Cardiac Output, Venous Return, and Their Regulation
ย
Radiotherapy Lymphomas
1. Radiotherapy L
R di th Lymphomas
h
Mary Gospodarowicz MD
Princess Margaret Hospital
University of Toronto, Toronto, Canada
2. Changing Landscape in Lymphoma
โข 90% of cases in adults
โข median age - 64 yrs
โข 2008 Statistics
US Canada
โข 66 120 new cases 7 000
โข 19 160 deaths 3 100
โข @ 500 000 people living with lymphoma
โข 90% B-cell
B-
โข @ 40% DLBCL
โข 10% T-cell
T-
3. RT in Non-Hodgkin L mphoma
Non- Lymphoma
โข Challenges
โ Only 4 - 6% of all cancers
โ Numerous distinct disease entities
โข Mycosis fungoides
โข Primary brain lymphoma
y yp
โข Gastric MALT
โข Burkittโs
โ Changing outcomes
โ Little level 1 evidence to guide practice
4. Radiation Therapy in Cancer
โข Local therapy
โ Proven most effective agent in
providing l
idi local t
l tumour control
tl
โ Proven capable of curing localized
disease in most cancers
โ Compensates for diagnostic ambiguity
p g gy
โข โhistology agnosticโ
โ Few contraindications
5. Radiation Therapy in Cancer
โข Local therapy
โข Proven most effective agent in providing
local tumour control
โข Proven capable of curing localized disease
in most cancers
โข Compensates for diagnostic ambiguity
โข โhistology agnosticโ
histology agnostic
โข Few contraindications
6. RT in Lymphomas
L mphomas
โข Objective of RT
Obj ti f
โ Almost always to achieve local control
โข Outcomes of interest
โ Pattern of failure
โข Local control
โข Overall failure rate
โ Survival
โ Toxicity
7. Stage I&II Follicular Lymphoma 1967-99
1967-
Stage I-II
I- - 668 pts
โข Stage I-II RT alone
I- - 460 pts
โ median follow-up
ed a follow-
oo - 12.5 y s
5 yrs
โข range - up to 32 yrs
โข Treatment โ IF RT 30-35 Gy
30-
โข Relapse
โข distant - 89 %
โข distant + local - 6%
โข isolated local relapse - 5%
9. PMH 1968 โ 1999
Stage I-II Follicular L
St I- F lli l Lymphoma RT Al
h Alone
No relapse
80
Relapse
70
60
Age
50
40
30
20
0 5 10 15 20 25 30 35
Time to relapse or f ll
Ti l follow-up
10. Stage I-II MZL PMH 1989-2004
MALT 1989 - 2004
โข 166 pts treated with RT
t t t d ith
โข median follow-up 7.6 yrs (0.6 โ 16.2)
follow-
โข median age 60 yrs (23-93)
(23-
โข F:M=2:1
โข stage I 148 (89%)
โข stage II
t 18 (11%)
16. Localized DLBCL
Heterogeneous disease
Phenotypic, molecular characteristics
Nodal vs. extranodal presentations
vs
Stage I vs. II (II localized vs.. extensive)
B-symptoms
LDH
Age d
A and performance status
f tt
Comorbidity
22. CHOP non-responders
non- p
Probability of Death from Lymphoma
PMH DLBCL โ CMT 1984-2003
1984-
23. Rituximab Era
Rituximab
Rit i b gradually i t d
d ll introduced t th
d to the
management of all DLBCL
Outcomes improved
Role of RT questioned
q
No level 1 evidence
For the benefit of RT
For the lack of benefit of RT
32. RO Practice in Lymphomas
โข Change in radiation oncology p
g gy practice
โ Target volume rather than nodal region
treated
โ GTV, CTB, PTV defined and treated
โ Most practice in adjuvant setting
โข N GTV CTV non-standard
No GTV, non- dd
โ Need to monitor and report RT relevant
outcomes
โข Local control
โข Patterns of relapse
33. RT Planning
Requires optimal
R i ti l
pre-chemotherapy
imaging
34. Current Standard
โข Target - post chemotherapy CTV
โข Dose and fractionation
โ 30 โ 35 Gy in 15-20 fractions
15-
โข 3D CRT / IMRT
โ protect normal tissues
โข CT planning
โข Image guidance as required
35.
36. Role of RT
All trials show improved local control
Very safe treatment
Minimal acute and late severe toxicity
Modern techniques โ lower acute toxicity
Best local therapy cannot improve
distant disease control
If systemic therapy results in 100% local
control โ no need for RT
37. Current contro ersies
C rrent controversies
โขL
Localized f lli l l
li d follicular lymphoma
h
โ Curable with RT or just very slow natural
history
hi t
โข MALT
โ Role of RT in rare presentations
โ Need to learn more about the natural
history
38. Current contro ersies
C rrent controversies
โข Localized DLBCL
L li d
โ Is RT needed in R-CHOP era
R-
โข Does it add to the chemotherapy
โ Must conduct studies that include optimal
chemotherapy and ask RT question
โข Extranodal lymphomas
โ Differences btwn EN and N presentations
39. Current contro ersies
C rrent controversies
โข R l of RT i FDG PET era
Role f in
โ Assessment of response to chemotherapy
using mid-treatment FDG PET
i mid-t t
id t
โ Post chemotherapy PET assessed
response as selection factor for RT
โข Role of RT in PET +ve and PET โve cases
โข Patterns of failures in above situations
40. Future
โข Biologic imaging
g gg
โข Disease extent
โข Response
p
โข Selection for adjuvant treatment
โข Role of precision RT
โข Molecular disease characteristics
โข D fi iti of di
Definition f disease entities
titi
โข Impact on the management