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Radiation Therapy in Practice > Lymphoma > Flashcards

Lymphoma Flashcards

1
Q

what is lymphoma

A

cancer of the lymphatics presenting as solid tumour of lymphoid cells

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2
Q

what are the two types of lymphoma

A

hodgkins 20%
non-hodgkins 80%

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3
Q

how does lymphoma present

A
  • depends on site/extent of disease
  • asymptomatic lump
  • B symptoms
    >10% weight loss
    drenching night sweats
    unexplained fevers > 38deg
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4
Q

investigations related to staging

A
  • routine
  • Blood FBC, ESR (erythrocyte reproduction rate), U&E, LFT (liver function tests), LDH (lactate dehydrogenase), alkaline phosphatase
  • CT neck, chest, abdomen and pelvis
  • tissue biopsy with expert review
  • immohistochemistry/ cytogenetics etc
  • occasional
  • PET/CT scan
  • bone marrow aspirate & Trephine biopsy if B symptoms, stage III/IV or aggressive histology
  • lumbar puncture if symptoms or disease close to CNS
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5
Q

investigations related to treatment

A
  • semen analysis & cryopreservation
  • ovarian tissue or oocyte cryopreservation
  • HIV test if risk factors or unusual disease presentation
  • evaluation of lung and cardiac function
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6
Q

staging (Ann Arbor)

A
  • I one lymph node region
  • II two or more lymph node regions on same side of the diaphragm
  • III lymph node regions on both sides of diaphragm
  • IV diffuse or disseminated involvement of >= 1 extralymphatic organs, including any involvement of liver, bone marrow or lungs
  • add E for extra-lymphatic involvement
  • add A or B for absence/presence of B symptoms
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7
Q

prognostic factors

A
  • stage
  • presence of symptoms (B symptoms)
  • age
  • LDH level
  • extent of extra-nodal involvement
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8
Q

epidemiology of Hodgkins Lymphoma

A
  • uncommon
  • most common age 20s-30s
  • second peak in 60s-80s
  • > 75% of newly diagnosed HD are curable with chemo +/ or RT
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9
Q

aetiology of Hodgkins Lymphoma

A
  • essentially unknown
  • age two peaks 20-30 and 60-80
  • Epstein-Barr Virus possible association
  • immunosuppression may increase risk
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10
Q

pathology of Hodgkins Lymphoma

A
  • Reed-Sternberg cells in a reactive background including normal T cells and eosinophils
  • NEGATIVE
    CD45
    CD3
    CD20
    CD15
  • POSITIVE
    CD30
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11
Q

sub-types of Hodgkins Lymphoma

A
  • classic Hodgkin’s disease includes
  • nodular sclerosing
  • mixed cellularity
  • lymphocyte-rich classical
  • lymphocyte-depleted subtypes
  • non-classic
  • lymphocyte-predominant Hodgkin’s disease (LPHD)
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12
Q

overview of treatment for Hodgkins Lymphoma

A
  • no role for surgery
  • classical hodgkins
  • Stage I/IIA chemo + RT ( with some exceptions)
  • Stage IIB/III/IV chemo alone + occasional RT to bulky/unresponsive sites
  • nodular lymphocyte predominant HD
  • stage I/II Rt alone usually
  • Stage III/IV
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13
Q

RT volumes and definitions
Involved field

A

includes involved or enlarged node(s) and nodes within same region

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14
Q

RT volumes and definitions
Involved site

A

includes pre- and post-chemo tumour volumes & margin of healthy tissue

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15
Q

RT volumes and definitions
Involved node

A

includes pre- and post-chemo nodal volumes and margin of 5-10mm of healthy tissue

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16
Q

early stage classical HD (IA/IIA)

A

2-4 cycles of ABVD chemotherapy (adriamycin, bleomycin, vinblastine, dacarbazine) followed 4 later by involved field RT (IFRT) (20-30Gy/10-15#/3 weeks)
2 x ABVD and 20Gy/10# in very favourable stage I-IIA HD

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17
Q

very favourable HD

A
  • stage I-II
  • <=3nodal regions involved
  • no extra-nodal disease
  • ESR<50 (or <30 if B symptoms present)
  • not bulky (>=10cm)
18
Q

side effects of ABVD (adriamycin, bleomycin, vinblastine, dacarbazine)

A
  • adriamycin: nausea, vomiting, hair loss, myelosuppression, cardiomyopathy
  • bleomycin: fevers or chills, bleomycin pneumonitis, skin changes
  • vinblastine: neutropenia, pain in jaw, constipation
  • dacarbazine: nausea, vomiting, pain at injection site
    1% risk of acute leaukaemia
19
Q

Classical HD (IIB-IV)

A
  • 6-8 cycles ABVD chemotherapy or more intensive regimens
  • role of RT controversial. usually only use RT if there was bulky mass or it was around the spine
  • response to chemo generally poor. generally high dose chemo
20
Q

Summary of RT in HD

A
  • stage I-II
    ISRT following 2-4 cycles of ABVD
  • stage III and IV
    ?consolidation RT following chemo to initial bulky sites
    ?consolidation RT to sites of residual disease in those who don’t achieve complete response
  • relapsed or refractory Hodgkin lymphoma
    unresponsive to chemo - regional RT
21
Q

Epidemiology of NHL

A
  • very heterogenous group of malignancies
  • more common than HD
  • incidence rising (people living longer and early lives are a lot more sterile/hygienic than they used to be)
  • generally affects middle aged - elderly
  • less predictable pattern of behaviour
22
Q

Classification of NHL

A
  • complex - IHC, cytogenetics, behaviour (LG vs HG), cell type
  • majority are tumours of B cells
  • rarer sub-types: T cells, Non-killer (NK) cell, myeloproliferative
23
Q

presentation of NHL

A

depends on subtype, stage and site
may present as losing weight, lumps in unusual places, people being unusually tired

24
Q

management of NHL

A
  • no role for surgery
    ?curative for early stage low grade NHL on the skin (very uncommon)
  • dominated by chemotherapy
  • RT utilised for some subtypes
25
Q

RT in NHL

A

subtypes where RT may form part of curative treatment ( alone or in combination )
- follicular lymphoma
- marginal zone (MALT)
- diffuse large B cell lymphoma (DLBCL)
- cutaneous lymphomas

RT may be used in palliation for any subtype

26
Q

Follicular NHL

A
  • around 20% of all NHL (developed world)
  • around 20-30% present with stage I-II
  • chemo-/radiosensitive but relapse common
  • median survival 7-10 years
  • usually CD20+
  • treatment varies from observation to HD chemo and stem cell transplant
  • may undergo HG transformation
27
Q

Follicular NHL: Stage I-II

A
  • around 30% present with stage I-II
  • IFRT 24Gy/12#
  • ongoing trials - smaller doses to smaller volumes ?addition chemo
  • 10 year DFS 40-60%
    median survival 14-15 years
28
Q

Follicular NHL: stage III-IV

A
  • 70% present with stage III-IV
  • options:
    observation
    single or multi-agent chemo
    +/- rituximab
    HD chemo (in select few)
    RT (4Gy/2#) to symptomatic sites
29
Q

Mucosa Associated Lymphoid Tissue (MALT) Lymphoma

A
  • 7-9% of lymphomas
  • usually affects stomach
  • other sites: orbit, skin, salivary glands, thyroid
  • rarely: bladder, cervix, breast, lung
  • 60-70% present with stage I-II
  • local RT (24Gy/12#) or in H. pylori +ve gastric MALT -> antibiotics
30
Q

MALT stage III-IV

A
  • slowly progressive
  • incurable
  • may transform into high grade NHL
  • treated when symptomatic with chemo +/- RT (4Gy/2#)
31
Q

Diffuse Large B Cell NHL (DLBCL)

A

stage I-II
- evidence base: numerous trials/ mixed inclusion criteria/ different treatment schedules
- RT alone: survival around 50%
- Chemo + RT: survival around 70-80%
- Chemo alone: survival ?as good as CRT
treatment is very individualised

32
Q

stage I-II DLBCL

A
  • 3 cycles R-CHOP chemo (rituximab, cyclophosphamide, hydroxyurea, vincristine, prednisiolone) followed by IFRT (30Gy/15#)
  • ?4-6 cycles if poor prognosis features - bulk, B symptoms, LHD, etc.
  • generally avoid RT in sites where toxicity significant e.g. H&N
33
Q

primary central nervous system NHL

A
  • usually B cell NHL
  • uncommon
  • often multifocal or diffuse
  • young patients: chemo +/- RT (45Gy/25#). median survival up to 5 years (excluding HIV+)
  • older patients: RT alone (40-50Gy). median survival up to 18 months
34
Q

cutaneous NHL

A

mixed group comprising
- B cell NHL around 25% (follicular, MALT, DLBCL)
- T cell NHL of large cells around 10%
- indolent T cell NHL around 65%

  • often treated with RT (30Gy/15#) when localised
  • most have good prognosis
35
Q

RT planning in lymphomas (non-cutaneous)

A
  • optimally CT- simulated
  • supine
  • arm position depends on target volume
  • international guidelines for CTV delineation
  • OAR delineated - conscious of longterm survival and late toxicity
  • usually AP/PA fields
  • DIBH/IMRT?
    (often in H&N shell)
36
Q

acute RT toxicity

A

depends on site irradiated
general - fatigue, skin erythema, anaemia, leucopenia, thrombocytopenia
- H&N: dry mouth, mucositis, hoarseness, alopecia
- thorax: dysphagia, dyspnoea, cough, etc.
- abdo/pelvis: nausea/diarrhoea

37
Q

late toxicity - mediastinum

A
  • lung
    pulmonary fibrosis
    minimised by:
    -> careful treatment planning
    -> allowing an interval of 4 weeks between chemo and RT
    many chemo drugs may potentiate the effects of RT on lung tissue e.g. bleomycin, cyclophosphamide and doxorubicin
  • heart
    -> coronary artery disease, valvular disease, conduction defects
    -> following (now outdated) treatment risk of developing symptomatic coronary artery disease is 6-10% at 10 years and 10-20% at 20 years
    -> actuarial risk of death from cardiac ischaemia appear to be 2-6% at 10 years and 10-12% at 15-20 years
    -> minimised by:
  • careful treatment planning
  • maximum cardiac shielding (subcarinal area and left ventricle)
  • avoidance of dose per # over 2Gy
    potential cardiotoxic effects of doxorubicin may also be additive to the long term damaging effects of radiation to the heart
  • thyroid (if included in field)
    -> hypothyroidism
    -> thyroid nodules
    -> thyroid cancer
38
Q

late RT toxicity - pelvis

A
  • genital organs
    -> large fields - direct and scattered radiation
    -> 20-24Gy - ovarian ablation -> menopause and sterility
    -> spare one ovary if possible with ultrasound or CT guidance to locate the ovary
    -> when bilateral pelvic irradiation is inevitable -> surgical oophoropexy with transposition of one ovary to lateral abdomen should be considered
    -> however vascular supply can be damaged -> infertility
  • testis
    -> very radisensitive
    -> 15cGy -> transient oligospermia
    -> 4-6Gy -> permanent azospermia
    -> infertility always follows scrotal irradiation
    -> testosterone production can be preserved after doses of 30-35Gy
    -> scattered dose should be considered in fields close to scrotum
39
Q

late toxicity - second malignancies

A
  • increased risk of 2nd malignancies in HL survivors
  • 55-65 excess malignancies per 10,000 years of follow up among patients treated for HL
  • 20 year cumulative incidence of malignancy of around 15-20%
  • excess risk of a 2nd solid tumour
    -> breast - more common in those treated in adolescence
    -> lung - worse in smokers
    -> oesophagus
    -> thyroid
40
Q

late effects of RT - breast cancer

A

following mediastinal RT (ie including some breast tissue)
- as children/adolescents: risk of breast cancer 1 in 3-5 over next 25 years
- 20-30: risk of breast cancer 1 in 4-7 over next 25 years
- >30s: risk of breast cancer not dissimilar to background risk (1 in 11)

41
Q

consider avoiding RT in lymphoma

A

significant risk of late side effects
- young women (<30years) where treatment would involve breast irradiation
- smokers
- risk of permanent xerostomia
- pre-existing lung/cardiac disease

Radiation Therapy in Practice (19 decks)

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