SlideShare una empresa de Scribd logo
1 de 65
Descargar para leer sin conexión
HODGKIN’S LYMPHOMA

    CHEMOTHERAPY
    RADIOTHERAPY


             DR ARNAB BOSE
             Dept. of Radiotherapy
             NRS Medical College, Kolkata

                                            1
Introduction
Hodgkin’s disease was initially described as an inflammatory
disease (hence the term “disease”), but is clearly
recognized and treated as a malignant lymphoma (hence the
more accurate term Hodgkin’s lymphoma (HL) is used
synonymously with Hodgkin’s disease).



The management of Hodgkin’s lymphoma has evolved from
extended-field radiation alone as the main therapy to a
combined-modality approach with
chemotherapy and radiation, or chemotherapy alone.

                                                         2
WHO classification (2008)




                            3
Staging




     4
Treatment Groups in Early Stage




                                  5
Adverse Prognostic Factors




The International Prognostic Score (IPS) is based on seven factors:
three clinical and four laboratory values .
Patients are given a score of from 0 to 7, and disease can
be categorized as low (0–1), intermediate (2–3), or high (4–7) risk.
                                                                       6
General guidelines for
Hodgkin’s Lymphoma treatment




                               7
The current standard is the result of careful clinical
trials that demonstrated three principles:

i) ABVD is the preferred chemotherapy based on both
     efficacy and safety,
ii) combined-modality therapy (chemotherapy + radiation
     therapy) is superior to wide-field radiation therapy alone
iii) there is no advantage of wide-field radiation therapy
     over involved-field radiation therapy when given in
     combination with chemotherapy.


                                                            8
Combination Chemotherapy Regimens




                                    9
10
11
The Milan trial was among the first and most influential in
demonstrating the high cure rate of a brief course of ABVD
(four cycles) combined with involved-field radiation therapy
in limited-stage Hodgkin’s lymphoma.

Subsequently, multiple trials have explored the questions of
how many cycles of ABVD are needed and what radiation
dose is needed to maintain these outstanding results.




                                                         12
Among favorable patients without risk factors, the GHSG
evaluated two versus four cycles of ABVD and 20 versus
30 Gy involved-field irradiation.

The final results of this trial have not been published, but
multiple presentations of the data to date have shown FFP
rates in excess of 95% for all four treatment arms.

Thus, for the approximately 35% of limited-stage patients
with very favorable presentations, as few as two cycles of
chemotherapy combined with low-dose involved-field
irradiation is sufficient for cure.
                                                           13
For patients with unfavorable, limited-stage Hodgkin’s
lymphoma the subjects of clinical trial inquiry have been
chemotherapy combination, number of cycles of
chemotherapy, and radiation dose.

The H9U trial conducted by the EORTC-GELA
demonstrated that the less toxic ABVD regimen was as
effective as the BEACOPP regimen and that four cycles of
treatment were sufficient.

Similarly, the GHSG HD11 trial has shown no differences
in outcome thus far between ABVD and BEACOPP in
limited-stage patients with risk factors.                   14
Randomized Clinical Trials in
Limited-Stage Hodgkin’s Lymphoma




                                   15
Randomized Clinical Trials in
Limited-Stage Hodgkin’s Lymphoma




                                   16
Following the ground-breaking demonstration of cure in
advanced Hodgkin’s lymphoma with MOPP chemotherapy,
a series of clinical trials was set in motion to identify the
best chemotherapy regimen in advanced disease and to
evaluate the role of radiation therapy in this setting.

Based on historical development and the efficacy of ABVD
in the relapsed setting, early trials pitted MOPP against
ABVD and the alternating MOPP/ABVD regimen.



                                                                17
The early CALGB study determined that ABVD-containing
combinations were superior.

A second U.S. Intergroup trial comparing ABVD to the
hybrid MOPP/ABV combination, concluded that the
treatments were similarly efficacious but ABVD was less
toxic.

On the basis of these trials, ABVD was widely adopted as
the standard chemotherapy for advanced Hodgkin’s
lymphoma with an expected cure rate of about 70%.

                                                           18
Stanford V is a brief, 12-week chemotherapy regimen with
minimal alkylating agent and lower cumulative doses of
doxorubicin and bleomycin that was devised to explicitly
address late effects of Hodgkin’s lymphoma treatment.



The GHSG developed a novel chemotherapy combination,
BEACOPP, which combines elements of COPP and ABVD with
etoposide. The regimen was designed and tested in standard
and escalated forms.

                                                      19
Randomized Clinical Trials in
Advanced-Stage Hodgkin’s Lymphoma




                                    20
Randomized Clinical Trials in
Advanced-Stage Hodgkin’s Lymphoma




                                    21
Secondary Therapy of Classical H L

Fortunately, fewer patients with Hodgkin’s lymphoma
currently progress after primary treatment. Those with
advanced disease and a high IPS are at greatest risk.



High-Dose Chemotherapy with either the
CBV (cyclophosphamide, carmustine, etoposide) or
BEAM (carmustine, etoposide, cytarabine, melphalan)
regimen followed by Autologous Stem Cell Transplantation
has been the most successful approach .

                                                         22
To achieve maximal cytoreduction before transplantation
the approach is to treat progressive and relapsing patients
with secondary chemotherapy,
most commonly the
DHAP (cisplatin, high-dose cytarabine, dexamethasone), or
ICE (ifosfamide, carboplatin, etoposide) regimen.
Recently a new regimen,
IGEV (ifosfamide, gemcitabine,etoposide, vinorelbine),
has demonstrated excellent tolerability and efficacy in the
second-line setting.

                                                         23
Complications of Chemotherapy

Sterility was a major adverse effect of the MOPP regimen.

ABVD does not seem to cause more than temporary
cessation of menses in women and temporary oligospermia
in men.

In contrast, BEACOPP chemotherapy routinely sterilizes
males and many young females. Semen preservation must
take place before chemotherapy.


                                                         24
Early reports implicated the alkylating agents in MOPP
chemotherapy in an increased risk of secondary acute
myelocytic leukemia (AML) and myelodysplasia.

ABVD chemotherapy does not seem to increase the risk of
secondary AML above baseline.

BEACOPP chemotherapy was accompanied by an increased
risk of secondary AML. In this case, etoposide was also
implicated.


                                                         25
Lung cancer is emerging as a leading cause of death in
Hodgkin’s lymphoma patients. Relative risks increase with
cumulative dose of alkylating agents and with increasing
doses of radiation.

The risk after chemotherapy is immediate, whereas there is
a latency of about 5 years after radiation therapy.

Importantly, the relative risk increases 20-fold with
tobacco use, indicating that smoking cessation is absolutely
imperative among Hodgkin’s lymphoma survivors.
                                                            26
Pulmonary toxicity related to bleomycin has been
recognized to be both idiosyncratic and related to
cumulative exposure.



Bone toxicity in the form of osteoporosis may accompany
prednisone use, particularly in the setting of gonadal
failure. Osteonecrosis is an uncommon complication that
occurs in the hips or shoulders in individuals exposed to
high cumulative doses of prednisone, particularly with the
addition of high-dose radiation therapy.
                                                         27
LYMPH NODAL REGIONS
                 Lymph Nodal
                   Groups




                               28
Radiotherapy Fields




                      29
Radiotherapy Fields




                      30
Fields for I F R T




                     31
Unilateral Cervical/Supraclavicular
                  Region
Arms position: Akimbo or at sides
Upper Border: 1 to 2 cm above the
  lower tip of the mastoid process
  and midpoint through the chin.
Lower Border: 2 cm below the
  bottom of the clavicle.
Lateral Border: To include the
  medial two-thirds of the
  clavicle.



                                          32
Medial Border:
                (a) If the SCL nodes are not involved, the
border is placed at the ipsilateral transverse processes
except when medial nodes close to the vertebral bodies are
seen on the initial staging neck CT scan. For medial nodes
the entire vertebral body is included.
                (b) When the SCL nodes are involved, the
border should be placed at the contralateral transverse
processes



                                                       33
Blocks:
       A posterior cervical cord block is required only if
cord dose exceeds 40 Gy.
       Mid-neck calculations should be performed to
determine the maximum cord dose, especially
when the central axis is in the mediastinum.

       A laryngeal block should be used unless lymph nodes
were present in that location. In that case the block should
be added at 20 Gy.

                                                             34
Bilateral Cervical/Supraclavicular
                   Region

Both cervical and SCL regions should
be treated as described in the
preceding slide regardless of the
extent of disease on each side.

Posterior cervical cord and larynx
blocks should be used.




                                          35
Mediastinum

Arms position: Akimbo or at sides. The arms-up position is
               optional if the axillary nodes are involved.

Upper Border: C5-6 interspace. If SCL nodes are also
              involved, the upper border should be placed
              at the top of the larynx.




                                                          36
Lower Border: The lower of: (a) 5 cm below the carina
              or (b) 2 cm below the pre-chemotherapy
              inferior border.

Lateral Border: The post-chemotherapy volume with
                1.5 cm margin.

Hilar Area: To be included with 1 cm margin unless
            initially involved, in which case the margin
            should be 1.5 cm.

                                                           37
Axillary Region

Arms position: Arms akimbo or arms up.

Upper Border: C5-6 interspace.

Lower Border: The lower of the two: (a) the tip of the
        scapula or (b) 2 cm below the lowest axillary node.

Medial Border: Ipsilateral cervical transverse process.
  Include the vertebral bodies only if the SCL are involved.

Lateral Border: Flash axilla.
                                                         38
39
Abdomen (Para-Aortic Nodes)

Upper Border: Top of T11 and at least 2 cm above
              pre-chemotherapy volume.

Lower Border: Bottom of L4 and at least 2 cm below
              pre-chemotherapy volume.

Lateral Borders: The edge of the transverse processes and
                  at least 2 cm from the
                  post-chemotherapy volume.



                                                       40
Inguinal/Femoral/External Iliac
                 Region

Upper Border: Middle of the sacroiliac joint.

Lower Border: 5 cm below the lesser trochanter.

Lateral Border: The greater trochanter and 2 cm lateral to
                initially involved nodes.




                                                       41
Medial Border: Medial border of the obturator foramen
               with at least 2 cm medial to involved nodes.

               If common iliac nodes are involved the field
               should extend to the L4-5 interspace and
               at least 2 cm above the initially involved
               nodal border.




                                                         42
43
Mantle:
bilateral cervical,
SCV, infraclavicular,
mediastinal, hilar,
and axilla

Mini-mantle:
mantle without
mediastinum, hila

Modified mantle:
mantle without axilla   mini mantle   modified mantle

                                                   44
Mantle Field
Simulate with
   Arms - up (to pull axillary LN from chest to allow for
              more lung blocking) or
   Arms akimbo (to shield humeral heads and minimize
                 tissue in SCV folds)

   Head extended
      this ensures the exclusion of the oral cavity and
teeth from the RT fields, and decreases the dose to the
mandible

                                                            46
Borders:   Lateral = beyond humeral heads;
           Inferior = bottom of diaphragm (T11/12);
           Superior = inferior mandible
Blocks:    Larynx on AP field
           Humeral heads on AP and PA fields
           PA cord block (if dose >40 Gy)
           Lung block at top of fourth rib to cover IC LN
           If pericardial or mediastinal extension, include
    entire heart to 15 Gy, then block apex of heart. After
    30 Gy, block heart beyond 5 cm inferior to carina
    (unless residual disease)

                                                         47
Inverted Y Field
STLI




TLI
        49
Dose of Radiotherapy
Combined Modality RT Dose

Non-bulky disease (stage I-II)
               20*-30 Gy (if treated with ABVD)
               30Gy (if treated with Stanford V)

Non-bulky disease (stage IB-IIB) and
Bulky and Non-bulky disease (stage III-IV)
               30-36 Gy if treated with BEACOPP

*A dose of 20Gy following ABVD x 2 is sufficient if the patient has non bulky
 stage I-IIA disease with ESR <50, no extra lymphatic lesions, and only one or
 two lymph node regions involved
                                                                           50
Bulky disease sites (all stages)
             30-36 Gy (if treated with ABVD)
             36Gy (if treated with Stanford V)



RT Alone Doses (uncommon except for NLPHL)

Involved regions   30-36Gy
Uninvolved regions 25-30Gy


                                                 51
Side Effects of Radiotherapy
Side effects of RT depend on
      the irradiated volume,
      the dose administered, and
      the technique employed.

They are also influenced by the extent and type of prior
chemotherapy, if any, and
by the patient's age.




                                                           52
Most of the information that we use today to estimate risk
of RT is derived from strategies that used radiation alone.

The sizes of the fields and configuration, doses and
technology have all drastically changed over the last
decade.

It is therefore probably misleading to judge
current RT for lymphomas and inform patients solely on the
basis of different past practice of using RT in treating
lymphomas.

                                                        53
Acute Effects
Radiation, in general, may cause fatigue and areas of the
irradiated skin may develop mild sun-exposure like
dermatitis.

The acute side effects of irradiating the full neck include
mouth dryness, change in taste, and pharyngitis. These side
effects are usually mild and transient.

The main potential side effects of sub-diaphragmatic
irradiation are loss of appetite, nausea, and increased bowel
movements. These reactions are usually mild and can be
minimized with standard antiemetic medications.
                                                            54
Irradiation of more than one field, particularly after
chemotherapy, can cause myelosuppression,
 which may necessitate short treatment interruption and
very rarely the administration of granulocyte-colony
stimulating factor (G-CSF).




                                                          55
Early Side Effects
Lhermitte's sign: <5% of patients may note an electric
shock sensation radiating down the backs of both legs when
the head is flexed (Lhermitte's sign) 6 weeks to 3 months
after mantle-field RT.
                   Possibly secondary to transient
demyelinization of the spinal cord, Lhermitte's sign
resolves spontaneously after a few months and is not
associated with late or permanent spinal cord damage.




                                                       56
Pneumonitis and pericarditis: During the same period,
radiation pneumonitis and/or acute pericarditis may
occur in <5% of patients; these side effects occur more
often in those who have extensive mediastinal disease.
                 Both inflammatory processes have
become rare with modern radiation techniques.




                                                          57
Late Side Effects
Subclinical Hypothyroidism: Irradiation of the neck and/or
upper mediastinal can induce subclinical hypothyroidism in
approximately one-third of patients.
             This condition is detected by the elevation of
the thyroid-stimulating hormone (TSH). Thyroid
replacement with levothyroxine (T4) is recommended, even
in asymptomatic patients, to prevent overt hypothyroidism
and decrease the risk of benign thyroid nodules.




                                                         58
Infertility: Only irradiation of the pelvic field may have
deleterious effects on fertility.
             In most patients, this problem can be avoided
by appropriate gonadal shielding.
             In women, the ovaries can be moved into a
shielded area laterally or inferomedially near the uterine
cervix.
             Irradiation outside of the pelvis does not
increase the risk of sterility.



                                                        59
Secondary Malignancies: Patients with HD who were cured
with RT and/or chemotherapy, have an increased risk of
secondary solid tumors (most commonly, lung, breast, and
stomach cancers, as well as melanoma) and NHL, 10 or more
years after treatment.
         Unlike MOPP and similar chemotherapy
combinations, RT for HD is not leukemogenic.




                                                       60
Lung Cancer: Patients who are smokers should be strongly
encouraged to quit the habit because the increase in lung
cancer that occurs after irradiation or chemotherapy has
been detected mostly in smokers.



Effects on Bone and Muscle Growth: In children, high-dose
irradiation will affect bone and muscle growth and may
result in deformities. Current treatment programs for
pediatric HD are chemotherapy based; RT is limited to low
doses.
                                                        61
Coronary Artery Disease: An increased risk of coronary
artery disease has been reported among patients
who have received mediastinal irradiation.
          To reduce this hazard, patients should be
monitored and advised about other established coronary
disease risk factors, such as smoking, hyperlipidemia,
hypertension, and poor dietary and exercise habits.




                                                         62
Breast Cancer as a long term
      sequelae of Radiotherapy in HL
For women whose HL was successfully treated at a young
age, the main long-term concern is the increased risk of
breast cancer.

The increase in risk of breast cancer is inversely related to
the patient's age at HL treatment; no increased risk has
been found in women irradiated after 30 years of age.

It is also related to the radiation dose to the breast and
the volume of breast tissue exposed.

                                                             63
Most breast exposure in the mantle era resulted from the
radiation of the axillae, and to a lesser extent from wide
mediastinal and hilar irradiation.

During the last decade, reduction in field size has been the
most important change in radiation therapy of HD.

Reduction in the volume of exposed breast tissue together
with dose reduction (from over 40 Gy to a dose in the range
of 20-30 Gy) is likely to dramatically change the long-term
risk profile of young male and female patients cured of HD.
                                                          64
thank you




            65

Más contenido relacionado

La actualidad más candente

Non hodgkins lymphoma
Non hodgkins lymphomaNon hodgkins lymphoma
Non hodgkins lymphomaChandan N
 
Follicular lymphoma
Follicular lymphomaFollicular lymphoma
Follicular lymphomahatem honor
 
Breast cancer screening
Breast cancer screeningBreast cancer screening
Breast cancer screeningBIJAPUROBG
 
Cancer early screening and protection
Cancer early screening and protectionCancer early screening and protection
Cancer early screening and protectionMonkez M Yousif
 
Non hodgkin's lymphoma
Non hodgkin's lymphomaNon hodgkin's lymphoma
Non hodgkin's lymphomarahulverma1194
 
Side-effects of radiotherapy
Side-effects of radiotherapySide-effects of radiotherapy
Side-effects of radiotherapymeducationdotnet
 
Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...
Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...
Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...Osama Elzaafarany, MD.
 
Oncological emergencies
Oncological emergenciesOncological emergencies
Oncological emergenciesAlok Gupta
 
Non hodgkin lymphoma
Non hodgkin lymphomaNon hodgkin lymphoma
Non hodgkin lymphomaAli Azher
 
Basics in radiation oncology
Basics in radiation oncologyBasics in radiation oncology
Basics in radiation oncologyVaRun Lakshman
 
Radiotherapy in benign disease.
Radiotherapy in benign disease.Radiotherapy in benign disease.
Radiotherapy in benign disease.Parag Roy
 

La actualidad más candente (20)

Non hodgkins lymphoma
Non hodgkins lymphomaNon hodgkins lymphoma
Non hodgkins lymphoma
 
Meningioma- Dr Kiran
Meningioma- Dr KiranMeningioma- Dr Kiran
Meningioma- Dr Kiran
 
Follicular lymphoma
Follicular lymphomaFollicular lymphoma
Follicular lymphoma
 
Management of lung cancer
Management of lung cancerManagement of lung cancer
Management of lung cancer
 
Breast cancer screening
Breast cancer screeningBreast cancer screening
Breast cancer screening
 
lymphoma
lymphomalymphoma
lymphoma
 
Hodgkin lymphoma
Hodgkin lymphomaHodgkin lymphoma
Hodgkin lymphoma
 
Cancer early screening and protection
Cancer early screening and protectionCancer early screening and protection
Cancer early screening and protection
 
Non hodgkin's lymphoma
Non hodgkin's lymphomaNon hodgkin's lymphoma
Non hodgkin's lymphoma
 
Side-effects of radiotherapy
Side-effects of radiotherapySide-effects of radiotherapy
Side-effects of radiotherapy
 
Lymphoma
LymphomaLymphoma
Lymphoma
 
Small Cell Lung Cancer
Small Cell Lung CancerSmall Cell Lung Cancer
Small Cell Lung Cancer
 
Lymphoma
LymphomaLymphoma
Lymphoma
 
Breast cancer staging
Breast cancer stagingBreast cancer staging
Breast cancer staging
 
Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...
Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...
Newly Diagnosed Glioblastoma Multiforme: Recent updates; evidence-based medic...
 
Oncological emergencies
Oncological emergenciesOncological emergencies
Oncological emergencies
 
Non hodgkin lymphoma
Non hodgkin lymphomaNon hodgkin lymphoma
Non hodgkin lymphoma
 
Lymphoma - cancer
Lymphoma - cancerLymphoma - cancer
Lymphoma - cancer
 
Basics in radiation oncology
Basics in radiation oncologyBasics in radiation oncology
Basics in radiation oncology
 
Radiotherapy in benign disease.
Radiotherapy in benign disease.Radiotherapy in benign disease.
Radiotherapy in benign disease.
 

Destacado

Hodgkins Lymphoma
Hodgkins LymphomaHodgkins Lymphoma
Hodgkins Lymphomaguestae7658
 
Hodgkin lymphoma
Hodgkin lymphomaHodgkin lymphoma
Hodgkin lymphomatashagarwal
 
Hodgkin’S And Non Hodgkin’S Lymphoma
Hodgkin’S And Non Hodgkin’S LymphomaHodgkin’S And Non Hodgkin’S Lymphoma
Hodgkin’S And Non Hodgkin’S Lymphomafondas vakalis
 
Radiotherapy contouring guideline for non-hodgkin lymphoma
Radiotherapy contouring guideline for non-hodgkin lymphomaRadiotherapy contouring guideline for non-hodgkin lymphoma
Radiotherapy contouring guideline for non-hodgkin lymphomaketan kalariya
 
Chemotherapy for Hodgkins disease
Chemotherapy for Hodgkins diseaseChemotherapy for Hodgkins disease
Chemotherapy for Hodgkins diseaseSantam Chakraborty
 
Non hodgkin lymphoma
Non hodgkin lymphomaNon hodgkin lymphoma
Non hodgkin lymphomatashagarwal
 
Hodgkin Lymphoma: Latest Concepts
Hodgkin Lymphoma: Latest ConceptsHodgkin Lymphoma: Latest Concepts
Hodgkin Lymphoma: Latest Conceptsspa718
 
How Radiation Therapy Is Used in the Treatment of Lymphoma
How Radiation Therapy Is Used in the Treatment of Lymphoma How Radiation Therapy Is Used in the Treatment of Lymphoma
How Radiation Therapy Is Used in the Treatment of Lymphoma Dana-Farber Cancer Institute
 
Hodgkin lymphoma db.pptx
Hodgkin lymphoma db.pptxHodgkin lymphoma db.pptx
Hodgkin lymphoma db.pptxDipalee Bagal
 
Hodgkin lymphoma
Hodgkin lymphomaHodgkin lymphoma
Hodgkin lymphomahjp9
 
Recent andvances hodgkins lymphoma
Recent andvances  hodgkins lymphomaRecent andvances  hodgkins lymphoma
Recent andvances hodgkins lymphomaSumanth Deva
 
Nhl with aiha dr nazim
Nhl with aiha dr nazimNhl with aiha dr nazim
Nhl with aiha dr nazimAYM NAZIM
 
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...Lymphoma Support Ireland
 
SCOOTEROER30c Sickle Cell in Schools Literature Review
SCOOTEROER30c Sickle Cell in Schools Literature ReviewSCOOTEROER30c Sickle Cell in Schools Literature Review
SCOOTEROER30c Sickle Cell in Schools Literature ReviewVivien Rolfe
 

Destacado (20)

Hodgkins Lymphoma
Hodgkins LymphomaHodgkins Lymphoma
Hodgkins Lymphoma
 
Hodgkin lymphoma
Hodgkin lymphomaHodgkin lymphoma
Hodgkin lymphoma
 
Lymphoma
LymphomaLymphoma
Lymphoma
 
Lymphoma
Lymphoma Lymphoma
Lymphoma
 
Hodgkin’S And Non Hodgkin’S Lymphoma
Hodgkin’S And Non Hodgkin’S LymphomaHodgkin’S And Non Hodgkin’S Lymphoma
Hodgkin’S And Non Hodgkin’S Lymphoma
 
Radiotherapy contouring guideline for non-hodgkin lymphoma
Radiotherapy contouring guideline for non-hodgkin lymphomaRadiotherapy contouring guideline for non-hodgkin lymphoma
Radiotherapy contouring guideline for non-hodgkin lymphoma
 
Chemotherapy for Hodgkins disease
Chemotherapy for Hodgkins diseaseChemotherapy for Hodgkins disease
Chemotherapy for Hodgkins disease
 
Non hodgkin lymphoma
Non hodgkin lymphomaNon hodgkin lymphoma
Non hodgkin lymphoma
 
Hodgkin Lymphoma: Latest Concepts
Hodgkin Lymphoma: Latest ConceptsHodgkin Lymphoma: Latest Concepts
Hodgkin Lymphoma: Latest Concepts
 
Hodgkin lymphoma
Hodgkin  lymphomaHodgkin  lymphoma
Hodgkin lymphoma
 
Rt in lymphoma
Rt in lymphomaRt in lymphoma
Rt in lymphoma
 
How Radiation Therapy Is Used in the Treatment of Lymphoma
How Radiation Therapy Is Used in the Treatment of Lymphoma How Radiation Therapy Is Used in the Treatment of Lymphoma
How Radiation Therapy Is Used in the Treatment of Lymphoma
 
Hodgkin lymphoma db.pptx
Hodgkin lymphoma db.pptxHodgkin lymphoma db.pptx
Hodgkin lymphoma db.pptx
 
Hodgkin lymphoma
Hodgkin lymphomaHodgkin lymphoma
Hodgkin lymphoma
 
Recent andvances hodgkins lymphoma
Recent andvances  hodgkins lymphomaRecent andvances  hodgkins lymphoma
Recent andvances hodgkins lymphoma
 
Nhl with aiha dr nazim
Nhl with aiha dr nazimNhl with aiha dr nazim
Nhl with aiha dr nazim
 
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...
Update on treatment for lymphoma, Lymphoma Support Ireland meeting - feb 2011...
 
Biochemistry Lab Wk 1
Biochemistry Lab Wk 1Biochemistry Lab Wk 1
Biochemistry Lab Wk 1
 
Research Brief: Massage Therapy and Sickle Cell
Research Brief: Massage Therapy and Sickle CellResearch Brief: Massage Therapy and Sickle Cell
Research Brief: Massage Therapy and Sickle Cell
 
SCOOTEROER30c Sickle Cell in Schools Literature Review
SCOOTEROER30c Sickle Cell in Schools Literature ReviewSCOOTEROER30c Sickle Cell in Schools Literature Review
SCOOTEROER30c Sickle Cell in Schools Literature Review
 

Similar a Hodgkin’s Lymphoma

Radiotherapy in lymphoma(dr fadavi)-001
Radiotherapy in lymphoma(dr fadavi)-001Radiotherapy in lymphoma(dr fadavi)-001
Radiotherapy in lymphoma(dr fadavi)-001pedramfadavi
 
Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?
Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?
Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?Sanudev Vadakke Puthiyottil
 
Lenalidomide maintenance compared with placebo in responding elderly
Lenalidomide maintenance compared with placebo in responding elderlyLenalidomide maintenance compared with placebo in responding elderly
Lenalidomide maintenance compared with placebo in responding elderlyravi jaiswal
 
indolent lymphomas
indolent lymphomasindolent lymphomas
indolent lymphomasArnab Bose
 
Treatment of hodgkin lymphoma
Treatment of hodgkin lymphomaTreatment of hodgkin lymphoma
Treatment of hodgkin lymphomaJaber Samer
 
Chemotherapy for lung cancer
Chemotherapy for lung cancerChemotherapy for lung cancer
Chemotherapy for lung cancerGil Lederman
 
Chemotherapy for lung cancer
Chemotherapy for lung cancerChemotherapy for lung cancer
Chemotherapy for lung cancerGil Lederman
 
Aggressive treatment for early lymphomas
Aggressive treatment for early lymphomasAggressive treatment for early lymphomas
Aggressive treatment for early lymphomasGil Lederman
 
Journal club hd 10 trial dr kiran
Journal club hd 10 trial dr kiranJournal club hd 10 trial dr kiran
Journal club hd 10 trial dr kiranKiran Ramakrishna
 
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptxrhmwt rhmwt
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...JohnJulie1
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...EditorSara
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...NainaAnon
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...AnonIshanvi
 

Similar a Hodgkin’s Lymphoma (20)

Radiotherapy in lymphoma(dr fadavi)-001
Radiotherapy in lymphoma(dr fadavi)-001Radiotherapy in lymphoma(dr fadavi)-001
Radiotherapy in lymphoma(dr fadavi)-001
 
Hodgkins lymphoma treat
Hodgkins lymphoma treatHodgkins lymphoma treat
Hodgkins lymphoma treat
 
Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?
Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?
Early stage Hodgkin s lymphoma -Can we avoid Radiotherapy ?
 
Lenalidomide maintenance compared with placebo in responding elderly
Lenalidomide maintenance compared with placebo in responding elderlyLenalidomide maintenance compared with placebo in responding elderly
Lenalidomide maintenance compared with placebo in responding elderly
 
Hodgkin chemo final
Hodgkin chemo finalHodgkin chemo final
Hodgkin chemo final
 
indolent lymphomas
indolent lymphomasindolent lymphomas
indolent lymphomas
 
Treatment of hodgkin lymphoma
Treatment of hodgkin lymphomaTreatment of hodgkin lymphoma
Treatment of hodgkin lymphoma
 
Chemotherapy for lung cancer
Chemotherapy for lung cancerChemotherapy for lung cancer
Chemotherapy for lung cancer
 
Chemotherapy for lung cancer
Chemotherapy for lung cancerChemotherapy for lung cancer
Chemotherapy for lung cancer
 
Aggressive treatment for early lymphomas
Aggressive treatment for early lymphomasAggressive treatment for early lymphomas
Aggressive treatment for early lymphomas
 
Radiosensitizers
RadiosensitizersRadiosensitizers
Radiosensitizers
 
Journal club hd 10 trial dr kiran
Journal club hd 10 trial dr kiranJournal club hd 10 trial dr kiran
Journal club hd 10 trial dr kiran
 
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx
3. Farmakoterapi Limfoma Non Hodgkins_Farmakoterapi III.pptx
 
Current Concepts in Chemotherapy for Head and Neck Cancer
Current Concepts in Chemotherapy for Headand Neck CancerCurrent Concepts in Chemotherapy for Headand Neck Cancer
Current Concepts in Chemotherapy for Head and Neck Cancer
 
oral mucositis
oral mucositisoral mucositis
oral mucositis
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
 
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
The Role of Immunity in Chemotherapy-Resistant Patient with Pembrolizumab: A ...
 
Khant zaw aung
Khant zaw aungKhant zaw aung
Khant zaw aung
 

Más de Arnab Bose

mediastinal tumors investigations
mediastinal tumors   investigationsmediastinal tumors   investigations
mediastinal tumors investigationsArnab Bose
 
11.cancers of oropharynx & hypopharynx
11.cancers of oropharynx & hypopharynx11.cancers of oropharynx & hypopharynx
11.cancers of oropharynx & hypopharynxArnab Bose
 
20.pet scan in oncology
20.pet scan in oncology20.pet scan in oncology
20.pet scan in oncologyArnab Bose
 
Interaction of Radiation with Matter
Interaction of  Radiation with  MatterInteraction of  Radiation with  Matter
Interaction of Radiation with MatterArnab Bose
 
Isotopic Teletherapy Machines
Isotopic Teletherapy MachinesIsotopic Teletherapy Machines
Isotopic Teletherapy MachinesArnab Bose
 
Low Grade Gliomas
Low  Grade  GliomasLow  Grade  Gliomas
Low Grade GliomasArnab Bose
 

Más de Arnab Bose (7)

mediastinal tumors investigations
mediastinal tumors   investigationsmediastinal tumors   investigations
mediastinal tumors investigations
 
11.cancers of oropharynx & hypopharynx
11.cancers of oropharynx & hypopharynx11.cancers of oropharynx & hypopharynx
11.cancers of oropharynx & hypopharynx
 
20.pet scan in oncology
20.pet scan in oncology20.pet scan in oncology
20.pet scan in oncology
 
Interaction of Radiation with Matter
Interaction of  Radiation with  MatterInteraction of  Radiation with  Matter
Interaction of Radiation with Matter
 
Radiobiology
RadiobiologyRadiobiology
Radiobiology
 
Isotopic Teletherapy Machines
Isotopic Teletherapy MachinesIsotopic Teletherapy Machines
Isotopic Teletherapy Machines
 
Low Grade Gliomas
Low  Grade  GliomasLow  Grade  Gliomas
Low Grade Gliomas
 

Último

High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 

Último (20)

High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 

Hodgkin’s Lymphoma

  • 1. HODGKIN’S LYMPHOMA CHEMOTHERAPY RADIOTHERAPY DR ARNAB BOSE Dept. of Radiotherapy NRS Medical College, Kolkata 1
  • 2. Introduction Hodgkin’s disease was initially described as an inflammatory disease (hence the term “disease”), but is clearly recognized and treated as a malignant lymphoma (hence the more accurate term Hodgkin’s lymphoma (HL) is used synonymously with Hodgkin’s disease). The management of Hodgkin’s lymphoma has evolved from extended-field radiation alone as the main therapy to a combined-modality approach with chemotherapy and radiation, or chemotherapy alone. 2
  • 5. Treatment Groups in Early Stage 5
  • 6. Adverse Prognostic Factors The International Prognostic Score (IPS) is based on seven factors: three clinical and four laboratory values . Patients are given a score of from 0 to 7, and disease can be categorized as low (0–1), intermediate (2–3), or high (4–7) risk. 6
  • 7. General guidelines for Hodgkin’s Lymphoma treatment 7
  • 8. The current standard is the result of careful clinical trials that demonstrated three principles: i) ABVD is the preferred chemotherapy based on both efficacy and safety, ii) combined-modality therapy (chemotherapy + radiation therapy) is superior to wide-field radiation therapy alone iii) there is no advantage of wide-field radiation therapy over involved-field radiation therapy when given in combination with chemotherapy. 8
  • 10. 10
  • 11. 11
  • 12. The Milan trial was among the first and most influential in demonstrating the high cure rate of a brief course of ABVD (four cycles) combined with involved-field radiation therapy in limited-stage Hodgkin’s lymphoma. Subsequently, multiple trials have explored the questions of how many cycles of ABVD are needed and what radiation dose is needed to maintain these outstanding results. 12
  • 13. Among favorable patients without risk factors, the GHSG evaluated two versus four cycles of ABVD and 20 versus 30 Gy involved-field irradiation. The final results of this trial have not been published, but multiple presentations of the data to date have shown FFP rates in excess of 95% for all four treatment arms. Thus, for the approximately 35% of limited-stage patients with very favorable presentations, as few as two cycles of chemotherapy combined with low-dose involved-field irradiation is sufficient for cure. 13
  • 14. For patients with unfavorable, limited-stage Hodgkin’s lymphoma the subjects of clinical trial inquiry have been chemotherapy combination, number of cycles of chemotherapy, and radiation dose. The H9U trial conducted by the EORTC-GELA demonstrated that the less toxic ABVD regimen was as effective as the BEACOPP regimen and that four cycles of treatment were sufficient. Similarly, the GHSG HD11 trial has shown no differences in outcome thus far between ABVD and BEACOPP in limited-stage patients with risk factors. 14
  • 15. Randomized Clinical Trials in Limited-Stage Hodgkin’s Lymphoma 15
  • 16. Randomized Clinical Trials in Limited-Stage Hodgkin’s Lymphoma 16
  • 17. Following the ground-breaking demonstration of cure in advanced Hodgkin’s lymphoma with MOPP chemotherapy, a series of clinical trials was set in motion to identify the best chemotherapy regimen in advanced disease and to evaluate the role of radiation therapy in this setting. Based on historical development and the efficacy of ABVD in the relapsed setting, early trials pitted MOPP against ABVD and the alternating MOPP/ABVD regimen. 17
  • 18. The early CALGB study determined that ABVD-containing combinations were superior. A second U.S. Intergroup trial comparing ABVD to the hybrid MOPP/ABV combination, concluded that the treatments were similarly efficacious but ABVD was less toxic. On the basis of these trials, ABVD was widely adopted as the standard chemotherapy for advanced Hodgkin’s lymphoma with an expected cure rate of about 70%. 18
  • 19. Stanford V is a brief, 12-week chemotherapy regimen with minimal alkylating agent and lower cumulative doses of doxorubicin and bleomycin that was devised to explicitly address late effects of Hodgkin’s lymphoma treatment. The GHSG developed a novel chemotherapy combination, BEACOPP, which combines elements of COPP and ABVD with etoposide. The regimen was designed and tested in standard and escalated forms. 19
  • 20. Randomized Clinical Trials in Advanced-Stage Hodgkin’s Lymphoma 20
  • 21. Randomized Clinical Trials in Advanced-Stage Hodgkin’s Lymphoma 21
  • 22. Secondary Therapy of Classical H L Fortunately, fewer patients with Hodgkin’s lymphoma currently progress after primary treatment. Those with advanced disease and a high IPS are at greatest risk. High-Dose Chemotherapy with either the CBV (cyclophosphamide, carmustine, etoposide) or BEAM (carmustine, etoposide, cytarabine, melphalan) regimen followed by Autologous Stem Cell Transplantation has been the most successful approach . 22
  • 23. To achieve maximal cytoreduction before transplantation the approach is to treat progressive and relapsing patients with secondary chemotherapy, most commonly the DHAP (cisplatin, high-dose cytarabine, dexamethasone), or ICE (ifosfamide, carboplatin, etoposide) regimen. Recently a new regimen, IGEV (ifosfamide, gemcitabine,etoposide, vinorelbine), has demonstrated excellent tolerability and efficacy in the second-line setting. 23
  • 24. Complications of Chemotherapy Sterility was a major adverse effect of the MOPP regimen. ABVD does not seem to cause more than temporary cessation of menses in women and temporary oligospermia in men. In contrast, BEACOPP chemotherapy routinely sterilizes males and many young females. Semen preservation must take place before chemotherapy. 24
  • 25. Early reports implicated the alkylating agents in MOPP chemotherapy in an increased risk of secondary acute myelocytic leukemia (AML) and myelodysplasia. ABVD chemotherapy does not seem to increase the risk of secondary AML above baseline. BEACOPP chemotherapy was accompanied by an increased risk of secondary AML. In this case, etoposide was also implicated. 25
  • 26. Lung cancer is emerging as a leading cause of death in Hodgkin’s lymphoma patients. Relative risks increase with cumulative dose of alkylating agents and with increasing doses of radiation. The risk after chemotherapy is immediate, whereas there is a latency of about 5 years after radiation therapy. Importantly, the relative risk increases 20-fold with tobacco use, indicating that smoking cessation is absolutely imperative among Hodgkin’s lymphoma survivors. 26
  • 27. Pulmonary toxicity related to bleomycin has been recognized to be both idiosyncratic and related to cumulative exposure. Bone toxicity in the form of osteoporosis may accompany prednisone use, particularly in the setting of gonadal failure. Osteonecrosis is an uncommon complication that occurs in the hips or shoulders in individuals exposed to high cumulative doses of prednisone, particularly with the addition of high-dose radiation therapy. 27
  • 28. LYMPH NODAL REGIONS Lymph Nodal Groups 28
  • 31. Fields for I F R T 31
  • 32. Unilateral Cervical/Supraclavicular Region Arms position: Akimbo or at sides Upper Border: 1 to 2 cm above the lower tip of the mastoid process and midpoint through the chin. Lower Border: 2 cm below the bottom of the clavicle. Lateral Border: To include the medial two-thirds of the clavicle. 32
  • 33. Medial Border: (a) If the SCL nodes are not involved, the border is placed at the ipsilateral transverse processes except when medial nodes close to the vertebral bodies are seen on the initial staging neck CT scan. For medial nodes the entire vertebral body is included. (b) When the SCL nodes are involved, the border should be placed at the contralateral transverse processes 33
  • 34. Blocks: A posterior cervical cord block is required only if cord dose exceeds 40 Gy. Mid-neck calculations should be performed to determine the maximum cord dose, especially when the central axis is in the mediastinum. A laryngeal block should be used unless lymph nodes were present in that location. In that case the block should be added at 20 Gy. 34
  • 35. Bilateral Cervical/Supraclavicular Region Both cervical and SCL regions should be treated as described in the preceding slide regardless of the extent of disease on each side. Posterior cervical cord and larynx blocks should be used. 35
  • 36. Mediastinum Arms position: Akimbo or at sides. The arms-up position is optional if the axillary nodes are involved. Upper Border: C5-6 interspace. If SCL nodes are also involved, the upper border should be placed at the top of the larynx. 36
  • 37. Lower Border: The lower of: (a) 5 cm below the carina or (b) 2 cm below the pre-chemotherapy inferior border. Lateral Border: The post-chemotherapy volume with 1.5 cm margin. Hilar Area: To be included with 1 cm margin unless initially involved, in which case the margin should be 1.5 cm. 37
  • 38. Axillary Region Arms position: Arms akimbo or arms up. Upper Border: C5-6 interspace. Lower Border: The lower of the two: (a) the tip of the scapula or (b) 2 cm below the lowest axillary node. Medial Border: Ipsilateral cervical transverse process. Include the vertebral bodies only if the SCL are involved. Lateral Border: Flash axilla. 38
  • 39. 39
  • 40. Abdomen (Para-Aortic Nodes) Upper Border: Top of T11 and at least 2 cm above pre-chemotherapy volume. Lower Border: Bottom of L4 and at least 2 cm below pre-chemotherapy volume. Lateral Borders: The edge of the transverse processes and at least 2 cm from the post-chemotherapy volume. 40
  • 41. Inguinal/Femoral/External Iliac Region Upper Border: Middle of the sacroiliac joint. Lower Border: 5 cm below the lesser trochanter. Lateral Border: The greater trochanter and 2 cm lateral to initially involved nodes. 41
  • 42. Medial Border: Medial border of the obturator foramen with at least 2 cm medial to involved nodes. If common iliac nodes are involved the field should extend to the L4-5 interspace and at least 2 cm above the initially involved nodal border. 42
  • 43. 43
  • 44. Mantle: bilateral cervical, SCV, infraclavicular, mediastinal, hilar, and axilla Mini-mantle: mantle without mediastinum, hila Modified mantle: mantle without axilla mini mantle modified mantle 44
  • 46. Simulate with Arms - up (to pull axillary LN from chest to allow for more lung blocking) or Arms akimbo (to shield humeral heads and minimize tissue in SCV folds) Head extended this ensures the exclusion of the oral cavity and teeth from the RT fields, and decreases the dose to the mandible 46
  • 47. Borders: Lateral = beyond humeral heads; Inferior = bottom of diaphragm (T11/12); Superior = inferior mandible Blocks: Larynx on AP field Humeral heads on AP and PA fields PA cord block (if dose >40 Gy) Lung block at top of fourth rib to cover IC LN If pericardial or mediastinal extension, include entire heart to 15 Gy, then block apex of heart. After 30 Gy, block heart beyond 5 cm inferior to carina (unless residual disease) 47
  • 49. STLI TLI 49
  • 50. Dose of Radiotherapy Combined Modality RT Dose Non-bulky disease (stage I-II) 20*-30 Gy (if treated with ABVD) 30Gy (if treated with Stanford V) Non-bulky disease (stage IB-IIB) and Bulky and Non-bulky disease (stage III-IV) 30-36 Gy if treated with BEACOPP *A dose of 20Gy following ABVD x 2 is sufficient if the patient has non bulky stage I-IIA disease with ESR <50, no extra lymphatic lesions, and only one or two lymph node regions involved 50
  • 51. Bulky disease sites (all stages) 30-36 Gy (if treated with ABVD) 36Gy (if treated with Stanford V) RT Alone Doses (uncommon except for NLPHL) Involved regions 30-36Gy Uninvolved regions 25-30Gy 51
  • 52. Side Effects of Radiotherapy Side effects of RT depend on the irradiated volume, the dose administered, and the technique employed. They are also influenced by the extent and type of prior chemotherapy, if any, and by the patient's age. 52
  • 53. Most of the information that we use today to estimate risk of RT is derived from strategies that used radiation alone. The sizes of the fields and configuration, doses and technology have all drastically changed over the last decade. It is therefore probably misleading to judge current RT for lymphomas and inform patients solely on the basis of different past practice of using RT in treating lymphomas. 53
  • 54. Acute Effects Radiation, in general, may cause fatigue and areas of the irradiated skin may develop mild sun-exposure like dermatitis. The acute side effects of irradiating the full neck include mouth dryness, change in taste, and pharyngitis. These side effects are usually mild and transient. The main potential side effects of sub-diaphragmatic irradiation are loss of appetite, nausea, and increased bowel movements. These reactions are usually mild and can be minimized with standard antiemetic medications. 54
  • 55. Irradiation of more than one field, particularly after chemotherapy, can cause myelosuppression, which may necessitate short treatment interruption and very rarely the administration of granulocyte-colony stimulating factor (G-CSF). 55
  • 56. Early Side Effects Lhermitte's sign: <5% of patients may note an electric shock sensation radiating down the backs of both legs when the head is flexed (Lhermitte's sign) 6 weeks to 3 months after mantle-field RT. Possibly secondary to transient demyelinization of the spinal cord, Lhermitte's sign resolves spontaneously after a few months and is not associated with late or permanent spinal cord damage. 56
  • 57. Pneumonitis and pericarditis: During the same period, radiation pneumonitis and/or acute pericarditis may occur in <5% of patients; these side effects occur more often in those who have extensive mediastinal disease. Both inflammatory processes have become rare with modern radiation techniques. 57
  • 58. Late Side Effects Subclinical Hypothyroidism: Irradiation of the neck and/or upper mediastinal can induce subclinical hypothyroidism in approximately one-third of patients. This condition is detected by the elevation of the thyroid-stimulating hormone (TSH). Thyroid replacement with levothyroxine (T4) is recommended, even in asymptomatic patients, to prevent overt hypothyroidism and decrease the risk of benign thyroid nodules. 58
  • 59. Infertility: Only irradiation of the pelvic field may have deleterious effects on fertility. In most patients, this problem can be avoided by appropriate gonadal shielding. In women, the ovaries can be moved into a shielded area laterally or inferomedially near the uterine cervix. Irradiation outside of the pelvis does not increase the risk of sterility. 59
  • 60. Secondary Malignancies: Patients with HD who were cured with RT and/or chemotherapy, have an increased risk of secondary solid tumors (most commonly, lung, breast, and stomach cancers, as well as melanoma) and NHL, 10 or more years after treatment. Unlike MOPP and similar chemotherapy combinations, RT for HD is not leukemogenic. 60
  • 61. Lung Cancer: Patients who are smokers should be strongly encouraged to quit the habit because the increase in lung cancer that occurs after irradiation or chemotherapy has been detected mostly in smokers. Effects on Bone and Muscle Growth: In children, high-dose irradiation will affect bone and muscle growth and may result in deformities. Current treatment programs for pediatric HD are chemotherapy based; RT is limited to low doses. 61
  • 62. Coronary Artery Disease: An increased risk of coronary artery disease has been reported among patients who have received mediastinal irradiation. To reduce this hazard, patients should be monitored and advised about other established coronary disease risk factors, such as smoking, hyperlipidemia, hypertension, and poor dietary and exercise habits. 62
  • 63. Breast Cancer as a long term sequelae of Radiotherapy in HL For women whose HL was successfully treated at a young age, the main long-term concern is the increased risk of breast cancer. The increase in risk of breast cancer is inversely related to the patient's age at HL treatment; no increased risk has been found in women irradiated after 30 years of age. It is also related to the radiation dose to the breast and the volume of breast tissue exposed. 63
  • 64. Most breast exposure in the mantle era resulted from the radiation of the axillae, and to a lesser extent from wide mediastinal and hilar irradiation. During the last decade, reduction in field size has been the most important change in radiation therapy of HD. Reduction in the volume of exposed breast tissue together with dose reduction (from over 40 Gy to a dose in the range of 20-30 Gy) is likely to dramatically change the long-term risk profile of young male and female patients cured of HD. 64
  • 65. thank you 65