An Introduction to the nature and
management of Lymphoma
Radiotherapy in the management of
lymphoma
Richard Cowan
Consultant in Clinical Oncology
13th October 2010
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Updated June 2010
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Radiotherapy in the management
of lymphoma
• Background to radiotherapy
• Place of radiotherapy in lymphoma
• Practical details of radiotherapy
• Future developments
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Wilhelm Conrad Röntgen
1845 - 1923
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Q Discovered X rays
1. 1865
2. 1875
3. 1885
4. 1895
5. 1905
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Q Discovered X rays
1. 1865
2. 1875
3. 1885
4. 1895 ✓
5. 1905
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1898
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Q Marie Curie was born in :
1.Russia
2.Bulgaria
3.Poland
4.France
5.Bolivia
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Q Marie Curie was born in :
1.Russia
2.Bulgaria
3.Poland ✓
4.France
5.Bolivia
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wavelength
Electromagnetic spectrum
Energy
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Until 1960s Radiotherapy
was the only non surgical
treatment for lymphoma
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How effective is Radiotherapy ?
• Resistant:
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How effective is Radiotherapy ?
• Resistant:
– Malignant melanoma
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How effective is Radiotherapy ?
• Resistant:
– Sarcomas / melanoma
• Intermediate:
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How effective is Radiotherapy ?
Q Which of these tumours is NOT Intermediate in terms of
radiosensitivity:
1.
2.
3.
4.
5.
Breast,
Testicular seminoma
Non small cell lung cancer
prostate cancer
head and neck cancer
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How effective is Radiotherapy ?
Q Which of these tumours is NOT Intermediate in terms of
radiosensitivity:
1.
2.
3.
4.
5.
Breast,
Testicular seminoma ✓
Non small cell lung cancer
prostate cancer
head and neck cancer
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Updated June 2010
How effective is Radiotherapy ?
• Resistant:
– Sarcomas / melanoma
• Intermediate:
– Breast, lung, prostate, head and neck cancer
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How effective is Radiotherapy ?
• Resistant:
– Sarcomas / melanoma
• Intermediate:
• Breast, lung, prostate, head and neck cancer
Sensitive:
• Germ cell tumours
• Lymphomas
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How does Radiotherapy work?
• Ionising radiation damages cells
DNA
• The most sensitive cellular component is DNA
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Radiotherapy – Biological Aspects
• DNA damage manifests at cell division
• “Early cell kill” v. “late cell kill”
• Related to proliferative activity
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Radiotherapy – Biological Aspects
• Early: - usually the cancer
–Skin, GI tract, Bone marrow
• Late:
–Kidney, CNS
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Q If the Kidneys receive a toxic dose of radiotherapy how
long after radiotherapy will the patient show maximum
renal impairment?
1.
2.
3.
4.
5.
10 days
4 weeks
3 months
12 months
24 months
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Updated June 2010
Q If the Kidneys receive a toxic dose of radiotherapy how
long after radiotherapy will the patient show maximum
renal impairment?
1.
2.
3.
4.
5.
10 days
4 weeks
3 months
12 months ✓
24 months
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How does Radiotherapy work?
• The most sensitive cellular
component is DNA
DNA
damage can
be repaired
DNA
•The malignant cell have impaired DNA repair mechanisms
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Radiotherapy – Biological Selectivity
Normal tissue
Cell
No.
cancer
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Place of radiotherapy in lymphoma
• Radiotherapy alone for cure
• Radiotherapy in combination for cure
• Palliation
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Radiotherapy alone for cure
• 73 yr old woman who
presents with a painless
lump in the groin
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Radiotherapy alone for cure
• 73 yr old woman who
presents with a painless
lump in the groin
• Biopsy :
Follicular lymphoma
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Radiotherapy alone for cure
• 73 yr old woman who
presents with a painless
lump in the groin
• Biopsy :
Follicular lymphoma
stage IA
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Radiotherapy alone for cure
• 73 yr old woman who presents with a painless lump in
the groin
• Biopsy :
Follicular lymphoma
stage IA
• FORT Study : 24Gy in 12 # compared with 4Gy in 2#
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How effective is Radiotherapy ?
• Intermediate:
– prostate cancer
Sensitive :
follicular lymphoma
70Gy
24Gy (4Gy)
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Radiotherapy alone for cure
• 73 yr old woman who presents with a painless lump in the groin
• Biopsy :
Follicular lymphoma stage IA
24 Gy Radiotherapy
Q 3 months later the chance of complete remission
1.
2.
3.
4.
5.
25% - 35%
40% - 50%
55% - 65%
65% - 75%
85% - 95%
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Radiotherapy alone for cure
• 73 yr old woman who presents with a painless lump in the groin
• Biopsy :
Follicular lymphoma stage IA
24 Gy Radiotherapy
Q 3 months later the chance of complete remission
1.
2.
3.
4.
5.
25% - 35%
40% - 50%
55% - 65%
65% - 75%
85% - 95% ✓
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Radiotherapy alone for cure
• 33 year old woman
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Radiotherapy alone for cure
• 33 year old woman
• Biopsy :
Hodgkins lymphoma Stage I A
(nodular lymphocyte predominant)
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Radiotherapy alone for cure
• 33 year old woman
• Biopsy :
Hodgkins lymphoma Stage I A
(nodular lymphocyte predominant)
30Gy in 15# (3 weeks)
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How effective is Radiotherapy ?
• Intermediate:
– prostate cancer
70Gy
Sensitive :
– follicular lymphoma
24Gy (4Gy)
– Hodgkins lymphoma
30Gy
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Radiotherapy in combination
• 32 year old man
With a cough and weight
loss
• Hodgkins stage III B
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Radiotherapy in combination
• 32 year old man
With a cough and weight
loss
• Hodgkins stage III B
• After 6 cycles of ABVD
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Following 6 cycles of ABVD
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Following 6 cycles of ABVD
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The practicalities of radiotherapy
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Dose and duration of treatment
• “Low Dose “
(30 Gy rather than 70Gy)
• Curative : 15 treatments
of 2 Gy = 3 weeks
• Shorter treatments :
Palliative Radiotherapy
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Dose and duration of treatment
summary
• Curative :
– Hodgkins
– DLBC
– Follicular
30Gy in 3 weeks (15#)
30 Gy in 3 weeks
24Gy in 2 weeks
• Palliative
• 1 – 10 #
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The practicalities of radiotherapy
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Low
energy
X-rays
e.g. 100KV
Electrons
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High energy x-rays
e.g. 6Mev
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PET CT
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Side effects of radiotherapy
• Acute : • Acute inflammation :
– Red skin
– Mucositis
– Bowel upset
– Alopecia
• Tiredness
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Side effects of radiotherapy
Q Acute side effects : 1.
2.
3.
4.
Start on the first day of treatment and last for the duration of the
treatment
Start towards the end of the treatment and last for 3 – 4 weeks
Start on the first day of treatment and last for 3 – 4 weeks post
treatment
Start towards the end of treatment and last for 3 – 4 months post
treatment
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Updated June 2010
Side effects of radiotherapy
Q Acute side effects : 1.
2.
3.
4.
Start on the first day of treatment and last for the duration of the
treatment
Start towards the end of the treatment and last for 3 – 4 weeks ✓
Start on the first day of treatment and last for 3 – 4 weeks post
treatment
Start towards the end of treatment and last for 3 – 4 months post
treatment
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Updated June 2010
Side effects of radiotherapy
late : - 6 months and beyond :
• chronic inflammation :
– Lung (visible on CXR)
– Bowel
– Salivary glands
– endocrine
• 2nd malignancy
• cardiac
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Side effects of radiotherapy
• Depend upon :
• Dose
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Side effects of radiotherapy
• Depend upon :
• Dose
(good for lymphoma)
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Side effects of radiotherapy
• Depend upon :
• Dose
(good for lymphoma)
• Volume irradiated
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Side effects of radiotherapy
• Depend upon :
• Dose
(good for lymphoma)
• Volume irradiated (small is beautiful)
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90Y
Zevalin
• Zevalin(Ibritumomab)
– Anti-CD20 murine
parent of rituximab
Zevalin
• Tiuxetan
– Chelator, conjugated to
antibody forming strong
urea-type bond
– Stable retention of 90Y
• Yttrium-90
Tiuxetan
90Y
radionuclide
– t1/2 = 64 hours
– Outpatient
administration
– Beta emission - 5mm
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Updated June 2010
Future developments
• Technical advances :
• Imaging
• Delivery
–Intensity Modulated Radiotherapy (IMRT)
–Image Guided Radiotherapy (IGRT)
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Future developments
• New molecules :
–Increase tumour sensitivity
–Protect normal tissues
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Q
1.
2.
3.
4.
What is for lunch ?
A Big Mac
Thai Chicken kebabs
Bacon butties
Salmon and Champagne
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