WELL PUT SEMINAR ON ALL COVERING SYMPTOMS DIAGNOSIS TILL MANAGEMENT OF ALL

1. ACUTE LYMPHOBLASTIC LEUKEMIA
(ALL)
Presented by: Moderator:
Dr. Prachi Kalra Dr. Paramjeet Kaur
Department of Radiation Oncology,
Pt. B.D.Sharma PGIMS, Rohtak

2. ALL
§ Acute lymphoblastic leukaemia (ALL) is a malignant disorder that
originate in single B and T Lymphocytes progenitor.
§ The proliferation and accumulation of blast cells in the marrow
result in suppression of haematopoiesis, thereafter causing
anaemia, thrombocytopenia and neutropenia.
§ Extra medullary accumulation of lymphoblast may occur in various
system especially in gonads, thymus, liver, spleen and CNS.
BR Kenneth, VK Gottfried, P Nikolai. Leukemia. Perez & Brady’s Principles and Practice of Radiation Oncology. 7th edition.
Philadelphia: Wolters Kluwer;2018. p6022-52.

4. Incidence
• Most common malignancy diagnosed in <15 years.
( 23 % of all cancers and 76 % of all leukemias)
• Only 20 % of adult leukemias are ALL.
• Bimodal peak
– Second decade
– sixth decade
• Males : females =1.3:1
• Cure rate in childhood ALL is 80-89% , in adults cure rate ranges from 30-
45%
Williams hematology 9th
edition, 2016

5. Etiology
• Genetic Syndrome
q Downs syndrome
q Ataxia-telangiectasia
q Bloom syndrome
• Environmental Factors
q Radiation exposure
q Smoking
q Pesticide
• Chemotherapeutic agents
q Alkylating agents
q Epipodophyllotoxins
Williams hematology 9th edition, 2016

6. Nonspecific (common)
• Fever
• Bleeding
• Petechiae
Musculoskeletal pain
• Limp/Refusal to bear weight
• Bone pain
• Sternal tenderness
Williams hematology 9th
edition, 2016
Clinical features

7. Clinical Features contd….
• Lymphadenopathy (~50% on presentation)
• Organomegaly
Liver, spleen, and lymph nodes are the most common sites of
extramedullary involvement
• CNS symptoms
o Headache
o Increased ICP
o Vomiting
o Lethargy
o Papilloedema
o Nuchal rigidity
o Cranial nerve abnormalities

8. Clinical Features contd….
• Testicular involvement
Painless enlargement of the scrotum
• Mediastinal mass
o Tracheal compression
o Superior vena cava syndrome
Pain
Dysphagia
Dyspnea
Swelling of the neck, face, and upper limbs.

9. DIAGNOSIS
1. Peripheral blood :
Leukocyte counts –
• 10,000-1,00,000/mm3
infection or leukemoid reaction can be in differential diagnosis
• > 1,00,000 cells/mm3 (10 – 16 %)
• 90% patients have circulating leukemic blast cells.
• Hyper-eosinophilia, generally reactive, may precede the diagnosis by
several months.
Williams hematology 9th edition, 2016

10. • Anemia : <12g/dl. Occasionally, a child with ALL has a level as low as 1
g/dl.
• Profound Neutropenia (<500 cells/mm3) is found in 20 – 40 % of patients.
• Decreased Platelet counts often are seen at diagnosis (median 48,000-52
,000 cells/mm3).
2. Serum lactate dehydrogenase (LDH) - increases.
normal value 140-280 U/L

11. 3. BONE MARROW examination:
q Bone marrow aspiration
q Bone marrow biopsy
q Immunophenotyping
q Cytogenetics
o 10 percent of patients lack circulating blasts at the time of diagnosis
o Bone marrow cells are better than peripheral blood cells for cytogenetic
studies.
>30% blasts present in bone marrow will result in definitive diagnosis .

12. Lumbar puncture
• If there is a risk of bleeding due to a very low platelet count or of blast cell
contamination due to a high leukemic blast content in the peripheral blood,
lumbar puncture should be postponed.
CNS leukemia is:
• Presence of at least five leukocytes per microliter of CSF and the
detection of leukemic blast cells.
• Presence of cranial nerve palsy.

13. Immunophenotyping
Flow Cytometry:
(Whole blood/ Bone Marrow)
• Leukocyte common antigen(LCA): CD 45
• Pan-T cell marker : CD 3 ,CD 7
• T cell marker: CD 5

14. CYTOGENETIC STUDY &
MOLECULAR ANALYSIS
Karyotyping [specific translocations like t(9;22) BCR ABL fusion]
Fluorescence in situ hybridization (FISH)
Reverse transcriptase polymerase chain reaction (RT-PCR) assays.
( Can identify several important submicroscopic genetic alterations not
visible by standard karyotyping procedures, such as the TEL-AML1 fusion)

15. CLASSIFICATION OF ALL
• Morphologic and Cytochemical (FAB)
• Immunological (WHO)
• Genetic

16. Morphologic and Cytochemical Classification:
FAB Classification of ALL

17. Immunologic Classification
World Health Organization
(WHO)classification (modified)

18. Risk Groups Cytogenetics
Good risk Hyperdiploidy (51-65 chromosomes;
cases with trisomy of chromosomes 4,
10 and 17 appear to have the most
favourable outcome);
t(12;21)(p13;q22): ETV6 –RUNX1
Poor risk Hypodiploidy (<44 chromosomes);
KMT2A rearranged (t[4;11]or others);
t(v;14q32)/IgH; t(9;22)(q34;q11.2):BCR-
ABL1(defined as high risk in the pre-TKI
era); complex karyotype (5 or more
chromosomal abnormalities); Ph-like
ALL; intrachromosomal amplification of
chromosome 21(iAMP21)

19. Classification of Acute Lymphoblastic Leukemia

20. TREATMENT
• Supportive Care
– Metabolic Complications
– Leukostasis
– Infection Control
– Hematologic Support

21. Metabolic Complications
• Especially with B cell or T cell ALL or B cell precursor leukemia with high
leukemic cell burden
• Tumor lysis syndrome
• Management :
– Hyperuricemia :
• IV fluids
• Allopurinol or rasburicase (recombinant urate oxidase) .
– Hyperphosphatemia :
• Phosphate binder, such as aluminum hydroxide
• Calcium carbonate (if the serum calcium concentration is low)
• Sevelamer .

22. Leukostasis
• Occurs with elevated blast count (25% of patients have WBC>50,000/mm3
)
• Symptoms result from capillary plugging by leukemic cells.
Dyspnea,headache,confusion and hypoxia
Management :
• Leukapheresis and aggressive hydration is repeated daily in conjunction
with chemotherapy (eg.,oral hydroxyurea or intravenous
cyclophosphamide) until blast count is<50,000/mm3.

23. Infection Control
• Due to neutropenia
Management:
– broad-spectrum antibiotic until fever is controlled.
• Due to Remission induction therapy
By exacerbating myelosuppression, immunosuppression, and mucosal
breakdown. (50 % of patients )

24. Infection Control contd…..
• Care during remission induction therapy:
1. Reverse protective isolation and air filtration
2. Elimination of contact with people with infections
3. Refraining from eating certain food products, such as raw cheese, uncooked
vegetables, or unpeeled fruits
4. Use of antiseptic mouthwash or sitz baths, especially for patients with
mucositis.
5. Administration of granulocyte colony stimulating factor can hasten
recovery .

25. Infection Control contd…..
• Due to early intensification of therapy,
(especially in combination with dexamethasone)
• resulted in an increased risk of disseminated fungal infection.
• Management:
– Trimethoprim-sulfamethoxazole,
• 2 to 3 days per week
• Prophylactic therapy for Pneumocystis carinii (Pneumocytis jiroveci)
pneumonia
• Prophylaxis is started after 2 weeks of remission induction and continues
until 6 weeks after completion of all chemotherapy.
– Alternatives - aerosolized pentamidine, dapsone, and atovaquone.

26. Hematologic Support
• ALL or its treatment can lead to thrombocytopenia.
Hemorrhagic manifestations are common
Management:
Platelet transfusions : inidication
• Overt bleeding
• Platelet counts < 10 x 109/liter.
Packed red cells transfusions : indication
• Anemia and marrow suppression
(delayed until the leukocyte count is reduced in patients with extreme
hyperleukocytosis)

27. Specific
• B Cell Precursor and T Cell ALL
Treatment consists of three standard phases:
• Remission induction
• Intensification (consolidation)
• Prolonged continuation therapy
• CNS-directed therapy
Started early and is given for different lengths of time, depending on the
patient's risk of relapse and the intensity of the primary systemic regimen.

28. Remission Induction
• Aim : To rapidly kill most tumor cells and get the patient into
remission.
• Clinical Remission:
Presence of less than 5% leukemic blasts in the bone marrow,
normal blood counts, absence of tumor cells from blood
absence of other signs and symptoms of the disease.
• Central nervous system (CNS) prophylaxis should begin during this phase
of treatment and continue during the consolidation/intensification period.

29. Intensification (Consolidation)
Therapy
• Aim: To further reduce tumor burden .
• When normal hematopoiesis is restored, patients in remission become
candidates for intensification therapy
• High doses of multiple agents not used during the induction phase

30. Maintenance therapy
• Aim: To kill any residual cell that was not killed by remission
induction, and intensification regimens.
• Long-term drug exposure or the host immune system is needed to kill
residual, slowly dividing leukemic cells or to suppress their growth and
thus allow programmed cell death to occur.
• total duration of 2 to 2.5 years

31. Berlin-Frankfurt-Munro Augmented
protocol
< 25years old
Induction: (4 weeks)
• Vincristine: 1.4 mg/m IV on days 1,8,15,22 once a week X4
weeks
• Daunorubicin: 25 mg/m2 IV on days 1,8,15,22
• Prednisolone :60 mg/m2 PO on days 1-28 then taper over 10 days
• L-asparginase- 6000 U/m2 total doses divided over 10 days IV/IM on
days 3,5,7,10,12,14,17,19,21
• Bone marrow - to assess the remission status on day 32±3

32. Consolidation: (9 weeks)
• Cyclophosphamide -1000 mg/m2 IV on days 0,28
• Cytarabine: 75mg/m2 i.v on d 1-4,8-11,29-32,36-39: 4 times a week(1,2,4,5)
• 6 –MP: 60mg/m2 /d P.O on d 0-13,28-41
• Vincristine:1.5mg/m2 /d i.v d 14,21,42,49 (once a week -2,3,6,7)
• L-asparginase - 6000U/m2 i.m d 14,16,18,21,23,25,42,44,46,49,51,53
(thrice a week –week 1,2,6,7)
• Methotrexate IT (intrathecal) days 1,8,15,22
• Radiotherapy – in first two weeks of consolidation. With CNS cranial – 2400cGy in 12
fractions and spinal 600cGy in 3 fractions, testiculomegaly at diagnosis 2400cGy in 8
fractions
• Rest for 10 days
6-MP 6-mercaptopurine

33. Interim maintenance I (8 weeks)
• Vincristine <1.5 mg/m²/d IV days
0,10,20,30,40
• methotrexate 100mg/m²/d IV days
0,10,20,30,40
• L-asparaginase 15,000U/m²/d IM days
1,11,21,31,41
• rest 2 weeks

34. Delayed intensification I (8 weeks)
Reinduction (4wks)
• Dexamethasone 10mg/m²/d (max 10mg/d) PO
BD days 1-7, 14-21
• Vincristine 1.5 mg/m²/d (max 2mg) IV days
0,7,14
• Doxorubicin 25mg/m²/d IV days 0,7,14
• Asparaginase 6000U/m²/d IM/IV days
3,5,7,10,12,14

35. Reconsolidation (4weeks)
• Vincristine 1.5mg/m²/d (max 2mg) IV days
42,49
• Cyclophosphamide 1000mg/m² IV day 28
• Thioguanine 60mg/m²/d PO days 28-41
• Cytarabine 75mg/m²/d IV days 29-32, 36-39
• Methotrexate IT 29,36 asparaginase
6000U/m²/d IM days 42,44,46,49,51,53

36. Interim maintenance II (8 weeks)
• Vincristine 1.5mg/m²/d (max 2mg) IV days
0,10,20,30,40
• Methotrexate 100mg/m²/d IV days
0,10,20,30,40 (escalate by 50mg/m²/dose)
• Asparaginase 15,000U/m²/day IM days
1,11,21,31,41
• Methotrexate IT days 0,20,40
• Rest 2 weeks

37. Delayed intensification II (8 weeks)
Reinduction (4wk)
• Dexamethasone 10mg/m²/d (max 10mg/day)
PO BD days 1-7, 14-21
• Vincristine 1.5mg/m²/day (max 2mg) IV days
0,7,14
• Doxorubicin 25mg/m²/day IV days 0,7,14
• Asparaginase 6000U/m²/d IM days
3,5,7,10,12,14

38. Reconsolidation (4wk)
• Vincristine 1.5mg/m²/d IV days 42,49
• Cyclophosphamide 1000mg/m² IV day 28
• Thioguanine 60mg/m²/d PO days 28-41
• Cytarabine 75mg/m²/d IV days 29-32,36-39
• Methotrexate IT days 29,36
• Asparaginase 6000U/m²/d IM days
42,44,46,49,51,53

39. Maintenance (12wk)
• BMA on day 0 of maintenance
• methotrexate IT day0/ 3 monthly
• mercaptopurine 75mg/m²/d PO daily
• methotrexate 20mg/m²/d PO weekly
• prednisolone 40mg/m²/d PO days 0-3/every 28
days
• vincristine 1.5mg/m²/d (max 2 mg) IV/ every 28
days
Two years for girls and three years for boys start
from first interim maintenance

42. Philadelphia Chromosome Positive Acute Lymphoblastic
Leukemia
• Patients with Ph+ ALL have a poor prognosis.
• Long-term DFS rate of 10% to 20%.
• Allogeneic transplantation from a related or unrelated donor has been
widely used for consolidation.
• Beyond first remission,
DFS : 5% to 17%.

43. • Imatinib mesylate has demonstrated significant activity in patients with
Ph+ALL.
• CR : 95%.
• Molecular negativity: 50% to 70%
• Second-generation TK inhibitors such as dasatinib and nilotinib in relapse
and refractory Ph+leukemias
Imatinib 340mg/m²/d

44. Prevention and Treatment of Central
Nervous System Leukemia
• 6% of patients at diagnosis present with CNS leukemia.
• Higher incidence in T-cell ALL (8%) and mature B-cell ALL (13%).
• Risk factors:
ü High-risk genetic features
ü Large leukemic cell burden
ü Mature B cell ALL
ü T-lineage ALL
ü Leukemic cells in the CSF (even if iatrogenic from a traumatic lumbar
puncture) .

45. PREVENTION
• Intrathecal methotrexate
• regular BM examination
CNS prophylaxis in ALL by radiation therapy :
• 18 Gy in 10-12 # over 2-2.2 wks (with intrathecal
methotrexate
TREATMENT triple IT
• Intrathecal (IT) methotrexate , cytarabine (Ara-C), steroid firstly weekly
till amorphous cells in CSF then monthly for three months, therafter three
monthly for two years
• Radiation (2400-3000cGy) can also be considered. In CNS prophylaxis for
ALL, 24 Gy RT to whole brain ( with CT) is associated with poorer
academic performance 5 yrs after RT. These toxicities were lower when 14-
18 Gy was used.

46. Whole brain field for leukemia
– Opposing lateral beams covering whole brain.
• Superior, anterior & posterior borders are 1 cm away
from the extreme edges of the calvaria.
• Cribriform plate is included in target volume.
• Lower border at inferior border of second cervical
vertebra.
Perez & brady, 7 th edition,2018

47. Whole brain field for leukemia
– The posterior half of eye globes are included in the
field (because of meningeal reflection along optic
nerve), by using antero-lateral aspect of bony orbit as
anatomic landmark as it lies along a line that bisects
the eye.
– Anterior orbit and naso-pharynx are protected by lead
shielding.
– To reduce radiation induced cataracts, pt. asked to look
downward towards his toes as forward gaze leads to
inclusion of superior half of lens into treatment fields.
Perez & brady, 7 th edition,2018

48. 1 cm from extreme edges of
calvaria
Lower border at inferior border of C-2
vertebra
Posterior half of orbit is included
in field
Lead
shield
Of ant
orbit and
nasophar
ynx

49. CNS relapse rate with various treatments:
CNS relapse rate
No treatment 30%
Intrathecal Chemotherapy 13%
Intravenous +Intrathecal
Chemotherapy
7%
Additional CNS irradiation 6%

50. Testicular Relapse
• Commonly in T cell subtype
• Approx 2% of males .
• Poor prognostic indicator.
• Systemic and/or CNS relapse usually follows .
• Both intensive systemic therapy and local radiotherapy are indicated.

51. • Unilateral irradiation or orchiectomy: significant risk of contralateral
testicular relapse.
• Treatment of both testes: infertility.
• CCG and POG studies :
( Children’s Cancer Group & pediatric oncology group )
Local irradiation and intensive systemic therapy :
Event-free survival : 50% to 65% .
• Dose: 24 to 26 Gy in 1.5- to 2.0-Gy/fraction.

52. Allogeneic Stem Cell Transplantation
INDICATIONS:
Ø All patients with relapsed or refractory disease
Overall Survival:
Ø <35% in relapsed disease
Ø < 10% in refractory disease.
Ø After first CR or early in the course for those patients with poor risk
cytogenetics, t(9;22)
Overall survival is 50%
Long-term event-free survival rates range from
• 30 to 40 percent with chemotherapy alone
• 40 to 60 percent with allogeneic transplantation
Perez & brady, 7 th edition,2018

53. • Dose-when given as conditioning therapy 12Gy / 8 fractions is
given at 1.5 Gy per fraction Total body irradiation (TBI) is given
with oral chemotherapy Cyclophosphamide (Cy).

54. Relapse
• Relapse is defined as the reappearance of leukemic cells at any site in the
body.
• Most relapses occur during treatment or within the first 2 years after its
completion
• Early Relapse:<6 months during treatment
• Late Relapse: >6 months after cessation of therapy
• Marrow is the most common site of relapse in ALL.
Anemia, leukocytosis, leukopenia, thrombocytopenia, enlargement of the
liver or spleen, bone pain, fever, or a sudden decrease in tolerance to
chemotherapy .

55. • Extramedullary sites : CNS , testes and eye.
Marrow relapse, with or without extramedullary involvement, is a poor
outcome .
• Late relapse : reinduction with the original regimen.
• Early relapse or refractory disease : Transplantation or changing treatment
plan.
• For patients who receive only chemotherapy, a second course of CNS-
directed treatment is needed to prevent subsequent CNS relapse

56. Treatment Options:
• High dose cytarabine with idarubicin,mitoxantrone or fludarabine
• Methotrexate,vincristine,asparginase,steroids(MOAD)
• Imatinib,dasatinib or nilotinib(if Ph positive)
• Hyper-CVAD ,if not given initially
• Vinorelbine with mitoxantrone, fludarabine, steroids or rituximab
• Nelarabine
• Clofarabine

57. Newer drugs in ALL:
Role in relapsed or refractory cases.
Antimetabolites(Purine nucleoside analogues):
o Clofarabine
o Nelarabine T cell ALL
o Forodesine
§ Overall response rates : 33% to 60%
§ Overall survival rate : 28%
o Alemtuzumab (Anti-CD 52)
o Gemtuzumab ,Ozogamicin (anti-CD33)
o Epratuzumab (anti-CD22)
o Blinatumomab(new class of drug which uses T cell to exert its action)
§ Overall survival rate: 75%

58. Summary
• Occurs in children <15 years, bimodal peak
• Incidence 26% of all cancer
• Cure rate of ALL in children 89-90%
• BFM augmented protocol
• Role of CNS prophylaxis
• Allogenic stem cell transplantation

60. Side Effects Associated with Antileukemic
Therapy
Acute complications Delayed complications

61. Side Effects Associated with Antileukemic Therapy contd….
Acute complications Delayed complications

62. Paeds deptt.,PGIMS Rohtak

63. • Vincristine- VINCRISTIN/ CYTOCRISTINE- 1mg/vial(inj)
• Daunorubicin- ADRIAMYCIN-50mg/vial(inj)
• L-asparaginase- LEUNARE-10,000 KU/vial(inj)
• Cyclophosphamide- ENDOXAN(10-15mg/kg) - 50mg,200mg,500mg (inj)
• Cytarabine- CYTARABIN, CYTABIN- 100mg,500mg,1gm (inj)
• 6-MP - PURIMETHOL -50mg tab
• 6-TG - 6-TG 100-200mg inj/day
• Methotrexate-NEOTREXATE- 50mg/2ml inj
• Dexamethasone- DEXONA 4mg/ml inj

64. COST OF VARIOUS TESTS
Oncquest Laboratories Ltd. 3, Factory Road. Adj. Safdarjung Hospital New Delhi -
110029. India. Phone, : + 91-11-26101240
[2-3 ml bone marrow/ 4-5 ml whole blood (heparinised)]
• Flow cytometry- Rs 9,000
• Cytogenetic karyotyping - Rs3,000
• FISH- Rs3,400
• RT-PCR- Rs3500

67. •Maintenance (12 week cycle)x 6 cycles
•Vincristine: 1.5mg/m2 i.v d 0,28,56
•Prednisolone:60mg/m2 po qd d0-4,28-
32,56-60
•6MP : 75mg/m2 p.o qd d 0-83
•Methotrexate: 20mg/m2 p.o d
7,14,21,28,35,42,56,63,70,77
• IT Methotrexate: d 0

68. Medicine deptt:
Induction:
• Inj Adriamycin 40mg i.v D1and D2
• Inj Vincristine 2mg i.v D1,7,14,21 and 28
• I/T Methotrexate D2,15 and 29
• Tab Prednisolone 20mg TDS x 28 days
• Inj L asparginase 10,000 U i.v every 3rd day.
Maintainence:
• Inj Vincristine 2mg i.v stat
• Tab Methotrexate 20mg weekly
• Tab 6MP 100mg OD
• Tab Prednisolone 20mg TDS X 5 days

69. Larson Regimen
(Cancer and leukemia Gp B :CALGB protocol 9111 )
Course I : Induction(4 wk)
• Cyclophoshamide 1,200mg/m2 i.v Day 1
• Daunorubicin 45mg/m2 i.v Day 1-3
• Vincristine 2mg i.v Day 1,8,15,22
• Prednisone 60mg/m2/day PO Day 1-21
• L-Asparaginase (E.coli ) 6,000IU /m2 SQ/IM Day 5,8,11,15,18,22
• G-CSF 5ug/kg/day SQ starting Day 4
Course IIA (repeat once for Course IIB)
• Methotrexate 15mg intrathecal (IT) Day 1
• Cyclophosphamide 1,000mg/m2 i.v Day1
• 6-Mercaptopurine 60mg/m2/day PO Day 1-14
• Cytarabine 75mg/m2/day SQ Day 1-4 and 8-11
• Vincristine 2mg i.v Day 15 and 22 (two doses)
• L-Asparaginase (E.coli ) 6,000IU /m2 SQ/IM Day 15,18,22,25(four doses)
• G-CSF 5ug/kg/day SQ starting Day 2

70. Course III
(CNS prophylaxis and interim maintenance(12 wk)
• IT methotrexate 15mg Day 1,8,15,22,29
• Cranial irradiation 2,400cGy(fractionated)
• 6-mercaptopurine 60mg/m2/d PO d1-70
• Methotrexate 20mg/m2 PO d 36,43,50,57,64
• Course IV: late intensification(8 wk)
• Doxorubicin 30mg/m2 i.v. d1,8,15
• Vincristine 2mg i.v. d 1,8, 15
• Dexamethasone 10mg/m2/d PO d 1-14
• Cyclophosphamide 1000mg/m2 i.v. d29
• 6-thioguanine 60mg/m2/d PO d 29-42
• Cytarabine 75mg/m2/d SQ d 29-32 and 36-39

71. Course V: prolonged maintainance (continue until 2 yrs
after diagnosis)
• Vincristine 2mg i.v Day 1 of every 4wk
• Prednisone 60mg/m2/d PO day 1-5 of every 4 wk
• 6-mercaptopurine 60mg/m2/d PO d1-28
• Methotrexate 20mg/m2 PO d 1,8,15,22
(dosage reduction for age more than 60 yrs)
• yclophosphamide 800mg/m2 d 1
• Daunorubicin 30mg/m2 d 1-3
• Prednisone 60mg/m2 d 1-7

73. B cell ALL

75. Technique
• Megavoltage energy of 4-6MV is used
• Anterior border of the field should be 3cm posterior to the ipsilateral
eyelid for the diverging beam to exclude the contralateral lens
• A better alternative is to angle the beam 4-5 degrees against the
frontal plane, so that the anterior beam border traverses posterior to
the lenses
• A radio-opaque marker is placed on the lateral canthus of both eyes
and they are aligned
• When doubt about tumor coverage or lens sparing for tumors in
frontal or middle cranial fossa location, one should consider CT
based contouring and planning
PEREZ
7th Ed. 2018

76. Technique to minimize dose to the anterior portion of the eyes
• Voluntary rotation of the eye downward (exception of very young children)
• Alignment of the anterior beam edge divergence
• Angle the gantry 3 to 5 degrees to achieve a parallel anterior beam margin
at the back of the eye.

79. Total
cases
Number Rank % Cum.risk
11,57,294 42,055 7 4.00 0.27
New cases
Number Rank % Cum.risk
32471 7 4.51 0.21
Deaths
Globocan factsheet 2018 details

80. Globocan -2018
India factsheet
ØIncidence – 4%
Ø5 year prevalence (all ages) - 4.6%
Ømortality – 30%
World
ØIncidence -Male : female :: 3.8 : 2.7
ØIncidence : mortality :: 3.2 : 2.5

82. Hyper CVAD and MTX/HIDAC REGIMEN:
Cycle 1,3,5,7
• Cyclophoshamide 300mg/m2 i.v over 3hr q12hr Day 1-3(six doses)
• (a/w Mesna 600mg/m2/d as continuous infusion Day 1-3
• Vincristine 2mg i.v Day 4,11
• Doxorubicin 50mg/m2 i.v Day 4
• Dexamethasone 40mg PO daily 1-4 and 11-14
• G-CSF 10ug/kg/d SQ starting after chemotherapy
Cycle 2,4,6,8
• Methotrexate 200mg/m2 i.v over 2 hr on Day1 ,followed by
• Methotrexate 800mg/m2 i.v over 22hr on Day 1
• Leucovorin 50mg starting 12hr after Mtx completed ,followed by leucovorin 15mg
every 6h x eight doses(dose adjusted on the basis of mtx levels)
• Cytarabine 3gm/m2 i.v. over 2hr every 12 hr on Day 2 and 3( four doses)
• Methylprednisolone 50mg i.v twice daily Day 1-3
• G-CSF 10ug/kg/d SQ starting after chemotherapy

83. Genetic Classification

84. Testicular Irradiation
Technique
• Patient in a frog-leg position
• Penile shaft taped onto the abdomen .
• Check the cremaster reflex and potential ascent of the testes into the
inguinal canal.
• For megavoltage photon beams, bolus may be required to avoid superficial
underdosing.
• In young boys in whom the scrotum/testes thickness is under 2 cm, 250 kV
orthovoltage x-rays may also be used.

85. Field of WBRT
• WBRT is administered through parallel opposed
lateral portal
• Patient positioned in supine position with neck
in comfortable neutral position.
• Superior : Skin fall off
• Anterior : Skin fall off
• Posterior : Skin fall off
• Inferior : should be inferior to cribriform plate,
the middle cranial fossa and foramen magnum
The inferior border is indicated by Reid’s base line,
which is a line extends from external auditory
meatus to outer canthus of eye
Basic radiation oncology 2010 ; PEREZ 7th Ed. 2018

86. Borders of WBRT
Reid’ base
line