• Highly radiosensitive
first modality
solely cured patients

exposure to X-rays
only partial did not last long
extending
clinically uninvolved areas

both involved and
uninvolved sites
EF-RT
localized disease
limited stage
70-80%.

dose
significantly lower solid tumors
secondary
malignancies heart and lung diseases
main concern

Milestones in Hodgkin Lymphoma:
Discovery & Evolution of RT in Management of
Hodgkin Lymphoma

Same time, Chemotherapy was
being developed:
MOPP,ABVD 1st used in
advanced disease.
Later on found that early stage
disease also respond
In 1973,Kaplan
used LINAC to
treat large
fields.
80% 5-yr survival
1953, Co replaced
X-ray units &
higher doses were
prescribed
1950 Vera Peters
found
5yr survival 50% with
RT;
EFRT better than
local RT
1925, Gilbert treated
involved + uninvolved
L.N
Improved 5 yr survival
1920s High energy x-ray
were discovered -
reduced toxicity, large
field treated
Good response but
disease recurrance
and drastic side
effects
1902 Pusey
used X ray for
neck nodes
till 1920 Xray
were used to
treat small
nodes
EFRT became
standard until
late 1980s/early
1990s.
20-30 yrs with the experience of RT
Noted late side effects: cardiac death &
2nd cancers
Need for reduction in field size & dose
This led to series of clinical trials of combined modality therapy (CMT) at Stanford,
EORTC/GELA,GHLSG/NCIC/ECOG looking at different combinations of CT & RT &
reducing RT fields & doses

Treatment Recommendations:
Early HL
Stage Recommended Treatment
Favorable cHL
IA/IIA
(no bulky disease ,<3 sites, ESR<50)
Standard
ABVD ×2-4 then IFRT [20 Gy−30 Gy]
• ABVD x 4cycles+ IFRT 30 Gy: standard HD8
• ABVD x 2 cycles+ IFRT 20 Gy: de-intensified HD10
Other:
 Stanford V × 8weeks + IFRT 30Gy [phase 2/3]
Unfavorable IA/IIA cHL
(bulky disease, >3 sites, or ESR>50),
 IB/IIB
Standard
ABVD ×4–6 then IFRT (30–36 Gy)
Other
 Stanford V × 12 weeks + IFRT 36Gy [phase 3]
 BEACOPP×4 +IFRT 20Gy
 Esc BEACOPP×2 + ABVD×2+ 30 Gy IFRT
For Lymphocytic predominant (LP)
 Stage I–IIA:
 Other stages:
 IFRT 30-36 Gy.
 Treat similar to classic HL

Treatment Recommendations:Advanced
HL
Stage RecommendedTreatment
III,IV Standard
ABVD ×4 then restage with PET/CT.
If CR:ABVD×2 + IFRT 20–36 Gy to bulky sites/extranodal sites.
If PR:ABVD ×4 -6 then IFRT 30–36 Gy to bulky
sites/residual/extra nodal
Other:
12 week StanfordV + IFRT 36 Gy bulky/residual/extra nodal sites.
Dose escalated BEACOPP ×6 +IFRT 30 Gy bulky/residual/extra
nodal sites
Escalation(ABVD-BEACOPP) & de-escalation (BEACOPP-ABVD-
AVD) strategy by interim PET evaluation for better results and
minimize toxicity

40 Gy
dose response analyses dose response curve
flat after 30 Gy
• Recommended dose : 30-36Gy/20#
1.8-2Gy/day recommended
entire heart or lung 1.5Gy or less

36-44Gy
type & no of cycles
response

four main defining the treatment volume

Total nodal
radiotherapy
Extended
field
radiotherapy
Involved field
radiotherapy
Involved site
radiotherapy
All LN of
both sides of
diaphragm
Multiple involved &
uninvolved LN groups
of one side of
diaphragm
Field Limited to
site of clinically
involved LN
Most limited RT
field , includes
only involved LN.

conventional fields
lymph node anatomy
lymphangiography
infra- and supradiaphragmatic
disease

• Extended Field
• Principal objective involved and
contiguous lymphatic chains
• Basis
high risk for subsequent
involvement untreated.

supradiaphragmatic
nodes
paraaortic and pelvic
lymph nodes
Mantle field
Inverted “Y “field

Total nodal irradiation
Mantle field Inverted “Y “field

• Mantle field
cloak
standard invertedY field
combination
total lymphoid irradiation (TLI)
Total nodal irradiation

• Extended Mantle
• Minimantle
• Paraaortic / Splenic

• B/L cervical
• Supraclavicular
• infraclavicular,
• axillary
• hilar
• mediastinal.
Mantle field
Mantle field
without
mediastinal & hilar
LNs.
Mini Mantle
Mantle field
without axillary
LNs.
Modified Mantle
Inverted “Y “field
• Para aortic ,
• bilateral pelvic,
• B/L inguinal-femoral
• Splenic ±

Neck and Paraaortic nodes contiguous
thoracic duct bypass around mediastinum
9%

• Neck most common nodal involvement in HL
B/L neck left neck adenopathy 50%
right
12-13%
*López F, Rodrigo JP, Silver CE, Haigentz M Jr, Bishop JA, Strojan P, Hartl DM, Bradley PJ, Mendenhall WM, Suárez C, Takes RP, Hamoir M, Robbins KT, Shaha AR,
Werner JA, Rinaldo A, Ferlito A. Cervical lymph node metastases from remote primary tumor sites. Head Neck. 2016 Apr;38 Suppl 1(Suppl 1):E2374-85. doi:
10.1002/hed.24344. Epub 2015 Dec 29. PMID: 26713674; PMCID: PMC4991634.

• Target volume
• Organ at risk
• Supine
• Arm position
Mantle field

• axillary nodes move away lung shielding
Akimbo position
humeral heads

Superior border
Passes through
midmandible,
midtragus &
mastoid
Inferior border –
-ve mediastinum – lower border ofT8/T9
+ve mediastinum – lower border of
T10/T11(diaphragm)
Laterally –junction of
lat margin of
pectoralis with
deltoid muscle
Inferiorly – at 4th
costochondral jn or
at or above inferior
border of scapula

cerrobend block
Lung blocks
• Larynx 2-cm-wide block
thyroid notch to
cricoid
Heart block

• Humeral Heads
not be blocked if
there is evidence of axillary
• Posterior spinal cord block 1.5-cm
top of field to bottom
of C7
• Heart blocks
5 cm inferior to carina
on total dose
and proximity
Heart block

Lung block
• Superiorly - 1.5 to 2cm below clavicle to treat infraclavicular nodes
• Medially – 1.5-2cm margin around lateral border of tumor
• Laterally - at least 1 cm lung included in lower axilla & 2-4cm of lung in upper
axilla to treat axillary L.N

avoid necessity
mantle & paraaortic single
extended SSD
one half the time
probability of bone marrow
suppression simultaneous acute
morbidities

• Excludes mediastinum
Combined modality
Treatment

large fields
minimize inhomogeneity
large field size
patient separation
supine only

Advantages
Disadvantages

• Upper border
• Inferior border
• Lateral border
or

beyond aortic
bifurcation common
iliac nodes
lateral border oblique line
lateral tip of each transverse
processes of L5 1-2cm
lateral to widest

• Superior border
• Inferior border
inguinal lymph nodes
inclusion of
femoral component
• Laterally

paraaortic
pelvic inguinofemoral
infradiaphragmatic

standard RT treatment EF-RT
overall 10-year PFS 80%
late toxicity
complication and newer techniques
much less harmful IF-RT

last decade
commonly used

region not an individual lymph node
Initially involved
Exception transverse diameter of mediastinum P.A L.N
post chemo volume

anatomical node
region/group before chemotherapy

entire neck supraclavicular fossa neck node
entire mediastinum supraclavicular nodes mediastinal
involvement
para-aortic chain
Inguinal and ipsilateral iliac groin node

conventional orthogonal planning
bony landmarks
no
longer applicable in the current setting

changing
two-dimensional
three-dimensional volume CT planning
principles are the same
more accurately on an
individualised basis

any cervical level
supraclavicular (SCL) nodes
supine with thermoplastic mask
at sides

Inferior:2 cm below med end
of clavicle
Medial:
• SCN uninvolved ,
I/L transverse
process.
• SCN involved: C/L
transverse
process.
Lateral: up to med 2/3 rd of
clavicle
Blocks
• Larynx
• Post. Cervical cord
• Lung
Superior:1-2 cm above the tip of mastoid & mid
point through the chin

bulky
superior cervical lymph nodes

of zygomatic
arch
submandibular triangle
spinous processes
• Inferior border
palpable cervical disease

mediastinum and/or the hilar
medial SCN not
at sides
axillary nodes are involved

Superior:
C5-C6 interspace –
top of larynx if SCN involved,
bottom of larynx if SCN not
involved or
2 cm above pre chemo Ds
Inferior:5 cm below carina, or 2 cm
below pre-CT ds
Lateral: Post-
CT GTV + 1.5
cm margin
Mediastinum/Hilar L.N
Blocks
• Larynx
• Post. Cervical
cord
• Lung
• Heart

ipsilateral axillary infraclavicular
supraclavicular
axilla is involved
• Superior border
• Inferior border
• Medial border
• Lateral border

EORTC-GELA Lymphoma
Group
prechemotherapy diagnostic CT and PET-CT
imaging treatment position
postchemotherapy CT
simulation
fusion prechemotherapy and
postchemotherapy images

Pre chemotherapy PET, axillary and mediastinal disease
marked as GTV
Post chemotherapy CT Simulation, fused with pre
chemotherapy gross GTV

missing
pretreatment PET-CT not done
poor registration
without intravenous
contrast
impossible to treat INRT
fields

involved-site RT
eradicates
identifiable pre-chemotherapy
significantly smaller
all adjacent lymph nodes
uninvolved not purposely treated

clinical judgment
best available
imaging CTV
prechemotherapy GTV

• Prechemotherapy (or presurgery)GTV
before any intervention
lymphoma volume
• No chemotherapy or postchemotherapyGTV
residual
GTV

clinical target volume (CTV) :
original (before any intervention) GTV
clearly uninvolved
excluded

Clinical target volume (CTV) :
separate nodal volumes
same CTV
more than 5 cm apart
separate fields CTV-to-PTV expansion

internal target volume (ITV) :
target is moving
chest and upper abdomen
4D CT simulation
1.5 to 2 cm superior-
inferior

• Breath-hold techniques
irradiation of the mediastinum
treatment in inspiration
significant sparing of the lung and heart
recommended

• Breath-hold techniques

Planning target volume (PTV) :
CTV
setup uncertainties in patient positioning
and alignment of the beams
standard margins setup variations
immobilization device, body site, and patient cooperation

early and long-term
dose exact site

skin
(Dermatitis)

several areas briefly after
chemotherapy bone marrow function

survivors
TRM
secondary cancer
exposed to radiation

neck region half
hypothyroidism 20% thyroid
nodule.

Heart Disease
may occur
cardiac failure

Lung
frequent and serious

secondary malignancies
breast cancer in female lung cancer in male
10 to 13% 15 years of
observation increases every year

inversely related age
women RT around puberty
decreases for the older

• Radiation-induced tumors are defined by Cahan’s criteria*
* Singh GK, Yadav V, Singh P, Bhowmik KT. Radiation-Induced Malignancies Making Radiotherapy a "Two-Edged
Sword": A Review of Literature. World J Oncol. 2017 Feb;8(1):1-6. doi: 10.14740/wjon996w. Epub 2017 Feb 23.
PMID: 28983377; PMCID: PMC5624654.

Cahan’s criteria
• These criteria define a secondary neoplasm as follows:
1) The second tumor must occur within the original radiation field, but
must not have been present on imaging at the time of initial irradiation;
2) there must be a latency period - preferably longer than 4 years between
the radiation exposure and the development of the second tumor;
3) the second tumor must be histologically unique to the original tumor;
and
4) the patient cannot have a genetic syndrome that predisposes to cancer

not only radiosensitive
chemosensitive cancer
nitrogen
mustard dissolution tumor masses
• MOPP
ABVD

success of chemotherapy RT-induced
toxicities and malignancy hypothesis
avoid RT
• HD6 trial ABVD alone
IA or IIA
controversial not confirmed by other large clinical studies

data available
CMT and CT alone
RT along with ABVD regimen standard of care
early advanced stages
large residual mass

was the primary modality
Combined modality treatment
• Involved Field RT
INRT ISRT
based
on outdated RT treatment