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Treatments > Radiotherapy
Last update: 07/27/2009 |
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Topics
Introduction
| Common Side Effects | Background and Glossary : Types
| Dosing | Effective NHL Treatment Info
Radiation Risks
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Treating Localized Disease | Low and
Fractionated Dosing | Resources & Research News
Radioimmunotherapy - Bexxar/Zevalin
TOPIC SEARCH: Review
| Therapies
| Prognosis
with Rituxan Review
| Therapies
Central lymphatic irradiation in follicular lymphomas PubMed
Treatment of
localized (stage I/ II) Lymphoma Survival
Clinical Trials using radiotherapy ClinicalTrials.gov
 Radiotherapy (radiation treatment)
uses high-energy x-rays to kill tumors. Since radiotherapy
affects the areas radiated, it can be effective as a management
intervention -- when there is a need to shrink a problem lymph node,
for example. Radiotherapy is sometimes combined or sequenced with
chemotherapy.
"The goal of
treatment may be curative or palliative [management]. If radiotherapy
is potentially curative, the length of treatment is often longer and
usually consists of smaller daily doses over a longer period of time.
This approach minimizes late side effects. If treatment is intended to
be strictly palliative, shorter treatment schedules consisting of
larger daily treatment doses over a shorter time period are used. In
such cases, late side effects are not likely to occur within the
patient's lifetime. Furthermore, a shorter treatment program will
negatively affect less of the patient's remaining life."
aafp.org Importantly,
radiotherapy can be curative [1] when the patient's lymphoma is diagnosed early
in it's clinical course (stage I and II) and the disease is still
localized.
Radiation Fields
Click to enlarge
Common Side Effects of
radiotherapy
"Radiation Therapy is in itself painless. Many low-dose palliative
treatments (for example, radiotherapy to bony metastases)
cause minimal or no side effects." wikipedia.org
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Skin changes may include dryness, itching,
peeling, or blistering
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Nausea, diarrhea, urinary problems - for
radiation therapy to the pelvis, stomach, and abdomen **
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Dryness (salivary and tear glands have a radiation tolerance of about 30 Gy in 2 Gy fractions)
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Hair loss in radiated area
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Fibrosis - decrease in elasticity to radiated
tissue
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Tiredness (anemia)
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Low blood counts (if location radiated affect the
bone marrow)
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Swelling (edema or Oedema)
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Infertility (if radiated areas includes gonads (ovaries and testicles),
which are very sensitive to radiation
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Secondary Cancer (delayed)
Note: secondary malignancies are seen in a very small minority of patients, generally many years after
they have received a course of radiation treatment. In the vast majority of cases, this risk is greatly
outweighed by the reduction in risk conferred by treating the primary cancer. *
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* Source: wikipedia.org
** Source: cancer.gov
Managing Common Side Effects
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| Radiation side effects and how to manage them cancer.gov
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More Resources on Side Effects
Recommended background resources
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New: NCI Guidance:
Radiotherapy and You Cancer.gov
| PDF
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New: NCI Radiation
Therapy Fact Sheet Series Cancer.gov
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When to Consider Radiation Therapy for Your
Patient aafp.org
Bernard A. Tisdale, M.D. ~ Chippenham Medical Center and
Johnston-Willis
Hospitals, Inc.
Richmond, Virginia
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Radiation Oncology/NHL/Treatment high grade
wikibooks.org
From Wikibooks, the open-content textbooks collection
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Resources - Basic Information
| Basic information
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Radiotherapy dosing and methods for spot
(localized) treatment of lymphoma
TOPIC
SEARCH: ASH
| ASCO
| Medscape
| PubMed
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A systematic overview of radiation therapy
effects in non-Hodgkin's lymphoma.
Acta Oncol. 2003;42(5-6):605-19. Review PMID:
14596518
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A systematic overview of radiation therapy
effects in Hodgkin's lymphoma.
Acta Oncol. 2003;42(5-6):589-604. Review PMID:
14596517
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Booklet: Radiotherapy - Your Questions answered
royalmarsden.org.uk
PDF
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Localized
Mucosa-Associated Lymphoid Tissue Lymphoma Treated With Radiation
Therapy Has Excellent Clinical Outcome. J Clin Oncol. 2003 Nov
15;21(22):4157-4164 PMID:
14615444 | full
text
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Radioimmunotherapy (Bexxar/Zevalin) of Non-Hodgkin's Lymphoma,
Bloodline
Review PDF
| PDF-Help
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Also see Radioimmunotherapy PAL
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Find answers to the questions patients ask
most often MDACC
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Radiation retinopathy Related
PubMed articles
A vision-threatening complication resulting from the
therapeutic irradiation of ocular, orbital, periorbital,
facial, nasopharyngeal, and cranial structures. NOTE:
fractionated dosing may reduce risk of this complication.
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| Radioprotective strategies? PAL
Important:
discuss with your doctor as items contained Radioprotective
strategies relate
mainly to protection from CT or other sources of exposures, and
not necessarily to treatment.
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Low and fractionated
dose radiotherapy
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Low and fractionated doses of radiotherapy in
treatment of lymphoma
TOPIC
SEARCH: ASH
| ASCO
| Medscape
| PubMed
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Potential role for low dose limited-field
radiation therapy (2 x 2 grays) in advanced low-grade
non-Hodgkin's lymphomas. Hematol
Oncol. 1994 Jan-Feb;12(1):1-8 PMID:
8194839
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Place of low-dose total body irradiation in the treatment of
localized follicular non-Hodgkin's lymphoma: results of a pilot
study. Int J Radiat Oncol Biol Phys. 1998 Jan
15;40(2):387-90 PMID:
9457825
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Rituximab followed by localized Radiation Therapy in limited stage indolent non-Hodgkin's lymphoma: preliminary results of a pilot study
ASCO
2005
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GLOSSARY
Fractionated
- when the total dose of radiation is divided into smaller doses to
give normal healthy cells time to heal.
Gray (Gy)
Is the unit used to describe the dose of radiation given.
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Radiation Biology By: Scott Williams, MD auntminnie.com
Comprehensive review of risks ... "it is reasonable to
assume that certain factors can modify the ultimate effects of
radiation [3]. Factors such as age at time of exposure and the
manner in which the radiation was received can affect the risk
relationship." |
Types of
Radiotherapy
Central
Lymphatic Irradiation (CLI)
treatment includes major lymphoid regions from Waldeyer's ring to the
femoral triangles.
Comprehensive
lymphatic irradiation - treating clinically involved
and uninvolved areas with radiotherapy, usually at different doses.
Conformal
avoidance radiotherapy for Hodgkin's disease and
non-Hodgkin's lymphoma: A new mantle - a high-precision radiotherapy
paradigm, which allows key structures to be spared from high-dose
irradiation. ASCO
2003
Intensity
Modulated Radiation Therapy (IMRT)
"a highly sophisticated new technology of radiotherapy. IMRT
enables the radiation oncologist to improve radiation targeting of
tumors regardless of their size or shape. This improved targeting
technique allows the radiation to attack the cancer without damaging
nearby healthy tissue and organs."
unmc.edu
| Details
on Intensity
Modulated Radiation Therapy (IMRT), about unmc.edu
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Involved-Field (IF)
radiotherapy - treating only the known areas of disease
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Extended-Field (EF) radiotherapy
treat the known areas of disease involvement and surrounding
areas.
Proton/Photon
type? Comparative risk assessment of secondary cancer incidence after
treatment of Hodgkin's disease with photon and proton radiation.
Radiat Res. 2000 Oct;154(4):382-8
PMID:
11023601
Radioimmunotherapy - Bexxar/Zevalin
- Treatment with a radioactive substance that is linked to an antibody that will attach to
a receptor (cd20) found on normal and malignant b-cells.
TomoTherapy
combines two different technologies, a CT scan and precisely directed
radiation. The CT scan creates a three- dimensional computer model of
the patient's internal anatomy. The scan allows doctors to determine
the daily changes to a patient's body that could influence the target
area."
City of Hope performs world's first total marrow irradiation procedure
pasadenastarnews.com
Total body irradiation (TBI)
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radiation is given in a way to cover the whole body. It is generally
used at as part of the conditioning regimen prior to allogeneic bone
marrow transplantation lymphomas
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Enhancing Radiotherapy
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Combined-Modality Treatment of Solid Tumors Using
Radiotherapy and Molecular Targeted Agents
http://jco.ascopubs.org/cgi/content/full/21/14/2760
The aim of combining different treatment modalities
is to reduce radioresistance and, therefore, improve the
therapeutic index. This is an important concept and the
fundamental objective of all cancer therapeutics. The
therapeutic index of RT can be improved by enhancing tumor
cell killing, minimizing normal tissue toxicity, avoiding
the addition of treatments with overlapping toxicity, and
exploiting agents with systemic antitumor activity that may
control disease outside the radiation field.7
Molecular targeted agents can potentially enhance tumor
response to RT through modification of these factors.
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Radiotherapy Dosing Limits (estimated)
Various tumors and viscera have different
dose limits described below
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Tumor
control dose (Gy = Gray)
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Normal
tissue tolerance
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Leukemic
cell
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6 Gy
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Brain
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50
Gy
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Histiocytosis
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12 Gy
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Spinal
cord
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45
Gy
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Wilms’
tumor
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20 Gy
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Eye
lens
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6
Gy
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Microscopic
disease
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50 Gy
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Eye
retina
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50
Gy
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Seminoma
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25 Gy
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Lungs
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22.5
Gy
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Lymphoma
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36 Gy
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Liver
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35
Gy
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Carcinoma
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60-70 Gy
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Stomach
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45
Gy
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Sarcoma
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70 Gy
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Kidney
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22.5
Gy
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Glioma
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55-60 Gy
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Uterus
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250
Gy
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Pituitary
tumor
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46 Gy
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Rectum
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50
Gy
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Ewings
sarcoma
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55 Gy
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Bladder
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60
Gy
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- Effective (Curative?)
Radiotherapy Treatments for Lymphoma
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With all the attention given to targeted therapies and combination
chemotherapyIt appears that early treatment with radiation can result in long term remissions
and possible cures.
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Personal story:
"This is the treatment I received at MDACC (MD Anderson Cancer Center), I've always been puzzled as to why it
isn't more widely used as my oncologists seem very enthusiastic about the results. Here's
some more references." - ML
ML is an NHL-info member who receive salvage central
lymphatic irradiation in follicular lymphomas following failure of chemotherapy: a
feasibility study.
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Long-term results with radiotherapy for Stage I-II follicular lymphomas.
Int J Radiat Oncol Biol Phys. 2001 Dec 1;51(5):1219-27. PMID: 11728680 PubMed
CONCLUSIONS: RT can cure approximately one half of Stage I and one quarter
of Stage II, World Health Organization Grade 1 or 2 follicular lymphomas.
Follicular lymphomas <3.0 cm can be controlled locally with doses of
27.8-30.8 Gy, and there is a trend toward a higher incidence of late
complications with doses of >30.8 Gy. Doses of 25-30 Gy delivered in 15-20
fractions should be examined prospectively in patients with follicular lymphomas
of <3.0 cm.
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CONCLUSIONS: These results demonstrate for the first time that with CLI, it is
possible to achieve complete remission of acceptable quality in follicular lymphoma
patients who experience a chemotherapy failure. The main toxicity is limited to transient
depression in hematological profiles. The treatment is fairly well tolerated and seems to
carry little risk compared with high-dose chemotherapy and bone marrow rescue. Salvage CLI
may not necessarily compromise future treatment with chemotherapy, including autologous
bone marrow or stem cell transplantation, because the patients' blood counts recover.
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Central
lymphatic irradiation for stage III nodular malignant lymphoma: long-term results.
CONCLUSION: These results suggest that initial comprehensive central lymphatic irradiation
may be the preferred approach to achieve a durable relapse-free interval for this group of
patients
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Is comprehensive lymphatic irradiation for low-grade non-Hodgkin's lymphoma
curative therapy? Long-term experience at a single institution.
Int J Radiat Oncol Biol Phys. 1997 Apr 1;38(1):3-8.
PMID: 9211997 PubMed
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Primary Radiotherapy May Benefit Stage III Follicular Lymphoma Patients
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Long-term follow-up of patients with Stage III follicular lymphoma treated
with primary radiotherapy at Stanford University. Int J Radiat Oncol Biol Phys.
2001 Jan 1;49(1):3-15. Erratum in: Int J Radiat Oncol Biol Phys 2001 May
1;50(1):285.
PMID:
11163492
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Long-term outcome after radiotherapy alone for
lymphocyte-predominant Hodgkin lymphoma. Cancer. 2005 Aug 10; PMID:
16094666
WESTPORT, CT (Reuters Health) Jan 25 - Patients with stage III follicular lymphoma,
especially those with "limited disease," respond well to primary radiotherapy,
according to the results of a study of patients treated at Stanford University. These
findings call into question whether this stage of disease is incurable, as is commonly
accepted, the investigators suggest.
Dr. Albert D. Murtha of the Cross Cancer Institute in Edmonton, Alberta, Canada and
associates analyzed prognostic variables for 61 patients treated with total lymphoid
irradiation and five treated with whole body irradiation between 1963 and 1982. Their
results appear in the January issue of the International Journal of Radiation Oncology
Biology and Physics.
The authors note that in the first 10 years following treatment, 22 individuals died from
progressive disease or treatment-related causes. Between years 10 and 16, patients
appeared to be at no more risk of dying than individuals in the general population. After
that, the mortality rate increased, which the authors attribute to late effects of
treatment.
Median overall survival and cause-specific survival were 9.5 years and 18.9 years,
respectively. After 10 years, only 5 of the 29 remaining patients died from lymphoma; and
after 20 years, only 1 of the 11 remaining patients died from lymphoma.
There was no apparent benefit to adjuvant chemotherapy, which was administered to 13
patients, nor was there a difference between groups who received total lymphoid and whole
body irradiation.
Of the eight patients with limited disease - defined as having fewer than five sites of
disease, all tumor masses less than 10 cm in maximal diameter, and no "B"
symptoms - none has died of lymphoma, and only one experienced relapse.
Dr. Murtha and his associates conclude that "no other approach [for stage III
follicular lymphoma] has consistently demonstrated results better than those reported for
primary radiotherapy alone." Int J Radiation Oncol Biol Phys 2001;49:3-15.
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Treating Localized Disease
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Treating
Localized Disease
"Localized" means when the lymphoma cells
are limited to one (stage I) or two (stage II) areas in the same part
of the body. See Stage
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TOPIC SEARCH:
ASCO
| Jco.org
| Medscape
| Web
| ClinicalTrials.gov
Survival - Treatment of localized ( stage I/ II) Lymphoma: PubMed
Radiotherapy can be curative [1] when the patient's lymphoma is diagnosed early
in it's clinical course (stage I and II) and the disease is still
localized.
Lay perspective: a bone marrow
biopsy and a PET scan could be
helpful to confirm that the lymphoma is truly
localized.
Note: Lymphoma in the bone marrow does not have the same connotation as for other cancers, as lymphocytes originate in this organ (the nursery for blood cells), and lymphoma cells in the marrow are expected and also reversible with systemic therapies.
Treating follicular lymphoma abstracts
| Long-term outcome and mortality trends in early-stage, Grade
1-2 follicular lymphoma treated with radiation therapy. Int
J Radiat Oncol Biol Phys. 2006 Mar 1;64(3):928-34. Epub
2005 Oct 21. PMID:
16243446
RESULTS: Median follow-up was 12 years. Median survival time
was 19 years. The 5-, 10-, and 15-year overall survival (OS) rates
were 93%, 75%, and 62%, respectively. Age > or = 60 was the
only significant adverse prognostic factor with respect to OS.
There were 35 deaths, 20 of which were attributable to lymphoma.
Freedom from treatment failure (FFTF) rates at 5, 10, and 15 years
were 72%, 46%, and 39%, respectively. Forty-seven patients (48%)
relapsed. Tumor size > 3 cm was the only significant adverse
factor for FFTF. Observed incidence of second malignancy did not
significantly exceed expected incidence.
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Stage I and II follicular non-Hodgkin's
lymphoma: long-term follow-up of no initial therapy. J Clin Oncol.
2004 Apr 15;22(8):1454-9. Epub 2004 Mar 15.
PMID:
15024027
In selected stage I and II follicular NHL patients, deferred therapy is an
acceptable approach, as more than half of our patients remained untreated at a
median of 6 or more years, and survival was comparable to that seen in reports
with immediate treatment.
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Long-term results with radiotherapy for Stage I-II follicular lymphomas.
Int J Radiat Oncol Biol Phys. 2001 Dec 1;51(5):1219-27. PMID: 11728680 - PubMed
CONCLUSIONS: RT can cure approximately one half of Stage I and one quarter
of Stage II, World Health Organization Grade 1 or 2 follicular lymphomas.
Follicular lymphomas <3.0 cm can be controlled locally with doses of
27.8-30.8 Gy, and there is a trend toward a higher incidence of late
complications with doses of >30.8 Gy. Doses of 25-30 Gy delivered in 15-20
fractions should be examined prospectively in patients with follicular lymphomas
of <3.0 cm.
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Is radiotherapy curative for stage I and II low-grade
follicular lymphoma? Results of a long-term follow-up study of
patients treated at Stanford University - www.jco.org
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Combined therapy in advanced stages (III and IV) of follicular lymphoma increases the possibility of cure: results of a large controlled clinical trial. [in patients with nodal bulky disease] - Eur J Haematol 2002: 68: 144-149 -
PDF | PDFHelp
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Combined therapy in advanced stages (III and IV) of
follicular lymphoma increases the possibility of cure: results of a
large controlled clinical trial.
Eur J Haematol. 2002 Mar;68(3):144-9. PMID: 12068794 PubMed
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Long term assessment of patterns of treatment failure
and survival in patients with stage I or II follicular
lymphoma.
Cancer. 1995 May 1;75(9):2361-7.
PMID: 7712449 PubMed
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MALT
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Role of radiation therapy in the treatment of stage I/II mucosa-associated
lymphoid tissue lymphoma (MALT) annonc.oxfordjournals.org
The prognosis following treatment of stage I/II MALT lymphoma is excellent.
Radiotherapy improves PFS and FFTF and has an important role in the curative treatment of patients with localized disease.
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Long-term follow-up results of no initial therapy
for ocular adnexal MALT
lymphoma http://annonc.oxfordjournals.org/cgi/reprint/17/1/135.pdf
In selected patients with ocular adnexal MALT lymphoma, no
initial therapy might be an acceptable approach, because 70% of
patients remained untreated at a median of 8.6 years, and their
survival was comparable to that of reports on immediate therapy.
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Indolent NHL
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High response rates and lasting remissions after
low-dose involved field radiotherapy in indolent
lymphomas. J Clin
Oncol. 2003 Jul 1;21(13):2474-80.
PMID: 12829665 PubMed
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Rituximab followed by localized Radiation Therapy in limited
stage indolent non-Hodgkin's lymphoma:
preliminary results of a pilot study ASCO
2005
Administration of 4 doses of Rb followed by L-RT appears to be
a safe, tolerable and active combined modality regimen for
patients with grade 1-2 FCL or low-grade MALT NHL presenting with
limited stage disease. Among them, the use of Rb along with RT
might result in prolonged event-free survival reducing
outside-field relapse rate without the need of CT administration.
Furthermore, the addition of Rb might allow to reduce RT doses and
treatment volumes, minimizing RT toxicity.
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Aggressive NHL
| Adjuvant radiotherapy [to sites of bulky
disease] in stage IV diffuse large cell lymphoma improve outcome.
Leuk Lymphoma. 2004 Jul;45(7):1385-9. PMID:
15359637 | Related
articles
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General
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Staging and management of localized non-Hodgkin's
lymphomas: variations among experts in radiation oncology. Int
J Radiat Oncol Biol Phys. 2002 Mar 1;52(3):643-51 abstract
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