An Introduction to the nature and management of Lymphoma

1. An Introduction to the nature and management of Lymphoma Radiotherapy in the management of lymphoma Richard Cowan Consultant in Clinical Oncology 13th October 2010

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5. Radiotherapy in the management of lymphoma Background to radiotherapy Place of radiotherapy in lymphoma Practical details of radiotherapy Future developments

6. Wilhelm Conrad Röntgen 1845 - 1923

7. Discovered X rays 1865 1875 1885 1895 1905 Q

8. Discovered X rays 1865 1875 1885 1895 ✓ 1905 Q

9. 1898

10. Q Marie Curie was born in : • Russia • Bulgaria • Poland • France • Bolivia

11. Q Marie Curie was born in : • Russia • Bulgaria • Poland ✓ • France • Bolivia

12. Electromagnetic spectrum wavelength Energy

15. Until 1960s Radiotherapy was the only non surgical treatment for lymphoma

16. How effective is Radiotherapy ? Resistant:

17. How effective is Radiotherapy ? Resistant: Malignant melanoma

18. How effective is Radiotherapy ? Resistant: Sarcomas / melanoma Intermediate:

19. How effective is Radiotherapy ? Which of these tumours is NOT Intermediate in terms of radiosensitivity: Q • Breast, • Testicular seminoma • Non small cell lung cancer • prostate cancer • head and neck cancer

20. How effective is Radiotherapy ? Which of these tumours is NOT Intermediate in terms of radiosensitivity: Q • Breast, • Testicular seminoma ✓ • Non small cell lung cancer • prostate cancer • head and neck cancer

21. How effective is Radiotherapy ? Resistant: Sarcomas / melanoma Intermediate: Breast, lung, prostate, head and neck cancer

22. How effective is Radiotherapy ? Resistant: Sarcomas / melanoma Intermediate: Breast, lung, prostate, head and neck cancer Sensitive: Germ cell tumours Lymphomas

23. How does Radiotherapy work? Ionising radiation damages cells DNA • The most sensitive cellular component is DNA

24. Radiotherapy – Biological Aspects DNA damage manifests at cell division “Early cell kill” v. “late cell kill” Related to proliferative activity

25. Radiotherapy – Biological Aspects Early: - usually the cancer Skin, GI tract, Bone marrow Late: Kidney, CNS

26. If the Kidneys receive a toxic dose of radiotherapy how long after radiotherapy will the patient show maximum renal impairment? 10 days 4 weeks 3 months 12 months 24 months Q

27. If the Kidneys receive a toxic dose of radiotherapy how long after radiotherapy will the patient show maximum renal impairment? 10 days 4 weeks 3 months 12 months ✓ 24 months Q

28. How does Radiotherapy work? The most sensitive cellular component is DNA DNA damage can be repaired DNA • The malignant cell have impaired DNA repair mechanisms

29. Radiotherapy – Biological Selectivity Normal tissue Cell No. cancer

30. Place of radiotherapy in lymphoma Radiotherapy alone for cure Radiotherapy in combination for cure Palliation

31. Radiotherapy alone for cure 73 yr old woman who presents with a painless lump in the groin

32. Radiotherapy alone for cure 73 yr old woman who presents with a painless lump in the groin Biopsy : Follicular lymphoma

33. Radiotherapy alone for cure 73 yr old woman who presents with a painless lump in the groin Biopsy : Follicular lymphoma stage IA

34. Radiotherapy alone for cure 73 yr old woman who presents with a painless lump in the groin Biopsy : Follicular lymphoma stage IA FORT Study : 24Gy in 12 # compared with 4Gy in 2#

35. How effective is Radiotherapy ? Intermediate: prostate cancer 70Gy Sensitive : follicular lymphoma 24Gy (4Gy)

36. Radiotherapy alone for cure 73 yr old woman who presents with a painless lump in the groin Biopsy : Follicular lymphoma stage IA 24 Gy Radiotherapy Q • 25% - 35% • 40% - 50% • 55% - 65% • 65% - 75% • 85% - 95% 3 months later the chance of complete remission

37. Radiotherapy alone for cure 73 yr old woman who presents with a painless lump in the groin Biopsy : Follicular lymphoma stage IA 24 Gy Radiotherapy Q • 25% - 35% • 40% - 50% • 55% - 65% • 65% - 75% • 85% - 95%✓ 3 months later the chance of complete remission

38. Radiotherapy alone for cure 33 year old woman

39. Radiotherapy alone for cure 33 year old woman Biopsy : Hodgkins lymphoma Stage I A (nodular lymphocyte predominant)

40. Radiotherapy alone for cure 33 year old woman Biopsy : Hodgkins lymphoma Stage I A (nodular lymphocyte predominant) 30Gy in 15# (3 weeks)

41. How effective is Radiotherapy ? Intermediate: prostate cancer 70Gy Sensitive : follicular lymphoma 24Gy (4Gy) Hodgkins lymphoma 30Gy

42. Radiotherapy in combination 32 year old man With a cough and weight loss Hodgkins stage III B

43. Radiotherapy in combination 32 year old man With a cough and weight loss Hodgkins stage III B After 6 cycles of ABVD

44. Following 6 cycles of ABVD

45. Following 6 cycles of ABVD

46. The practicalities of radiotherapy

47. Dose and duration of treatment “Low Dose “ (30 Gy rather than 70Gy) Curative : 15 treatments of 2 Gy = 3 weeks Shorter treatments : Palliative Radiotherapy

48. Dose and duration of treatment summary Curative : Hodgkins 30Gy in 3 weeks (15#) DLBC 30 Gy in 3 weeks Follicular 24Gy in 2 weeks Palliative 1 – 10 #

49. The practicalities of radiotherapy