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![Page 1: The Christie NHS Foundation Trust Updated June 2010 An Introduction to the nature and management of Lymphoma Radiotherapy in the management of lymphoma.](https://reader035.fdocuments.us/reader035/viewer/2022062712/56649c935503460f9494f821/html5/thumbnails/1.jpg)
The Christie NHS Foundation TrustUpdated June 2010
An Introduction to the nature and management of Lymphoma
Radiotherapy in the management of lymphoma
Richard CowanConsultant in Clinical Oncology
13th October 2010
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The Christie NHS Foundation TrustUpdated June 2010
How to use your Handset
Please ensure that your handset is switched on
and active
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The Christie NHS Foundation TrustUpdated June 2010
How to use your Handset
Use the keypad buttons to select your choice/choices. The keypad supports numeric and alphanumeric
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The Christie NHS Foundation TrustUpdated June 2010
How to use your Handset
The Screen will illuminate for a few seconds when voting begins
Once you have voted it will say ‘received’ on
the screen
![Page 5: The Christie NHS Foundation Trust Updated June 2010 An Introduction to the nature and management of Lymphoma Radiotherapy in the management of lymphoma.](https://reader035.fdocuments.us/reader035/viewer/2022062712/56649c935503460f9494f821/html5/thumbnails/5.jpg)
The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy in the management of lymphoma
• Background to radiotherapy
• Place of radiotherapy in lymphoma
• Practical details of radiotherapy
• Future developments
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The Christie NHS Foundation TrustUpdated June 2010
Wilhelm Conrad Röntgen
1845 - 1923
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The Christie NHS Foundation TrustUpdated June 2010
Discovered X rays
1.1865
2.1875
3.1885
4.1895
5.1905
Q
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The Christie NHS Foundation TrustUpdated June 2010
Discovered X rays
1.1865
2.1875
3.1885
4.1895 ✓
5.1905
Q
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The Christie NHS Foundation TrustUpdated June 2010
1898
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The Christie NHS Foundation TrustUpdated June 2010
Marie Curie was born in :Q
1.Russia2.Bulgaria3.Poland4.France5.Bolivia
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The Christie NHS Foundation TrustUpdated June 2010
Marie Curie was born in :Q
1.Russia2.Bulgaria3.Poland ✓4.France5.Bolivia
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The Christie NHS Foundation TrustUpdated June 2010
Energy
wavelength Electromagnetic spectrum
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The Christie NHS Foundation TrustUpdated June 2010
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The Christie NHS Foundation TrustUpdated June 2010
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The Christie NHS Foundation TrustUpdated June 2010
Until 1960s Radiotherapy was the only non surgical treatment for lymphoma
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Resistant:
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Resistant:– Malignant melanoma
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Resistant:– Sarcomas / melanoma
• Intermediate:
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
Which of these tumours is NOT Intermediate in terms of radiosensitivity:
1. Breast, 2. Testicular seminoma3. Non small cell lung cancer4. prostate cancer 5. head and neck cancer
Q
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
Which of these tumours is NOT Intermediate in terms of radiosensitivity:
1. Breast, 2. Testicular seminoma ✓3. Non small cell lung cancer4. prostate cancer 5. head and neck cancer
Q
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Resistant:– Sarcomas / melanoma
• Intermediate:– Breast, lung, prostate, head and neck cancer
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Resistant:– Sarcomas / melanoma
• Intermediate:• Breast, lung, prostate, head and neck cancer
Sensitive:• Germ cell tumours• Lymphomas
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The Christie NHS Foundation TrustUpdated June 2010
How does Radiotherapy work?
• Ionising radiation damages cells
• The most sensitive cellular component is DNA
DNA
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy – Biological Aspects
• DNA damage manifests at cell division
• “Early cell kill” v. “late cell kill”
• Related to proliferative activity
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy – Biological Aspects
• Early: - usually the cancer
–Skin, GI tract, Bone marrow
• Late:
–Kidney, CNS
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The Christie NHS Foundation TrustUpdated June 2010
If the Kidneys receive a toxic dose of radiotherapy how long after radiotherapy will the patient show maximum
renal impairment?
1. 10 days
2. 4 weeks
3. 3 months
4. 12 months
5. 24 months
Q
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The Christie NHS Foundation TrustUpdated June 2010
If the Kidneys receive a toxic dose of radiotherapy how long after radiotherapy will the patient show maximum
renal impairment?
1. 10 days
2. 4 weeks
3. 3 months
4. 12 months ✓5. 24 months
Q
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The Christie NHS Foundation TrustUpdated June 2010
How does Radiotherapy work?
• The most sensitive cellular component is DNA
•The malignant cell have impaired DNA repair mechanisms
DNA
DNA damage can be repaired
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy – Biological Selectivity
Normal tissue
cancer
Cell
No.
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The Christie NHS Foundation TrustUpdated June 2010
Place of radiotherapy in lymphoma
• Radiotherapy alone for cure
• Radiotherapy in combination for cure
• Palliation
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy alone for cure
• 73 yr old woman who presents with a painless lump in the groin
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy alone for cure
• 73 yr old woman who presents with a painless lump in the groin
• Biopsy :
Follicular lymphoma
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy alone for cure
• 73 yr old woman who presents with a painless lump in the groin
• Biopsy :
Follicular lymphoma
stage IA
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The Christie NHS Foundation TrustUpdated June 2010
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#
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Intermediate:– prostate cancer 70Gy
Sensitive :follicular lymphoma 24Gy (4Gy)
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The Christie NHS Foundation TrustUpdated June 2010
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
3 months later the chance of complete remissionQ
1. 25% - 35%
2. 40% - 50%
3. 55% - 65%
4. 65% - 75%
5. 85% - 95%
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The Christie NHS Foundation TrustUpdated June 2010
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
3 months later the chance of complete remissionQ
1. 25% - 35%
2. 40% - 50%
3. 55% - 65%
4. 65% - 75%
5. 85% - 95% ✓
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy alone for cure
• 33 year old woman
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy alone for cure
• 33 year old woman• Biopsy : Hodgkins lymphoma Stage I A
(nodular lymphocyte predominant)
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy alone for cure
• 33 year old woman• Biopsy :
Hodgkins lymphoma Stage I A
(nodular lymphocyte predominant)
30Gy in 15# (3 weeks)
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The Christie NHS Foundation TrustUpdated June 2010
How effective is Radiotherapy ?
• Intermediate:– prostate cancer 70Gy
Sensitive :– follicular lymphoma 24Gy (4Gy)
– Hodgkins lymphoma 30Gy
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy in combination
• 32 year old man
With a cough and weight loss
• Hodgkins stage III B
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The Christie NHS Foundation TrustUpdated June 2010
Radiotherapy in combination
• 32 year old man
With a cough and weight loss
• Hodgkins stage III B
• After 6 cycles of ABVD
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The Christie NHS Foundation TrustUpdated June 2010
Following 6 cycles of ABVD
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The Christie NHS Foundation TrustUpdated June 2010
Following 6 cycles of ABVD
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The Christie NHS Foundation TrustUpdated June 2010
The practicalities of radiotherapy
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The Christie NHS Foundation TrustUpdated June 2010
Dose and duration of treatment
• “Low Dose “
(30 Gy rather than 70Gy)
• Curative : 15 treatments of 2 Gy = 3 weeks
• Shorter treatments :
Palliative Radiotherapy
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The Christie NHS Foundation TrustUpdated June 2010
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 #
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The Christie NHS Foundation TrustUpdated June 2010
The practicalities of radiotherapy
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The Christie NHS Foundation TrustUpdated June 2010
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The Christie NHS Foundation TrustUpdated June 2010
Low energy
X-rays
e.g. 100KV
Electrons
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The Christie NHS Foundation TrustUpdated June 2010
High energy x-rays
e.g. 6Mev
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The Christie NHS Foundation TrustUpdated June 2010
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The Christie NHS Foundation TrustUpdated June 2010
PET CT
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The Christie NHS Foundation TrustUpdated June 2010
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
• Acute : - • Acute inflammation :
– Red skin– Mucositis– Bowel upset– Alopecia
• Tiredness
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
Acute side effects : - Q
1. Start on the first day of treatment and last for the duration of the treatment
2. Start towards the end of the treatment and last for 3 – 4 weeks3. Start on the first day of treatment and last for 3 – 4 weeks post
treatment4. Start towards the end of treatment and last for 3 – 4 months post
treatment
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
Acute side effects : - Q
1. Start on the first day of treatment and last for the duration of the treatment
2. Start towards the end of the treatment and last for 3 – 4 weeks ✓3. Start on the first day of treatment and last for 3 – 4 weeks post
treatment4. Start towards the end of treatment and last for 3 – 4 months post
treatment
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
late : - 6 months and beyond :• chronic inflammation :
– Lung (visible on CXR)– Bowel– Salivary glands– endocrine
• 2nd malignancy• cardiac
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
• Depend upon :
• Dose
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
• Depend upon :
• Dose (good for lymphoma)
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
• Depend upon :
• Dose (good for lymphoma)
• Volume irradiated
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The Christie NHS Foundation TrustUpdated June 2010
Side effects of radiotherapy
• Depend upon :
• Dose (good for lymphoma)
• Volume irradiated (small is beautiful)
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The Christie NHS Foundation TrustUpdated June 2010
90Y Zevalin
• Zevalin(Ibritumomab)
– Anti-CD20 murine parent of rituximab
• Tiuxetan
– Chelator, conjugated to antibody forming strong urea-type bond
– Stable retention of 90Y
• Yttrium-90
– t1/2 = 64 hours
– Outpatient administration – Beta emission - 5mm
90Y radionuclide
Tiuxetan
Zevalin
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The Christie NHS Foundation TrustUpdated June 2010
Future developments
• Technical advances :
• Imaging
• Delivery–Intensity Modulated Radiotherapy (IMRT)–Image Guided Radiotherapy (IGRT)
![Page 66: The Christie NHS Foundation Trust Updated June 2010 An Introduction to the nature and management of Lymphoma Radiotherapy in the management of lymphoma.](https://reader035.fdocuments.us/reader035/viewer/2022062712/56649c935503460f9494f821/html5/thumbnails/66.jpg)
The Christie NHS Foundation TrustUpdated June 2010
Future developments
• New molecules :
–Increase tumour sensitivity–Protect normal tissues
![Page 67: The Christie NHS Foundation Trust Updated June 2010 An Introduction to the nature and management of Lymphoma Radiotherapy in the management of lymphoma.](https://reader035.fdocuments.us/reader035/viewer/2022062712/56649c935503460f9494f821/html5/thumbnails/67.jpg)
The Christie NHS Foundation TrustUpdated June 2010
What is for lunch ?
1. A Big Mac
2. Thai Chicken kebabs
3. Bacon butties
4. Salmon and Champagne
Q