Terry Lee, MD
November 2014
Radiation in Lymphoma
 The trend over the years has been to increase
chemotherapy and decrease radiation for treatment.
 Radiation volume has decrease over time
 Total nodal radiation
 Mantle radiation
 Involved field radiation
 Radiation dose has decrease over time
 45 to 50 Gy
 20 to 36 Gy
Nodal Regions
Radiation in Hodgkin
 Stage IA, IIA Favorable
 Chemotherapy alone
 Combined



Chemotherapy (ABVD or Stadford V)
Restage PET after 2 or 4 cycles
If complete response on PET
 Involved field radiation 20 to 30 Gy
Radiation in Hodgkin
 Stage I, II unfavorable or bulky disease
 Chemotherapy alone
 Combined



Chemotherapy
Restage PET after 4 cycles
If complete response on PET
 Additional 2 cycles of chemotherapy
 Or involved field radiation 30 Gy
Radiation in Hodgkin
 Stage III, IV
 Chemotherapy alone
 Restage PET

If complete response on PET
 Additional chemotherapy
 Optional involved field radiation to original bulky site of
disease
Radiation in Hodgkin
 Stage IA, IIA Nodular Lymphocyte predominant
Hodgkin’s disease
 Involved field radiation
 30 to 36 Gy
Hodgkin’s Case Example
 26 year old male with 2 months history of left lower





neck mass. No B symptoms.
Excisional biopsy was positive Hodgkin’s lymphoma,
mixed cellularity.
Bone marrow was negative.
PET scan showed uptake in the left neck, left supra
and infraclavicular nodes. Stage IIA.
4 cycles of ABVD
Restaging PET scan showed no uptake
Prechemotherapy PET
Restaging PET
Radiation Field
Radiation





20 Gy in 10 fractions
Mandible is out of the field
Salivary gland is out of the field
Esophagus is out of the field
Possible acute side effects
 Fatigue
 Mild redness of the skin
 Possible long term side effects
 Thyroid
 Secondary malinancy
Radiation for NHL
 Low grade/Indolent NHL
 Grade 1-2 follicular lymphoma
 Radiation for stage I and II
 Intermediate grade NHL
 Diffuse
 Follicular grade 3
 Radiation for stage I and II
 High grade NHL
 Lymphoblastic
 Burkitt’s
 Radiation rarely used
Radiation for NHL
 Low grade stage I and II NHL
 Involved field radiation is the preferred treatment
 Other options include chemotherapy or observation
 24 to 30 Gy
 10 year overall survival 70%
Radiation for NHL
 Intermediate grade NHL
 Diffuse large B cell lymphoma
 Stage I, II nonbulky


RCHOP followed by involved field radiation
RCHOP plus or minus involved field radiation
 Stage I, II bulky

RCHOP plus or minus involved field radiation
 30 to 36 Gy
Radiation for NHL
 Gastric MALT Lymphoma
 Stage I or II and H. pyloric negative
 Involved field radiation to 30 Gy
 Nongastric MALT lymphoma
 Stage I or II
 Involved field radiation to 30 Gy
 Mycosis Fungoides, cutaneous lymphoma
 20 to 30 Gy
 Palliative treatment
 20 to 30 Gy
Radiation Used for Therapy
 Electrons
 High energy electromagnetic wave (photons)
 X-ray
 Gamma ray
E electric field
M magnetic field
Linear Accelerator
6 to 23 MeV
Bremsstrahlung
Beam Shaping
Varian
X1
Y1
Tertiary
X2
MLCLeaf Ai
Leaf Bi
y1n
xAi,n
x1n
xBi,n
x2n
y2n
Radiobiology
DNA
Radiation Tolerance
 Radiation tolerance depends on:
 Total dose
 Dose per fractionation
 Volume of tissue treated
 TD 5/5 is 5% probability of severe damage in 5 years
 TD 50/5 is 50% probability of severe damage in 5 years
TD5/5 (Gy)
TD50/5 (Gy)
Volume
Volume
Organ
1/3
2/3
3/3
1/3
2/3
3/3
End point
Kidney
50
30
23
--
40
28
Clinical nephritis
Brain
60
50
45
75
65
60
Necrosis/ infraction
Brain stem
60
53
50
--
--
65
Necrosis/ infraction
Ear(Mid/Ext)
30
30
30
40
40
40
Acute serious otitis
Ear(Mid/Ext)
55
55
55
65
65
65
Esophagus
60
58
55
72
70
68
Chronic
serious
otitis
Clinical stricture/
perforation
Heart
60
45
40
70
55
50
Pericarditis
Bladder
--
80
65
--
85
80
Symptomatic
bladder
contracture
volume loss
and
TD5/5 (Gy)
TD50/5 (Gy)
Volume
Volume
Organ
1/3
2/3
3/3
1/3
2/3
3/3
End point
Larynx
79
70
70
90
80
80
Cartilage necrosis
Larynx
--
45
45
--
--
80
Laryngeal edema
Liver
50
35
30
55
45
40
Liver failure
Lung
45
30
17.5
65
40
24.5
Pneumonitis
Skin
10cm2
30cm2
100cm2
10cm2
30cm2
100cm2
70
60
55
--
--
70
Small
intestine
50
--
40
60
--
55
Obstruction/
perforation
Colon
55
--
45
65
--
55
Obstruction/
perforation/
ulceration/fistula
5cm
10cm
20cm
5cm
10cm
20cm
Myelitis/necrosis
50*
50
47
70*
70
--
Spinal cord
Necrosis/
ulceration
Radiation Side Effects
 Common side effects
 Fatigue
 Redness of the skin
 Severity of the side effects should be less than typically
seen for other cancer treatment with radiation that uses
doses of 60 to 70 Gy.
Radiation Side Effects
 Organ specific side effects
 Head and neck:


Dry mouth, decrease taste, dental problems, hypothyroid, sore
throat, hair loss
Manage with fluoride treatments, magic mouth wash, and thyroid
replacement therapy
 Chest:
 Esophagitis, cough, Lhermitte’s syndrome
 Manage with magic mouth wash and cough medication. If severe,
use steroid.
 Abdomen and pelvis:
 Nausea and diarrhea are most common
 Fertility issues (move ovaries for radiation)