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HODGKINS LYMPHOMA

Dr Sandip Barik
Department of
Radiotherapy,KGMU,Lucknow

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 Hodgkins lymphoma called Reed
Stenberg cells.
Hodgkins lymphoma was the first cancer which could be
successfully treated by radiation therapy and also by
combination chemotherapy.

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)

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

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.

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 CoughDyspnoea
Infradiaphragmatic
involvement is seen in 5%
cases and usually seen with
older patients.

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)

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

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

Routine blood investigations

Complete blood count


Liver function
Renal function
Serum albumin
ESR
Lactate Dehydrogenase

OTHERS
Bone marrow biopsy

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%

Revised International Workshop Criteria With


PET Scan

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

Pathological Classification
Histologic

Subtypes

Nodular lymphocyte predominant Hodgkins


lymphoma
(NLPHL)
Classical Hodgkins lymphoma(CHL)
1

Nodular sclerosis Hodgkins lymphoma

Lymphocyte rich classical Hodgkins lymphoma

Mixed cellularity Hodgkins lymphoma

Lymphocyte depletion Hodgkin lymphoma

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

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

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

Lymphocyte Depleted

Constitutes <5%

Worst prognosis of all


subtypes

Older males

Advanced stage

HIV infection

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.

Lymphnodes group

Prognostic Factors
Prognostic factor for Early stage Hodgkins disease

Prognostic factors cont


Advanced stage hodgkins lymphoma
International prognostic score

Management
CHEMOTHERAPY

Chemotherapy
25mg/m2
10
6
375

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

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

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

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

Treatment Field:

Superiorly: Inferior portion


of mandible bisecting the
mastoid process
Laterally: Both the axillae
Inferiorly: T10-11
interspace

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.

Subdiaphragmatic Fields

The classical subdiaphragmatic field is the Inverted-Y.

Target Volume:

Para aortic
Pelvis
Inguinal nodes(b/l)
Spleen

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.

Inverted Y Field
Para aortic fields

pelvic field

BLOCKS:

Central midline block for


Bladder
Small bowel
Oophoropexy if performed
Testicular shielding

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.

Major fields of IFRT

IFRT

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,reproducibili
ty,organ motion.usually 10
mm margin is added to CTV

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

Sequelae of Treatment
ACUTE REACTIONS:
Fatigue ,nausea,vomiting,dry cough
Occipital hair loss
Sore throat
Skin reactions
Alteration of taste
Dysphagia
Reflux symptoms
Myelosupression

LATE REACTIONS
Radiation Pneumonitis(6-12 wks)
Radiation Pericarditis
Subclinical Hypothyroidism:most common delayed
symotoms
Herpes Zoster infections:
Lhermittes sign(1-2 mths)

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

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.

THANK YOU