1. Terry Lee, MD November 2014

2. 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

3. Nodal Regions

4. 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

5. 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

6. 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

7. Radiation in Hodgkin Stage IA, IIA Nodular Lymphocyte predominant Hodgkin’s disease Involved field radiation 30 to 36 Gy

8. 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

9. Prechemotherapy PET

10. Restaging PET

11. Radiation Field

12. 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

13. 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

14. 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%

15. 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

16. 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

17. Radiation Used for Therapy Electrons High energy electromagnetic wave (photons) X-ray Gamma ray E electric field M magnetic field

19. Linear Accelerator

20. 6 to 23 MeV

21. Bremsstrahlung

22. y1 n y2 n x1 n x2 n xA i,n Y1 X1 X2 Leaf A i xB i,n Leaf B i Varian Tertiary MLC Beam Shaping

24. Radiobiology DNA

25. 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

26. TD 5/5 (Gy) Volume TD 50/5 (Gy) Volume Organ 1/3 2/3 3/3 1/3 2/3 3/3 End point Kidney 503023--4028 Clinical nephritis Brain 605045756560 Necrosis/ infraction Brain stem 605350-- 65 Necrosis/ infraction Ear(Mid/Ext) 30 40 Acute serious otitis Ear(Mid/Ext) 55 65 Chronic serious otitis Esophagus 605855727068 Clinical stricture/ perforation Heart 604540705550 Pericarditis Bladder --8065--8580 Symptomatic bladder contracture and volume loss

27. TD 5/5 (Gy) Volume TD 50/5 (Gy) Volume Organ 1/3 2/3 3/3 1/3 2/3 3/3 End point Larynx 7970 9080 Cartilage necrosis Larynx --45 -- 80 Laryngeal edema Liver 503530554540 Liver failure Lung 453017.5654024.5 Pneumonitis Skin 10cm 2 70 30cm 2 60 100cm 2 55 10cm 2 -- 30cm 2 -- 100cm 2 70 Necrosis/ ulceration Small intestine 50--4060--55 Obstruction/ perforation Colon 55--4565--55 Obstruction/ perforation/ ulceration/fistula Spinal cord 5cm 50* 10cm 50 20cm 47 5cm 70* 10cm 70 20cm -- Myelitis/necrosis

28. 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.

29. 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)