Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Dr Sandip Barik
Department of
Radiotherapy,KGMU,Lucknow
INTRODUCTION
Are group of cancers which originates from
Reticuloendothelial systems
It was named after Thomas Hodgkin who first described it
in 1832.
Dorothy Reed and Carl Stenberg first described the
malignant cells of Hodgkins lymphoma called Reed
Stenberg cells.
Hodgkins lymphoma was the first cancer which could be
successfully treated by radiation therapy and also by
combination chemotherapy.
Epidemiology
Accounts for 0.58% of all cancers diagnosed and 0.23% of all
cancer deaths in U.S each year.
Incidence is less than 3 per 100,000
In 2010 in U.S 8490 cases were registered (4670 males,
3820 females) and accounted for 1320 deaths.
It has a slightly male predominance (1.1:1)
It is rare in children younger than 10 years
It has Bimodal peak of distribution (25-30 yrs and >55 yrs)
Risk Factors
Natural History
Hodgkins lymphoma arises in a single node or a chain of nodes
and spreads first to anatomically contiguous lymphoid tissue.
Visceral involvement by Hodgkins lymphoma may be secondary
to extension from adjacent lymph nodes.
Haematogenous spread occurs to liver or multiple bony sites
It rarely involves the gut associated lymphoid tissue such as
Waldeyer ring and Peyers patches.
Mechanism of spleen involvement is unclear but all pts with
hepatic and bone involvement are associated with splenic
involvement.
Clinical features
Most common presentation is
asymptomatic lymphnode
enlargement typically in the
neck.
Cervical lympnodes are
involved in 80% cases .
Mediastinal involvement is
seen in about 50% cases .they
produce symps like Chest
pain CoughDyspnoea
Infradiaphragmatic
involvement is seen in 5%
cases and usually seen with
older patients.
Diagnostic Workup
History
Complete physical examination
Confirmatory workup
Chest x ray(pa,lat)
Usg neck,whole abdomen
CT scan thorax,abdomen and pelvis
FDG PET scan
OTHERS
Bone marrow biopsy
PET SCAN
Pathological Classification
Histologic
Subtypes
<5% of Hodgkins
lymphoma
Mainly involves
cervical,axillary or
mediastinal
Nodular Sclerosis
CD 15 and 30 positive
EBV negative
Mixed Cellularity
Presents in advanced
stages
Tendency to involve
spleen,bone marrow
Lymphocyte Depleted
Constitutes <5%
Older males
Advanced stage
HIV infection
Staging
I
II
III
Lymphnodes group
Prognostic Factors
Prognostic factor for Early stage Hodgkins disease
Management
CHEMOTHERAPY
Chemotherapy
25mg/m2
10
6
375
Radiotherapy
2D Planning
3D Planning
IMRT
Pre RT Evaluation:
Oro dental prophylaxis
Pulmonary function test
Pre chemotherapy and post chemotherapy information from CT
or PET scan
Position
Usually supine.
Arms up position pulled up the axillary node further from the
chest wall ,thereby permitting more generous lung shielding.
Arms down or akimbo position permitted shielding of the humeral
head and minimize the effect of tissue folds in supraclavicular
If neck is to be treated head in hyperextension
Frog leg for inguinal nodes
Immobilization
OTHERS
Oophoropexy in young females
Fields are shaped using multileaf collimators
Respiatory gating has to be taken care of
Mantle technique
Treatment Field:
BLOCKS :
Larynx anteriorly
Humeral heads
Spinal cord if >40 Gy
Heart after 30 Gy
Lung blocks: The upper border of lung block curves centrally to
include infraclavicular nodes
The medial borders are
shaped so as to treat the hilar nodes.
A gap of 8-10
cm is left in midline between blocks to treat mediastinal nodes.
Subdiaphragmatic Fields
Target Volume:
Para aortic
Pelvis
Inguinal nodes(b/l)
Spleen
Treatment Fields:
For Paraaortic
Superiorly:The T10-11 vertebrae
Inferiorly:The lower limit of L4
Laterally:width of transverse process.
Pelvis F ield:
Laterally:1.5-2 cm lat to the widest point in pelvis
Inferiorly:Lesser trochanter.
Inverted Y Field
Para aortic fields
pelvic field
BLOCKS:
IFRT
IFRT
3DCRT
GTV:Original prechemo
volume of involved
lymphnodes clinically and
radiologically
CTV:GTV with whole nodal
regions that contains the
involved lymphnodes.
PTV:Depends on
immobilization,reproducibili
ty,organ motion.usually 10
mm margin is added to CTV
INRT
Newer concept evolved with advent and more usage of ct and PET
scan
Target volume is based on initial macroscopic prechemo disease
rather than based on lymphnode region.
Treatment Portals:
Beam arrangement is often // & opposite pair fields(ap-pa)
DOSE
Early stage :after complete response to chemotherapy 20 Gy in 10#
Advanced stage with residual disease after chemotherapy
30 Gy in 15# with additional 6 Gy in 3# depending on bulk of
disease
Sequelae of Treatment
ACUTE REACTIONS:
Fatigue ,nausea,vomiting,dry cough
Occipital hair loss
Sore throat
Skin reactions
Alteration of taste
Dysphagia
Reflux symptoms
Myelosupression
LATE REACTIONS
Radiation Pneumonitis(6-12 wks)
Radiation Pericarditis
Subclinical Hypothyroidism:most common delayed
symotoms
Herpes Zoster infections:
Lhermittes sign(1-2 mths)
Late Reactions(cont)
Secondary malignancy:
Leukaemia
Lymphoma(diffuse large cell type most common after 5 years)
Solid Tumors:In males Lung (>30 Gy),colorectal
In females
Breast,lung,colorectal
Conclusion
Radiation therapy is the most effective single therapeutic agent
for treating Hodgkins lymphoma
THANK YOU