
• Infradiaphragmatic involvement is seen
in 5% cases and usually seen with older
patients.
Clinical features cont…
• B symptoms
 About 33% presents with B symptoms overall.
 Only 15-20% of stage I-II have B symptoms like
o Fever(>38oC)
 May first present as fever of unknown origin
 Fever persists for days to weeks followed by afebrile intervals and then
recurrence
 Such type of pattern is called Pel Ebstein Fever
o Drenching night sweats
o Weight loss(> 10% in 6 mths)
Clinical features cont…
• Other less frequently symptoms are
 Pruritus
 Alcohol induced pain over involved lymph nodes
 Nephrotic syndrome
 Erythema nodosum
 Cerebellar degeneration
 Immune hemolytic anaemia, Thrombocytopenia
 Hypercalcaemia
Diagnostic Workup
• History
• Complete physical examination
• Confirmatory workup
 Excisional biopsy of the lymph node
 Staging workup
 Chest x ray(pa,lat)
 Usg neck,whole abdomen
 CT scan thorax,abdomen and pelvis
 FDG PET scan
• Routine blood investigations
 Complete blood count
 Liver function
 Renal function
 Serum albumin
 ESR
 Lactate Dehydrogenase
 OTHERS
 Bone marrow biopsy
PET SCAN
• PET Scan has become an integral
component of initial staging.
• Information provided by PET has
been recently incorporated in the
lymphoma guidelines for response
evaluation after completion of
treatment.
• Useful for follow up study to
evaluate residual masses , dx of
early recurrence and predicting
outcome.
• It has a specificity of 90-95%
Revised International Workshop Criteria With PET Scan
Bone Marrow Biopsy
• Less commonly put into practice
• Overall involvement of bone marrow in Hodgkins lymphoma is
5%.
• Indicated in pts with
 B symptoms
 Clinical evidence of sub diaphragmatic disease
 Stage iii-iv
 Recurrent disease
Pathological Classification
Histologic Subtypes
Nodular lymphocyte predominant Hodgkins lymphoma
(NLPHL)
Classical Hodgkins lymphoma(CHL)
1 Nodular sclerosis Hodgkins lymphoma
2 Lymphocyte rich classical Hodgkins lymphoma
3 Mixed cellularity Hodgkins lymphoma
4 Lymphocyte depletion Hodgkin lymphoma
Lymphocyte predominant Hodgkins lymphoma
• <5% of Hodgkins lymphoma
• Mainly involves cervical,axillary or
mediastinal
• “L&H” cells or Popcorn cells are
seen
• Positive for CD20,45
• Negative for CD15,30.EBV
Nodular Sclerosis
• Most common type diagnosed.
About 70%
• Lacunar ceells are seen
• CD 15 and 30 positive
• EBV negative
• Only subtype without a male
predominance
• Seen in younger pts with stage I –
II disease
Mixed Cellularity
• Constitutes about 20%
• More common in young children
• CD 15,30 EBV positive
• Presents in advanced stages
• Tendency to involve spleen,bone
marrow
Lymphocyte Depleted
• Constitutes <5%
• Worst prognosis of all subtypes
• Older males
• Advanced stage
• HIV infection
Staging
I Involvement of a single lymph node
Or,lymphoid structure
Or single extralymphatic site
II Involvement of two or more lymphnode region on same side of diaphragm
Localized contiguous involvement of only one extranodal organ or site and
lymphnode regions on same side of diaphragm
III Involvement of lymphnode regions on both side of diaphragm
III1 With or without involvement of splenic,hilar.celiac or portal nodes
III2 With involvement of paraaortic ,iliac,and mesenteric nodes
IV Diffuse or disseminated involvement of one or more extranodal organs or
tissues,with or without involvement of associated lymphnodes.
Lymphnodes group
Prognostic Factors
Prognostic factor for Early stage Hodgkins disease
Prognostic factors cont…
Advanced stage hodgkins lymphoma
International prognostic score
Management
RADIATION CHEMOTHERAPY
Chemotherapy
25mg/m2
10
6
375
Radiotherapy
• Radiation therapy is the most effective single therapeutic agent for
treating Hodgkins lymphoma.
• The main objective of radiation in Hodgkins lymphoma is to treat involved
and contiguous field.
• Radiotherapy can be given by
• 2D Planning
• 3D Planning
• IMRT
• Pre RT Evaluation:
 Oro dental prophylaxis
 Pulmonary function test
 Pre chemotherapy and post chemotherapy information from CT or PET scan
 Position
 Usually supine.
 Arms up position pulled up the axillary node further from the chest wall
,thereby permitting more generous lung shielding.
 Arms down or akimbo position permitted shielding of the humeral head and
minimize the effect of tissue folds in supraclavicular
 If neck is to be treated head in hyperextension
 Frog leg for inguinal nodes
• Immobilization
 Mask for head and neck
 Body cast for pelvis
 OTHERS
 Oophoropexy in young females
 Fields are shaped using multileaf collimators
 Respiatory gating has to be taken care of
Mantle technique
• Target volume definition.
 The target volume for mantle field includes the
 Occipital
 Submental
 Submandibular
 Ant and Post cervical
 Infraclavicular
 Axillary
 Medial pectoral
 Paratracheal
 Mediastinal and hilar nodes
• Treatment Field:
 Superiorly: Inferior portion of
mandible bisecting the mastoid
process
 Laterally: Both the axillae
 Inferiorly: T10-11 interspace
• BLOCKS :
 Larynx anteriorly
 Humeral heads
 Spinal cord if >40 Gy
 Heart after 30 Gy
 Lung blocks: The upper border of lung block curves centrally to
include infraclavicular nodes
The medial borders are shaped so as to treat the hilar nodes.
A gap
of 8-10 cm is left in midline between blocks to treat
mediastinal nodes.
Subdiaphragmatic Fields
• The classical subdiaphragmatic field is the Inverted-Y.
• Target Volume:
 Para aortic
 Pelvis
 Inguinal nodes(b/l)
 Spleen
• Treatment Fields:
 For Paraaortic
 Superiorly:The T10-11 vertebrae
 Inferiorly:The lower limit of L4
 Laterally:width of transverse process.
 Pelvis F ield:
 Laterally:1.5-2 cm lat to the widest point in pelvis
 Inferiorly:Lesser trochanter.
Inverted “Y” Field
Para aortic fields pelvic field
• BLOCKS:
 Central midline block for
 Bladder
 Small bowel
 Oophoropexy if performed
 Testicular shielding
IFRT
• Involved field radiotherapy.
• IFRT is the most commonly used technique at present
• Targets a smaller area rather than a classical extended field.
• IFRT(ASTRO 2002)DEFINITION
 IFRT encompasses region and not an individual lymph node.
 Initially involved Pre chemo sites and volume are treated
 Exception to above rule is for transverse diameter of mediastinum and
paraaortic lymphnodes for which reduced post chemo volume is treated.
Major fields of IFRT
IFRT
3DCRT
• GTV:Original prechemo volume
of involved lymphnodes clinically
and radiologically
• CTV:GTV with whole nodal
regions that contains the involved
lymphnodes.
• PTV:Depends on
immobilization,reproducibility,org
an motion.usually 10 mm margin
is added to CTV
• INRT
• Newer concept evolved with advent and more usage of ct and PET scan
• Target volume is based on initial macroscopic prechemo disease rather
than based on lymphnode region.
• Treatment Portals:
 Beam arrangement is often // & opposite pair fields(ap-pa)
 DOSE
 Early stage :after complete response to chemotherapy 20 Gy in 10#
 Advanced stage with residual disease after chemotherapy
30 Gy in 15# with additional 6 Gy in 3# depending on bulk of disease
Sequelae of Treatment
• ACUTE REACTIONS:
 Fatigue ,nausea,vomiting,dry cough
 Occipital hair loss
 Sore throat
 Skin reactions
 Alteration of taste
 Dysphagia
 Reflux symptoms
 Myelosupression
• LATE REACTIONS
 Radiation Pneumonitis(6-12 wks)
 Radiation Pericarditis
 Subclinical Hypothyroidism:most common delayed symotoms
 Herpes Zoster infections:
 Lhermittes sign(1-2 mths)
• Late Reactions(cont…)
 Streptococcus pneumoniae and H influenzae infection following splenic
radiation.
 Azoospermia in males
 Premature menopause in females
 Secondary malignancy:
• Leukaemia
• Lymphoma(diffuse large cell type most common after 5 years)
• Solid Tumors:In males Lung (>30 Gy),colorectal
In females Breast,lung,colorectal
Conclusion
• Radiation therapy is the most effective single therapeutic agent for
treating Hodgkins lymphoma
• The management of Hodgkins lymphoma has evolved from extended field
radiation to a combined modality of chemo radiation or chemo alone.
• Interest is in achieving the best therapeutic ratio by minimizing late
toxicity while maintaining effectiveness.
• With improvement in diagnostic modality and PET scanning and improved
treatment policy the results in future will be encouraging.
THANK YOU

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Hodgkins lymphoma

  • 1. HODGKIN’S LYMPHOMA Dr Sandip Barik Department of Radiotherapy,KGMU,Lucknow
  • 2. INTRODUCTION • Are group of cancers which originates from Reticuloendothelial systems • It was named after Thomas Hodgkin who first described it in 1832. • Dorothy Reed and Carl Stenberg first described the malignant cells of Hodgkin’s lymphoma called Reed Stenberg cells. • Hodgkins lymphoma was the first cancer which could be successfully treated by radiation therapy and also by combination chemotherapy.
  • 3. Epidemiology • Accounts for 0.58% of all cancers diagnosed and 0.23% of all cancer deaths in U.S each year. • Incidence is less than 3 per 100,000 • In 2010 in U.S 8490 cases were registered (4670 males, 3820 females) and accounted for 1320 deaths. • It has a slightly male predominance (1.1:1) • It is rare in children younger than 10 years • It has Bimodal peak of distribution (25-30 yrs and >55 yrs)
  • 4. Risk Factors • First degree relatives have five fold increase in risk for Hodgkins Disease. • Associated with EBV infection mainly with mixed cellularity type. • Associated with Infectious Mononucleosis. Incidence is about 2.55 times higher • High socio economic status. • Prolonged uses of human growth hormone
  • 5. Natural History • Hodgkins lymphoma arises in a single node or a chain of nodes and spreads first to anatomically contiguous lymphoid tissue. • Visceral involvement by Hodgkins lymphoma may be secondary to extension from adjacent lymph nodes. • Haematogenous spread occurs to liver or multiple bony sites • It rarely involves the gut associated lymphoid tissue such as Waldeyer ring and Peyers patches. • Mechanism of spleen involvement is unclear but all pts with hepatic and bone involvement are associated with splenic involvement.
  • 6. Clinical features • Most common presentation is asymptomatic lymphnode enlargement typically in the neck. • Cervical lympnodes are involved in 80% cases . • Mediastinal involvement is seen in about 50% cases .they produce symps like Chest pain Cough Dyspnoea • Infradiaphragmatic involvement is seen in 5% cases and usually seen with older patients.
  • 7. Clinical features cont… • B symptoms  About 33% presents with B symptoms overall.  Only 15-20% of stage I-II have B symptoms like o Fever(>38oC)  May first present as fever of unknown origin  Fever persists for days to weeks followed by afebrile intervals and then recurrence  Such type of pattern is called Pel Ebstein Fever o Drenching night sweats o Weight loss(> 10% in 6 mths)
  • 8. Clinical features cont… • Other less frequently symptoms are  Pruritus  Alcohol induced pain over involved lymph nodes  Nephrotic syndrome  Erythema nodosum  Cerebellar degeneration  Immune hemolytic anaemia, Thrombocytopenia  Hypercalcaemia
  • 9. Diagnostic Workup • History • Complete physical examination • Confirmatory workup  Excisional biopsy of the lymph node  Staging workup  Chest x ray(pa,lat)  Usg neck,whole abdomen  CT scan thorax,abdomen and pelvis  FDG PET scan
  • 10. • Routine blood investigations  Complete blood count  Liver function  Renal function  Serum albumin  ESR  Lactate Dehydrogenase  OTHERS  Bone marrow biopsy
  • 11. PET SCAN • PET Scan has become an integral component of initial staging. • Information provided by PET has been recently incorporated in the lymphoma guidelines for response evaluation after completion of treatment. • Useful for follow up study to evaluate residual masses , dx of early recurrence and predicting outcome. • It has a specificity of 90-95%
  • 12. Revised International Workshop Criteria With PET Scan
  • 13. Bone Marrow Biopsy • Less commonly put into practice • Overall involvement of bone marrow in Hodgkins lymphoma is 5%. • Indicated in pts with  B symptoms  Clinical evidence of sub diaphragmatic disease  Stage iii-iv  Recurrent disease
  • 14. Pathological Classification Histologic Subtypes Nodular lymphocyte predominant Hodgkins lymphoma (NLPHL) Classical Hodgkins lymphoma(CHL) 1 Nodular sclerosis Hodgkins lymphoma 2 Lymphocyte rich classical Hodgkins lymphoma 3 Mixed cellularity Hodgkins lymphoma 4 Lymphocyte depletion Hodgkin lymphoma
  • 15. Lymphocyte predominant Hodgkins lymphoma • <5% of Hodgkins lymphoma • Mainly involves cervical,axillary or mediastinal • “L&H” cells or Popcorn cells are seen • Positive for CD20,45 • Negative for CD15,30.EBV
  • 16. Nodular Sclerosis • Most common type diagnosed. About 70% • Lacunar ceells are seen • CD 15 and 30 positive • EBV negative • Only subtype without a male predominance • Seen in younger pts with stage I – II disease
  • 17. Mixed Cellularity • Constitutes about 20% • More common in young children • CD 15,30 EBV positive • Presents in advanced stages • Tendency to involve spleen,bone marrow
  • 18. Lymphocyte Depleted • Constitutes <5% • Worst prognosis of all subtypes • Older males • Advanced stage • HIV infection
  • 19. Staging I Involvement of a single lymph node Or,lymphoid structure Or single extralymphatic site II Involvement of two or more lymphnode region on same side of diaphragm Localized contiguous involvement of only one extranodal organ or site and lymphnode regions on same side of diaphragm III Involvement of lymphnode regions on both side of diaphragm III1 With or without involvement of splenic,hilar.celiac or portal nodes III2 With involvement of paraaortic ,iliac,and mesenteric nodes IV Diffuse or disseminated involvement of one or more extranodal organs or tissues,with or without involvement of associated lymphnodes.
  • 21. Prognostic Factors Prognostic factor for Early stage Hodgkins disease
  • 22. Prognostic factors cont… Advanced stage hodgkins lymphoma International prognostic score
  • 25. Radiotherapy • Radiation therapy is the most effective single therapeutic agent for treating Hodgkins lymphoma. • The main objective of radiation in Hodgkins lymphoma is to treat involved and contiguous field. • Radiotherapy can be given by • 2D Planning • 3D Planning • IMRT
  • 26. • Pre RT Evaluation:  Oro dental prophylaxis  Pulmonary function test  Pre chemotherapy and post chemotherapy information from CT or PET scan  Position  Usually supine.  Arms up position pulled up the axillary node further from the chest wall ,thereby permitting more generous lung shielding.  Arms down or akimbo position permitted shielding of the humeral head and minimize the effect of tissue folds in supraclavicular  If neck is to be treated head in hyperextension  Frog leg for inguinal nodes
  • 27. • Immobilization  Mask for head and neck  Body cast for pelvis  OTHERS  Oophoropexy in young females  Fields are shaped using multileaf collimators  Respiatory gating has to be taken care of
  • 28. Mantle technique • Target volume definition.  The target volume for mantle field includes the  Occipital  Submental  Submandibular  Ant and Post cervical  Infraclavicular  Axillary  Medial pectoral  Paratracheal  Mediastinal and hilar nodes
  • 29. • Treatment Field:  Superiorly: Inferior portion of mandible bisecting the mastoid process  Laterally: Both the axillae  Inferiorly: T10-11 interspace
  • 30. • BLOCKS :  Larynx anteriorly  Humeral heads  Spinal cord if >40 Gy  Heart after 30 Gy  Lung blocks: The upper border of lung block curves centrally to include infraclavicular nodes The medial borders are shaped so as to treat the hilar nodes. A gap of 8-10 cm is left in midline between blocks to treat mediastinal nodes.
  • 31. Subdiaphragmatic Fields • The classical subdiaphragmatic field is the Inverted-Y. • Target Volume:  Para aortic  Pelvis  Inguinal nodes(b/l)  Spleen
  • 32. • Treatment Fields:  For Paraaortic  Superiorly:The T10-11 vertebrae  Inferiorly:The lower limit of L4  Laterally:width of transverse process.  Pelvis F ield:  Laterally:1.5-2 cm lat to the widest point in pelvis  Inferiorly:Lesser trochanter.
  • 33. Inverted “Y” Field Para aortic fields pelvic field
  • 34. • BLOCKS:  Central midline block for  Bladder  Small bowel  Oophoropexy if performed  Testicular shielding
  • 35.
  • 36. IFRT • Involved field radiotherapy. • IFRT is the most commonly used technique at present • Targets a smaller area rather than a classical extended field. • IFRT(ASTRO 2002)DEFINITION  IFRT encompasses region and not an individual lymph node.  Initially involved Pre chemo sites and volume are treated  Exception to above rule is for transverse diameter of mediastinum and paraaortic lymphnodes for which reduced post chemo volume is treated.
  • 38. IFRT
  • 39. 3DCRT • GTV:Original prechemo volume of involved lymphnodes clinically and radiologically • CTV:GTV with whole nodal regions that contains the involved lymphnodes. • PTV:Depends on immobilization,reproducibility,org an motion.usually 10 mm margin is added to CTV
  • 40. • INRT • Newer concept evolved with advent and more usage of ct and PET scan • Target volume is based on initial macroscopic prechemo disease rather than based on lymphnode region. • Treatment Portals:  Beam arrangement is often // & opposite pair fields(ap-pa)  DOSE  Early stage :after complete response to chemotherapy 20 Gy in 10#  Advanced stage with residual disease after chemotherapy 30 Gy in 15# with additional 6 Gy in 3# depending on bulk of disease
  • 41.
  • 42. Sequelae of Treatment • ACUTE REACTIONS:  Fatigue ,nausea,vomiting,dry cough  Occipital hair loss  Sore throat  Skin reactions  Alteration of taste  Dysphagia  Reflux symptoms  Myelosupression
  • 43. • LATE REACTIONS  Radiation Pneumonitis(6-12 wks)  Radiation Pericarditis  Subclinical Hypothyroidism:most common delayed symotoms  Herpes Zoster infections:  Lhermittes sign(1-2 mths)
  • 44. • Late Reactions(cont…)  Streptococcus pneumoniae and H influenzae infection following splenic radiation.  Azoospermia in males  Premature menopause in females  Secondary malignancy: • Leukaemia • Lymphoma(diffuse large cell type most common after 5 years) • Solid Tumors:In males Lung (>30 Gy),colorectal In females Breast,lung,colorectal
  • 45. Conclusion • Radiation therapy is the most effective single therapeutic agent for treating Hodgkins lymphoma • The management of Hodgkins lymphoma has evolved from extended field radiation to a combined modality of chemo radiation or chemo alone. • Interest is in achieving the best therapeutic ratio by minimizing late toxicity while maintaining effectiveness. • With improvement in diagnostic modality and PET scanning and improved treatment policy the results in future will be encouraging.