Radiotherapy for Hodgkin Lymphoma (eBook)

In 2004, Dr. Specht received the annual Oncology Prize awarded by the Danish Society for Clinical Oncology.

Radiotherapy for Hodgkin Lymphoma 1
Preface 4
Contents 6
1: History of Radiotherapy of Hodgkin’s Disease (Now Hodgkin Lymphoma) 8
1.1 Introduction 8
1.2 Radiotherapy as a Curative Treatment Modality 10
1.3 Radiotherapy as Part of Combined Modality Treatment 11
References 12
2: Background and Rationale for Radiotherapy in Early-Stage Hodgkin Lymphoma 14
2.1 Introduction 14
2.2 Combined Modality Therapy for Early-Stage Hodgkin Lymphoma 15
2.2.1 Radiation Dose and Fractionation 16
2.2.2 Radiation Field Size 16
2.2.3 Association of Radiation Dose/Field Size and Late Toxicity 18
2.3 Can Radiation Therapy Be Safely Eliminated in Early-Stage Hodgkin Lymphoma? 19
2.3.1 Trials Comparing Combined Modality Therapy Versus Chemotherapy Alone 19
2.3.2 Trials of Early PET Scans for Selecting Patients for Omission of Radiotherapy 24
2.3.3 Patterns of Failure After Chemotherapy for Early-Stage Hodgkin Lymphoma 24
2.4 Conclusion 25
References 25
3: Background and Rationale for Radiotherapy in Advanced-Stage Hodgkin Lymphoma 28
3.1 Historical Context, Treatment of Advanced Disease with Radiation Therapy Alone 28
3.2 Summary of the Literature on Advanced-Stage Hodgkin Lymphoma 29
3.2.1 GELA 32
3.2.2 EORTC 32
3.2.3 GHSG 32
3.2.4 Stanford 33
3.3 Current Opinion 34
3.3.1 Treatment Recommendations Advanced-Stage Hodgkin Lymphoma 34
3.4 Future 34
References 35
4: Salvage Therapy for Relapsed and Refractory Hodgkin Lymphoma 37
4.1 Introduction 37
4.2 Salvage After Radiotherapy Alone 37
4.3 Salvage of Patients Who Relapse or Remain Refractory After Chemotherapy Alone or Combined-Modality Therapy 39
4.4 Salvage with Radiation Alone 39
4.5 Salvage of Systemic Chemotherapy Failures with Standard-Dose Chemotherapy Regimen 41
4.6 High-Dose Therapy (HDT) and Autologous Stem-Cell Transplantation 41
4.6.1 The Randomized Trials 41
4.6.2 Standard-Dose Salvage Prior to HDT/ASCT 42
4.6.3 High-Dose Therapy Regimens and Stem-Cell Source 42
4.6.4 Predictive Factors of HDT/ASCT Salvage Outcome 43
4.6.5 Incorporation of Radiotherapy into HDT/ASCT Programs 44
4.6.6 Salvage After ASCT Failure 46
4.7 Role of RT in Local Control and Palliation 46
4.8 Conclusion 47
References 47
5: Principles of Chemotherapy in Hodgkin Lymphoma 51
5.1 Introduction 51
5.2 Common Chemotherapy Regimens in Classical Hodgkin Lymphoma 52
5.2.1 MOPP Chemotherapy 52
5.2.1.1 Side-Effect Profile 52
5.2.1.2 Long-Term Side Effects of MOPP 52
5.2.2 ABVD 53
5.2.2.1 Side-Effect Profile 53
5.2.3 BEACOPP 54
5.2.3.1 Acute Side Effects 55
5.2.4 Stanford V 55
5.2.5 Rituximab 56
5.2.6 Bendamustine 56
5.2.7 SGN-35 56
5.3 Late Side Effects of Chemotherapy 57
5.3.1 Myelodysplasia and Acute Myeloid Leukemia 57
5.3.2 Non-Hodgkin Lymphoma 57
5.3.3 Solid Tumors 57
5.4 Follow-Up 57
References 58
6: Management of Lymphocyte Predominant Hodgkin Lymphoma 59
6.1 Introduction 59
6.2 Histopathology 60
6.3 Clinical Presentation 61
6.4 Diagnosis and Staging Work-Up 62
6.5 Treatment and Outcomes for Stage I/II Disease 62
6.5.1 Outcomes from Combined-Modality Treatment 63
6.5.2 Role of Chemotherapy in the Treatment of Stage I/II Disease 63
6.5.3 RT Technique 66
6.5.4 Treatment-Related Complications 67
6.5.5 Observation or Minimal Treatment After Surgical Resection 67
6.6 Treatment and Outcomes for Stage III/IV Disease 68
6.7 Role of Monoclonal Antibody Therapy for LPHL 69
6.8 Follow-Up After Treatment Completion 69
6.9 Treatment and Outcomes for Recurrent Disease 69
6.10 Conclusion 70
References 70
7: Pediatric Hodgkin Lymphoma, the Rationale for Radiation Therapy 73
7.1 Treatment of Pediatric Hodgkin Lymphoma 73
7.1.1 Radiation Therapy 74
7.1.2 Chemotherapy 74
7.1.3 Combined-Modality Treatment 74
7.2 Rationale for Radiotherapy 75
7.2.1 Favorable Risk Disease 75
7.2.2 Intermediate and Unfavorable Risk Disease 76
7.2.3 Omission of Radiotherapy 77
7.2.4 Response-Adapted Therapy 79
7.2.5 Modern Radiation Therapy 80
7.2.6 Involved Node Radiotherapy 80
7.2.7 RT Volumes for Advanced-Stage Disease 82
7.3 Future 82
References 82
8: The Role of Imaging in Radiotherapy for Hodgkin Lymphoma 86
8.1 Introduction 86
8.2 CT and PET/CT in the Selection of Patients for Radiotherapy 87
8.2.1 Pre-chemotherapy Selection at Staging 87
8.2.2 Post-Chemotherapy Evaluation 88
8.2.3 Early Treatment Monitoring and Risk-Adapted Treatment Selection 89
8.3 CT and PET/CT for Radiotherapy Planning in HL 89
8.3.1 Current Concepts and Guidelines 89
8.3.2 Clinical Data on CT and PET in HL Radiotherapy 90
8.4 Conclusion 92
References 92
9: Target Definitions for Hodgkin Lymphoma: The Involved Node Radiation Field Concept 95
9.1 Introduction 95
9.2 Imaging Procedure Guidelines for the Assessment of Initially Involved Lymph Nodes and the Design of Involved Node Radiati 96
9.3 Assessment and Delineation of Initially Involved Lymph Nodes 96
9.3.1 Introduction 96
9.3.2 Assessment of Initially Involved Lymph Nodes 98
9.3.2.1 Stepwise Assessment of Lymph Node Involvement 98
9.3.2.2 The Pre-Chemotherapy Assessment 99
9.3.2.3 Final Conclusion Based on the Analysis of Post-Chemotherapy CT Scans 101
9.3.2.4 Conclusions 103
9.4 Delineation of Involved Node Fields 104
9.4.1 General Guidelines 104
9.4.1.1 Pre-Chemotherapy Contouring 104
9.4.1.2 Post-Chemotherapy Contouring 105
9.4.2 Specific Guidelines 105
9.4.2.1 Introduction 105
9.4.2.2 Initially Involved Lymph Nodes in CR or CRu 106
9.4.2.3 Initially Involved Lymph Nodes in PR 111
9.5 Treatment and Dose Prescription 114
9.6 Quality Assurance Programs 115
9.7 Conclusions 125
References 126
10: Traditional and Modern Techniques for Radiation Treatment Planning 127
10.1 Introduction 127
10.2 Historical Aspects 128
10.3 Photon Energy 128
10.4 Prescription Dose 129
10.5 Extended-Field Radiation Treatment 130
10.5.1 Radiation Field Terminology 130
10.5.2 Mantle Field 131
10.5.2.1 Technical Considerations of the Mantle Field 133
10.5.3 Paraaortic/Inverted Y Field 135
10.5.3.1 Technical Considerations of the Paraaortic/Inverted Y Field 135
10.6 Involved-Field Radiation 137
10.6.1 Technical Considerations for Involved-Field Radiation 137
10.6.1.1 Cervical (Including Supraclavicular Lymph Nodes) Field 137
10.6.1.2 Axillary Field 138
10.6.1.3 Mediastinal Field 139
10.6.1.4 Paraaortic/Pelvic Lymph Nodes Field(s) 139
10.7 Involved-Node Radiation 140
10.8 Field Matching 140
10.8.1 Skin-Gap Technique 140
10.8.2 Half-Beam Technique 141
10.8.3 Matching-Divergence Technique 141
10.9 Blocking 142
10.10 CT-Based Treatment Planning 143
10.11 Conformal Radiation Planning and Delivery Techniques 145
10.12 PET/CT Radiation Treatment Planning 148
10.13 Respiratory Motion Management 150
10.14 Conclusion 152
References 152
11: Quality Assurance of Radiotherapy for Hodgkin Lymphoma 156
11.1 Introduction 156
11.2 Central Prospective Radiation Oncological Review of Cross-Sectional Imaging in Early-Stage Hodgkin Lymphoma 157
11.3 Retrospective Quality Control of the Involved-Field Radiotherapy 160
11.4 Conclusion 161
References 161
12: Evaluation of Response After Radiotherapy for Hodgkin Lymphoma 163
12.1 Introduction 163
12.2 Evaluation of Response Using Size Criteria 164
12.3 Evaluation of Response Using Anatomical and Functional Imaging Methods 164
12.4 FDG-PET in Response Evaluation of HL 166
12.5 Conclusion 167
References 167
13: Hodgkin Lymphoma in Special Populations and Rare Localizations 169
13.1 Introduction 169
13.2 Hodgkin Lymphoma in Special Patient Populations 169
13.2.1 Hodgkin Lymphoma in the Elderly 169
13.2.1.1 Presentation and Staging 170
13.2.1.2 Comorbidity 170
13.2.1.3 Treatment 170
13.2.1.4 Chemotherapy 170
13.2.1.5 Radiation Therapy 170
13.2.1.6 Choice of Treatment 171
13.2.1.7 Outcome 171
13.2.2 Hodgkin Lymphoma in Pregnancy 171
13.2.2.1 Presentation 171
13.2.2.2 General Consideration of Cytotoxic Agents and Radiation to the Foetus 172
13.2.2.3 Diagnosis 173
13.2.2.4 Chemotherapy 173
13.2.2.5 Radiotherapy 174
13.2.2.6 Treatment Outcome for Mother and Child 175
13.2.2.7 First Trimester Pregnancy 175
13.2.2.8 Second and Third Trimester Pregnancy 175
13.2.2.9 Supportive Treatment 175
13.2.2.10 The Choice of Treatment Strategy 176
13.2.3 Hodgkin Lymphoma in HIV 176
13.2.3.1 Biology/Pathogenesis 176
13.2.3.2 Presentation 177
13.2.3.3 Treatment 177
13.2.3.4 Outcome 178
13.3 Hodgkin Lymphoma in Rare Locations 178
13.3.1 Bone 179
13.3.1.1 Presentation 179
13.3.1.2 Primary Osseous Hodgkin’s Lymphoma 179
13.3.1.3 Treatment 179
13.3.1.4 Outcome 180
13.3.2 Central Nervous System 180
13.3.2.1 Presentation 180
13.3.2.2 Treatment 180
13.3.2.3 Outcome 180
13.3.3 Visceral 180
13.3.3.1 Presentation 181
13.3.3.2 Treatment 181
13.3.3.3 Outcome 181
References 181
14: Acute and Long-Term Complications of Radiotherapy for Hodgkin Lymphoma 185
14.1 Introduction 185
14.2 Acute and Subacute Effects 186
14.2.1 Temporary Local Alopecia and Skin Reaction 186
14.2.2 Oral Complications: Dysphagia and Xerostomia/Dental Caries 186
14.2.3 L’Hermitte’s Sign 186
14.2.4 Radiation Pneumonitis 186
14.2.5 Thyroid Abnormalities 187
14.2.6 Sterility 187
14.2.6.1 Reproductive Function After Chemotherapy 187
14.2.6.2 Reproductive Function After Radiation Therapy 188
14.3 Late Effects 188
14.3.1 Second Malignancies 188
14.3.1.1 Leukemia 189
14.3.1.2 Non-Hodgkin’s Lymphoma 190
14.3.1.3 Solid Tumors 190
14.3.1.4 Follow-Up Strategies for Second Malignancies 192
14.3.2 Cardiovascular Disease 192
14.3.2.1 Cardiovascular Disease After Mediastinal Irradiation 193
14.3.2.2 Cardiovascular Disease After Chemotherapy 193
14.3.2.3 Screening for Cardiovascular Disease 194
14.3.2.4 Modifying Effect of Traditional Cardiac Risk Factors 195
14.3.2.5 Cardiac Follow-Up Guidelines 195
14.3.3 Noncoronary Vascular Complications 195
References 196
15: Proton Therapy for Hodgkin Lymphoma 199
15.1 Introduction to Proton Therapy 199
15.2 Rationale for Proton Therapy in Hodgkin Lymphoma 201
15.3 Dosimetry for Supradiaphragmatic Hodgkin Lymphoma 202
15.4 Dosimetry for Infradiaphragmatic Hodgkin Lymphoma 204
15.5 Dosimetry for Total Nodal Irradiation 204
15.6 Conclusion 205
References 205
16: Future Prospects for Radiotherapy for Hodgkin Lymphoma 206
16.1 Introduction 206
16.2 Staging 206
16.3 Radiotherapy as Single Modality: Lymphocyte Predominant HL 207
16.4 Radiotherapy in the Combined Modality Setting 207
16.4.1 Radiotherapy in the Primary Treatment 208
16.4.1.1 Target Volume 208
16.4.1.2 Dose 208
16.4.2 Radiotherapy in Salvage Treatment 209
16.5 FDG-PET Response and the Need for Radiotherapy 209
16.6 Conclusion 210
References 210
Index 212