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Treatment Planning

Treatment Planning. Hodgkin Lymphoma. LN groups above diaphragm : Cervical Supraclavicular Infraclavicular Axillary Mediastinal Hilar. LN groups below diaphragm: Para-aortic Iliac Inguinal Femoral. Hodgkin Lymphoma. ► Incidence: 1% of new cancer cases

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Treatment Planning

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  1. Treatment Planning Hodgkin Lymphoma

  2. LN groups above diaphragm: • Cervical • Supraclavicular • Infraclavicular • Axillary • Mediastinal • Hilar • LN groups below diaphragm: • Para-aortic • Iliac • Inguinal • Femoral

  3. Hodgkin Lymphoma • ►Incidence: • 1% of new cancer cases • Bimodal age incidence: 1st in 20s & 2nd after 50 years • 85% of children are boys • ►Risk Factors:unclear • Viral infection: • EBV • HIV

  4. Hodgkin Lymphoma Pathology • ►Histology: • Reed -Sternberg cells • ►The Rye classification: • According to clinical behavior and prognosis • Lymphocyte predominant • Nodular sclerosis • Mixed cellularity • Lymphocyte depletion

  5. Hodgkin Lymphoma Mode of Spread • Site of origin:nodal • Spread: contiguous • Nodal distribution: axial • Hematogenous dissemination: late • CNS: rare (< 1%) • Liver or bone marrow: uncommon

  6. Hodgkin Lymphoma Diagnosis • ►Symptoms & Signs: • Painless lymphadenopathy: cervical in > 70% • Systemic symptoms: Fever, night sweats and weight loss • ►Biopsy : • FNA cytology or excision • Bone marrow ? • ►Imaging: • Chest radiographs • CT scans: neck, chest , abdomen and pelvis • Bipedal lymphangiography: aortic and iliac nodes ? • Bone scan: ? • PET scan: ? ►Laboratory tests: CBC, chemistries, ESR

  7. Bipedal lymphangiography

  8. Hodgkin Lymphoma Staging Classification

  9. Hodgkin Lymphoma Treatment ►Curable disease • ►Surgery: • Limited to diagnosis • Laparotomy ? • ►Radiotherapy: • Early stage without risk factors (non-bulky stage IA or IIA) • ► Chemotherapy: • A dvanced stage III or stage IV • Early stage withrisk factor (symptoms or bulky ) ► Combined modality: chemotherapy + radiotherapy ?

  10. Hodgkin Lymphoma Radiotherapy Techniques-1 ►Target Volumes: depends on the stage of the disease • LN groups above diaphragm (Mantle field) • LN groups below diaphragm+ spleen (Inverted Y field) • Total Nodal Irradiation (Mantle field + Inverted Y field) • LN groups of known disease only (Involved field) • Only curative in combination with chemotherapy ►Patient positioning & immobilization: • Supine • The arms raised above the head • The chin extended

  11. Hodgkin Lymphoma Radiotherapy Techniques-2 ►Methods: • External Beam: megavoltage radiation, photons, 4-6 MV ►Fields arrangement: Problem of Matching Fields? • Opposed anterior and posterior fields ?? ►Dose /Time / Fractionation: • 35-40 Gy without chemotherapy, conventional schedule • 20-25 Gy with chemotherapy ►Beam Modifications: • Shields (5 HVL) over: lung, humeral head, larynx • Gap between: • Inferior border of mantle • Superior border of periaortic fields

  12. Mantle Field • Inverted Y field • Subtotal nodal Irradiation • Total Nodal Irradiation

  13. Hodgkin Lymphoma Morbidity Directly related to the area treated Mantle fields Inverted Y fields Inverted Y fields • ►Acute: • Occipital epilation • Dysphagia • Myeolsuppression • Xerostomia • ►Acute: • Nausea • vomiting • Diarrhea • Myeolsuppression • ►Late: • Hypothyroidism • Pneumonitis • Pericarditis • ►Late: • Infertility

  14. Thank You

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