Doses for all

Question 1

Doses, benefit, evidence for Follicular lymphoma stg I/II and grd I-II

Answer 1

Evidence shows 24Gy equivalent to 40.
TROG 99. R-CVP x6 then RT 24/12 OS for

PFS benefit (50% vs 33%, with suggestion that after 10yrs progression is rare).

ISRT:
CTV = GTV + 1cm radial (or entire nodal compartment on axial) + 2-3cm sup-inf expansion

PTV = 5mm (3mm H&N)

Question 2

Doses, benefit, evidence for Follicular lymphoma stg I/II and grd III

Answer 2

treat as DLBCL:
R-CHOP x6 (x3 if FLIP-2 B-BLAH<2) then 30Gy ISRT

Question 3

Doses, benefit, evidence for Follicular lymphoma >= stg III

Answer 3

No treatment considered curative
Indications for treatment:
Pain, end-organ dysfunction, cytopenia, progression patient preference

Question 4

Doses, benefit, evidence for palliative lymphoma RT

Answer 4

RCT data (FORT trial) 4Gy/2# non-inferior to 24/12 in terms of time to progression or OS
BUT higher doses may have higher response rate.

Question 5

Doses, benefit, evidence for DLBCL

Name the Chemo

Answer 5

Stg I/II (bulk <7.5cm) and
1.1) IPI 0: LYSA trial x3 R-CHOP then ISRT 30Gy or x6RCHOP
Or R-CHOPx3 then PET directed.
1.2) IPI>0 (1-5): R-CHOPx6 NO RT

Stg I/II (bulky = >7.5cm)
3-6 Cycles R-CHOP then

Stg III/IV
R-Chop 6-8
Consider INRT to bulky sites
Upfront stem cell transplant is investigational

Question 6

Treatment approach and outcomes for primary mediastinal lymphoma:

Answer 6

Mean age 35, the only lymphoma with signif F>M, Usually presents as bulky (>10cm) disease. Intermediate size diffuse or clusterd lymphoma cells.
Can be treated with chemo alone R-EPOCH +/consolidative RT (E.g 20/10)

70-90% chance of cure

Question 7

Name the marginal zone lymphomas
Doses for the most common type

Answer 7

Nodal, splenic, mucosal (MALT)
90% are MALT, 60% are GI, 85% of which are gastric.

Gastric: If failure of x3 therapy or t(18,11) then 30/20 to GTV and whole stomach.
H&N MALT (Waldeyers most common) 24/12

Question 8

Doses, benefit, evidence for Hodgkins

name the chemo

Answer 8

Stg I/II
1) Fav (AMEEN=0): RCT H10: x2c ABVD (x4cyles equivalent to 2) -> 20Gy ISRT. (alternative: PET after 2cycles - if CR x2 ABVD = worse PFS. IF PR then xBEACOPP and 30Gy)

2) Unfav (AMEEN>0) H11: x4 ABVD + 30Gy ISRT is standard.

Stg >= III
HD15 - BEACOPP is toxic and >6 cycles may decrease OS.
SOC = BEACOPP x 6 then 30Gy ISRT IF residual mass >2.5cm or PET avid.

ABVD = Adiamycin Bleomycin, vincristine, Darcazpine

BEACOPP = Bleomycin Etoposide, Cycolphosphamide Vincritine, Procarbizine, prednisolone

(i.e add etop, cyclophos and pred to ABVD)

Question 9

Describe a suitable whole breast technique:

Answer 9

Adjuvant hypofractionated radiotherapy to the left breast: 26Gy/5#s, 5#s/week, DIBH, 3D planned technique, 6Mv photons, tangent fields with non-divergent superior border, field-in-field (FIF) as needed.

Pre sim: assess lymphoedema risk, ensure recovered/healed from surgery.
Sim: Supine arms above head (breast board), head towards gantry, vac bag immobilization, knee rests/comfort measures. Skin marker over scar (but not breast reduction scar!!).
CT 2mm slice from C4 to below diaphragm. DIBH.
CTV = Whole breast: e.g START protocol. Includes the soft tissues of the whole breast from 5 mm below the skin to
deep fascia (i.e. excluding muscle).
PTV = CTV+5mm

OARS:
Ipsi lung V20Gy<15%.
MHD < 4Gy (aim less than 2Gy), V20Gy<5%
Contra breast V4Gy<5%

Verification: Kv daily matched to bone - soft tissue review