2. 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 Hodgkin’s lymphoma called Reed Stenberg cells.
• Hodgkins lymphoma was the first cancer which could be
successfully treated by radiation therapy and also by
combination chemotherapy.
3. 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)
4. Risk Factors
• First degree relatives have five fold increase in risk for Hodgkins Disease.
• Associated with EBV infection mainly with mixed cellularity type.
• Associated with Infectious Mononucleosis. Incidence is about 2.55 times
higher
• High socio economic status.
• Prolonged uses of human growth hormone
5. 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.
6. 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
Cough
Dyspnoea
• Infradiaphragmatic involvement is seen
in 5% cases and usually seen with older
patients.
7. Clinical features cont…
• B symptoms
About 33% presents with B symptoms overall.
Only 15-20% of stage I-II have B symptoms like
o Fever(>38oC)
May first present as fever of unknown origin
Fever persists for days to weeks followed by afebrile intervals and then
recurrence
Such type of pattern is called Pel Ebstein Fever
o Drenching night sweats
o Weight loss(> 10% in 6 mths)
8. Clinical features cont…
• Other less frequently symptoms are
Pruritus
Alcohol induced pain over involved lymph nodes
Nephrotic syndrome
Erythema nodosum
Cerebellar degeneration
Immune hemolytic anaemia, Thrombocytopenia
Hypercalcaemia
9. Diagnostic Workup
• History
• Complete physical examination
• Confirmatory workup
Excisional biopsy of the lymph node
Staging workup
Chest x ray(pa,lat)
Usg neck,whole abdomen
CT scan thorax,abdomen and pelvis
FDG PET scan
10. • Routine blood investigations
Complete blood count
Liver function
Renal function
Serum albumin
ESR
Lactate Dehydrogenase
OTHERS
Bone marrow biopsy
11. PET SCAN
• PET Scan has become an integral
component of initial staging.
• Information provided by PET has
been recently incorporated in the
lymphoma guidelines for response
evaluation after completion of
treatment.
• Useful for follow up study to
evaluate residual masses , dx of
early recurrence and predicting
outcome.
• It has a specificity of 90-95%
13. Bone Marrow Biopsy
• Less commonly put into practice
• Overall involvement of bone marrow in Hodgkins lymphoma is
5%.
• Indicated in pts with
B symptoms
Clinical evidence of sub diaphragmatic disease
Stage iii-iv
Recurrent disease
15. Lymphocyte predominant Hodgkins lymphoma
• <5% of Hodgkins lymphoma
• Mainly involves cervical,axillary or
mediastinal
• “L&H” cells or Popcorn cells are
seen
• Positive for CD20,45
• Negative for CD15,30.EBV
16. Nodular Sclerosis
• Most common type diagnosed.
About 70%
• Lacunar ceells are seen
• CD 15 and 30 positive
• EBV negative
• Only subtype without a male
predominance
• Seen in younger pts with stage I –
II disease
17. Mixed Cellularity
• Constitutes about 20%
• More common in young children
• CD 15,30 EBV positive
• Presents in advanced stages
• Tendency to involve spleen,bone
marrow
19. Staging
I Involvement of a single lymph node
Or,lymphoid structure
Or single extralymphatic site
II Involvement of two or more lymphnode region on same side of diaphragm
Localized contiguous involvement of only one extranodal organ or site and
lymphnode regions on same side of diaphragm
III Involvement of lymphnode regions on both side of diaphragm
III1 With or without involvement of splenic,hilar.celiac or portal nodes
III2 With involvement of paraaortic ,iliac,and mesenteric nodes
IV Diffuse or disseminated involvement of one or more extranodal organs or
tissues,with or without involvement of associated lymphnodes.
25. Radiotherapy
• Radiation therapy is the most effective single therapeutic agent for
treating Hodgkins lymphoma.
• The main objective of radiation in Hodgkins lymphoma is to treat involved
and contiguous field.
• Radiotherapy can be given by
• 2D Planning
• 3D Planning
• IMRT
26. • 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
27. • Immobilization
Mask for head and neck
Body cast for pelvis
OTHERS
Oophoropexy in young females
Fields are shaped using multileaf collimators
Respiatory gating has to be taken care of
28. Mantle technique
• Target volume definition.
The target volume for mantle field includes the
Occipital
Submental
Submandibular
Ant and Post cervical
Infraclavicular
Axillary
Medial pectoral
Paratracheal
Mediastinal and hilar nodes
29. • Treatment Field:
Superiorly: Inferior portion of
mandible bisecting the mastoid
process
Laterally: Both the axillae
Inferiorly: T10-11 interspace
30. • 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.
31. Subdiaphragmatic Fields
• The classical subdiaphragmatic field is the Inverted-Y.
• Target Volume:
Para aortic
Pelvis
Inguinal nodes(b/l)
Spleen
32. • 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.
34. • BLOCKS:
Central midline block for
Bladder
Small bowel
Oophoropexy if performed
Testicular shielding
35.
36. IFRT
• Involved field radiotherapy.
• IFRT is the most commonly used technique at present
• Targets a smaller area rather than a classical extended field.
• IFRT(ASTRO 2002)DEFINITION
IFRT encompasses region and not an individual lymph node.
Initially involved Pre chemo sites and volume are treated
Exception to above rule is for transverse diameter of mediastinum and
paraaortic lymphnodes for which reduced post chemo volume is treated.
39. 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,reproducibility,org
an motion.usually 10 mm margin
is added to CTV
40. • 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
44. • Late Reactions(cont…)
Streptococcus pneumoniae and H influenzae infection following splenic
radiation.
Azoospermia in males
Premature menopause in females
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
45. Conclusion
• Radiation therapy is the most effective single therapeutic agent for
treating Hodgkins lymphoma
• The management of Hodgkins lymphoma has evolved from extended field
radiation to a combined modality of chemo radiation or chemo alone.
• Interest is in achieving the best therapeutic ratio by minimizing late
toxicity while maintaining effectiveness.
• With improvement in diagnostic modality and PET scanning and improved
treatment policy the results in future will be encouraging.