Treatment PlanningTreatment Planning

Hodgkin LymphomaHodgkin Lymphoma

LN groups above diaphragm:

1. Cervical

2. Supraclavicular

3. Infraclavicular

4. Axillary

5. Mediastinal

6. Hilar

LN groups below diaphragm:

1. Para-aortic

2. Iliac

3. Inguinal

4. Femoral

Hodgkin LymphomaHodgkin Lymphoma

►►Incidence:Incidence: • 1% of new cancer cases1% of new cancer cases• Bimodal age incidence: 1Bimodal age incidence: 1stst in 20s & 2 in 20s & 2ndnd after 50 years after 50 years• 85% of children are boys85% of children are boys

►► Risk FactorsRisk Factors:: unclearunclear• Viral infection: Viral infection:

• EBVEBV• HIV HIV

PathologyPathology

►► Histology:Histology: • Reed -Sternberg cellsReed -Sternberg cells

Hodgkin LymphomaHodgkin Lymphoma

►► The Rye classification:The Rye classification:

According to clinical behavior and prognosisAccording to clinical behavior and prognosis

1.1. Lymphocyte predominantLymphocyte predominant

2.2. Nodular sclerosisNodular sclerosis

3.3. Mixed cellularityMixed cellularity

4.4. Lymphocyte depletionLymphocyte depletion

Mode of SpreadMode of Spread

• Site of origin: nodal

• Spread: contiguous

• Nodal distribution: axial

• Hematogenous dissemination: late

• CNS: rare (< 1%)

• Liver or bone marrow: uncommon

Hodgkin LymphomaHodgkin Lymphoma

DiagnosisDiagnosis

►► Symptoms & SignsSymptoms & Signs::• Painless lymphadenopathy: cervical in > 70% Painless lymphadenopathy: cervical in > 70% • Systemic symptoms: Fever, night sweats and weight lossSystemic symptoms: Fever, night sweats and weight loss

►► Biopsy :Biopsy : • FNA cytology or excisionFNA cytology or excision• Bone marrow ?Bone marrow ?

►► Imaging:Imaging:• Chest radiographsChest radiographs• CT scans: neck, chest , abdomen and pelvisCT scans: neck, chest , abdomen and pelvis• Bipedal lymphangiography: aortic and iliac nodes ?Bipedal lymphangiography: aortic and iliac nodes ?• Bone scan: ? Bone scan: ? • PET scan: ?PET scan: ?

Hodgkin LymphomaHodgkin Lymphoma

►► Laboratory tests:Laboratory tests: CBC, chemistries, ESR CBC, chemistries, ESR

Bipedal lymphangiographyBipedal lymphangiography

Staging ClassificationStaging ClassificationHodgkin LymphomaHodgkin Lymphoma

StageStageDescriptionDescription

IIInvolvement of Involvement of singlesingle LN region or lymphoid structure LN region or lymphoid structure

IIIIInvolvement of Involvement of two or moretwo or more LN regions on the LN regions on the same sidesame side of the of the diaphragmdiaphragm

IIIIIIInvolvement of LN regions or structures on the Involvement of LN regions or structures on the both sidesboth sides of the of the diaphragm diaphragm

IVIVInvolvement of one or more extranodal sites Involvement of one or more extranodal sites

A: No symptomsA: No symptoms

B: Symptoms present B: Symptoms present Applicable to any stageApplicable to any stage

X: BulkyX: Bulky

TreatmentTreatment

►► Surgery:Surgery:• Limited to diagnosisLimited to diagnosis• Laparotomy ?Laparotomy ?

►► Radiotherapy: Radiotherapy: • Early stage Early stage without without risk factors (non-bulky stage IA or IIA) risk factors (non-bulky stage IA or IIA)

►► Chemotherapy: Chemotherapy: • A dvanced stage III or stage IV A dvanced stage III or stage IV • Early stage Early stage withwith risk factor risk factor (symptoms or bulky )(symptoms or bulky )

Hodgkin LymphomaHodgkin Lymphoma

►► Curable diseaseCurable disease

►► Combined modality: Combined modality: chemotherapy + radiotherapy ? chemotherapy + radiotherapy ?

Radiotherapy Techniques-1Radiotherapy Techniques-1

►► Target Volumes: Target Volumes: depends on the stage of the diseasedepends on the stage of the disease

►► Patient positioning & immobilization:Patient positioning & immobilization:

• LN groups above diaphragm LN groups above diaphragm (Mantle field)(Mantle field)

• LN groups below diaphragm+ spleen LN groups below diaphragm+ spleen (Inverted Y field)(Inverted Y field)

• Total Nodal IrradiationTotal Nodal Irradiation (Mantle field + Inverted Y field) (Mantle field + Inverted Y field)

• LN groups of known disease only LN groups of known disease only (Involved field)(Involved field)Only curative in combination with chemotherapyOnly curative in combination with chemotherapy

Hodgkin LymphomaHodgkin Lymphoma

• Supine Supine • The arms raised above the headThe arms raised above the head• The chin extendedThe chin extended

Radiotherapy Techniques-2Radiotherapy Techniques-2

►► Fields arrangement: Fields arrangement: Problem of Matching Fields ?

Hodgkin LymphomaHodgkin Lymphoma

• Opposed anterior and posterior fields ?? Opposed anterior and posterior fields ??

• External Beam: megavoltage radiation, photons, 4-6 MVExternal Beam: megavoltage radiation, photons, 4-6 MV

►► Methods:Methods:

►► Dose /Time / Fractionation:Dose /Time / Fractionation:

• 35-40 Gy without chemotherapy, conventional schedule35-40 Gy without chemotherapy, conventional schedule• 20-25 Gy with chemotherapy20-25 Gy with chemotherapy

►► Beam Modifications:Beam Modifications:

• Shields (5 HVL) over: lung, humeral head, larynxShields (5 HVL) over: lung, humeral head, larynx• Gap between:Gap between:

1.1. Inferior border of mantleInferior border of mantle2.2. Superior border of periaortic fieldsSuperior border of periaortic fields

• Mantle Field

• Subtotal nodal Irradiation

• Inverted Y field

• Total Nodal Irradiation

MorbidityMorbidity

►► Late:Late:• HypothyroidismHypothyroidism• PneumonitisPneumonitis• PericarditisPericarditis

►► Acute: Acute: • Occipital epilationOccipital epilation• DysphagiaDysphagia• MyeolsuppressionMyeolsuppression• XerostomiaXerostomia

Hodgkin LymphomaHodgkin Lymphoma

Directly related to the area treatedDirectly related to the area treated

Mantle fieldsMantle fields Inverted Y fieldsInverted Y fields

►► Acute: Acute: • NauseaNausea• vomitingvomiting• DiarrheaDiarrhea• Myeolsuppression Myeolsuppression

►► Late: Late: • InfertilityInfertility

Inverted Y fieldsInverted Y fields