NHL

1. NON HODGKIN’S
LYMPHOMA
Presentor: Dr Gowtham Manimaran
Moderator: Dr Neha Kakkar

2. Introduction
• Non-Hodgkinlymphomas (NHLs) are a heterogeneous group of malignancies of
the lymphoid system characterized by an abnormal clonal proliferation of B cells,T
cells, or NK (natural killer) cells.
• More common in males (lifetime risk 1.26:1)
• Approximately 50% to 60% of NHLs are classified as aggressive.
• Most common NHL: DLBCL (29%), follicular (26%), SLL/CLL (7%), MZL/MALT
(9%), mantle cell (8%), MZL/nodal (3%), primary mediastinal DLBCL(2%) among
others.
World India
- Incidence – 12th (3.17%)
- Mortality – 12th (2.81%)
- Incidence – 11th (2.68%)
- Mortality – 11th (3.27%)
Globocan 2018

3. Etiology and risk factors
• Immunodeficiency – congenital
(SCID, ataxia telangiectasia), acquired
(HIV, organ transplant).
• Autoimmune (Sjogren’s, Hashimoto’s
disease, rheumatoid arthritis,
systemic lupus erythematosus).
• Environmental – chemicals
(pesticides and solvents).
• Borrelia burgdorferi [tick bite, mantle
cell].
• previous CLL/hairy cell leukemia
(Richter’s transformation into DLBCL
in 5%–10%).
Condition Comment
HIV Cumulative incidence by 4.5 %
Solid organ transplant Incidence of NHL increased by 7.9 times the
general population
Dialysis Incidence of NHL increased by 5.1 times the
general population
Inherited autoimmune
disorders
- 7 % life time risk of NHL
EBV - 40% OF HIV associated NHL & 10-15 %
sporadic NHL
- May work synergistically with
Plasmodium falciparum
HTLV-1 Life time increase of 5 %
HCV 2 – 3 fold increase
H. Pylori - Gastric MALT
- Observed in 90% patients
- Complete remission in 62 % patients after
antibiotic therapy
C. psittaci - Orbital MALT
Campilobacter jejuni - Cutaneous MZL

4. Classification
• There are currently approximately 70 distinct
NHL entities within the 2016 WHO classification.

5. Clinical presentation
• Median age of diagnosis - 65 years
• Slight male to female predominance – 55 to 60 %
• Extra nodal involvement in 40 % patients
• NHL may present in any part of the body.Therefore, the presenting signs and
symptoms of NHL are highly variable.
• Mc presentation – painless lymphadenopathy
• Patients may also present with systemic symptoms of fever, weight loss, and
night sweats, usually - presence of more advanced disease.
• In the absence of nodal involvement,lymphoma is often not suspected or
distinguished clinically from carcinoma; therefore, immunophenotypic and
histochemical analysis is particularly important.
• Extra nodal involvement is rarely seen in FL
• Extra nodal presentation is the rule for MZL
Mediastinal - 20 %
Spleen involvement - 30 to 40 %
Hepatic infiltration - 25 to 50 %
- Advanced stage – 75 %
Primary lymphoma of bone - < 5 %
- Common sites – femur,
pelvis and vertebrae
Renal infiltration - 2 to 14 %

6. STAGING –LUGANO SYSTEM (2014)

7. Work up
• Excisional Biopsy of Lymph Node.
• If Lymph Node Not Accessible-Core + FNA Biopsies +
Appropriate Ancillary Techniques ( FISH, PCR) used.
• The diagnosis of the individual pathologic and clinical entities
continues to be based on morphology but is assisted by
immunophenotyping and genotyping.

8. Importance of PET CT
• Now the imaging of choice
• PET-CT should be performed with contrast (if no CI)
• If a PET CT indicates bone marrow disease – no confirmation is
needed by Bone marrow biopsy (which had remained the
standard of care for several decades)
• DLBCL –sensitive , FL – BM biopsy recommended
• Respones – complete , partial,no response/stable ,progressive
• Score 1,2,3 –CR
• Score 4 or 5 – PR (Reduced uptake and >50% decrease in
measurable size (transverse diameter))
• Has prognostic value also –In DLBCL ,Interim PET CT –if no
favourable response indicates poor prognosis

9. Immunophenotyping and molecular markers
• FL – translocation t(14;18)(q32;q21) involving BCL-2 (80-90%) + c- MYC (dual translocation has worse prognosis)
• DLBCL – GCB and ABC based on microarray analysis of c DNA , c-MYC +BCL-2 double hit lymphoma (<1 yr MS)

10. Prognostic factors
Site of presentation :
• Adverse – testis , ovary , eye ,CNS ,Liver
• Good – skin ,obit

11. DLBCL
• Most common NHL -30%
• Clinical features:
IHC Genetics
CD 19 MYC, BCL2,and/or BCL6 gene rearrangements are present
CD 20 - BLC6 + MYC – double hit lymphoma
CD 22 - All 3 genes are present – triple hit lymphoma – 5 to 10 %
CD 79a - Triple hit have worse prognosisStage I or II disease 30 to 40 %
Stage IV disease 40 %
B symptoms 40 %
Elevated serum
b microglobulin
50 %
Bone marrow involvement 10 - 20 %

12. Treatment protocol
Stage I, II
BulkyNon-bulky
RCHOP x 3 cycles + ISRT
(Category 1)
RCHOP x 6 cycles +- ISRT
CR
Complete planned course
of therapy
PR
Complete planned course
of therapy with higher RT dose
If PR after 6 cycles of RCHOP
or 4-6 cycles of RCHOP-14
HDT + ASCT +- ISRT
No response/
Progressive
disease
Relapsed
disease
Pre-RT evaluation by PET scan

13. Treatment protocol
Stage III, IV
RCHOP x 2-4 cycles
Interim restaging after 2-4 cycles
Response No response/ progressive disease
Continue RCHOP to 6 cycles
CR
Observation or
ISRT to initially
bulky disease
PR/ Progressive disease
- 2nd line chemotherapy
- ISRT
- 2nd line chemotherapy
- ISRT

14. Majority relapses are seen within 2 years of treatment
.
18 % relapses occur more than 5 years after initial
treatment
Relapsed/ refractory disease
Intention to proceed
to transplant
Non-candidate for transplant
2nd line chemotherapy
CR PR No response/
Progressive disease
HDT +
ASCT Axicabtagene
or HDT + ASCT
- 2nd line chemotherapy
- Palliative ISRT
CR
Follow-up
PR/ Progressive
disease
- 2nd line chemotherapy
- Palliative ISRT- 2nd line chemotherapy
- Palliative ISRT

15. R CHOP-21, 3 Weekly
Rituximab – 375 mg/m2 i/v - day 1
Cyclophosphamide – 750 mg/m2 i/v - day 1
Doxorubicin – 50 mg/m2 i/v - day 1
Vincristine – 1.4 mg/m2 i/v – day 1
Prednisolone – 100 mg/m2/day orally – days 1-5
Chemotherapy
Response rate – 98 %
CR – 83 %
PR – 15 %
R CHOP-14, 2 Weekly
Rituximab – 375 mg/m2 i/v - day 1
Cyclophosphamide – 1000 mg/m2 i/v - day 1
Doxorubicin – 70 mg/m2 i/v - day 1
Vincristine – 2 mg/m2 i/v – day 1
Prednisolone – 100 mg/m2/day orally – days 1-5
Regime 3-year OS 3-year PFS
R-CHOP 21 72% 69%
R-CHOP-14 62% 60%
- Only Rituximab – RR – 48 %

16. RADIOTHERAPY
Palliationthough doses of 24Gy to 30Gy are commonly used ,
even 4Gy/2# has to have response rates of 50% to 80 %
(but median time to progression is 1 year)

17. Various regimens for different subtypes

18. Chemotherapy

19. Follicular lymphoma
• The most common indolent lymphoma – 70 %.
• Grading based on centrocytes and centroblasts
Grading Number of cells (centeroblasts)per high powered field
1 0 to 5
2 5 to 15
3
- A
- B
> 15
- Presence of centrocytes
- Absence of centrocytes, similar to DLBCL, treated as
such
IHC Genetics
CD 19 14;18 translocation
is characteristic
CD 20 BCL 6 in some cases
CD 21 BCL 2 -
overexpression
CD 10 (in 60 %
cases)
CD 5, 23 - negative

20. • Clinical features Prognostic markers:
Follicular lymphoma
- Slight female preponderance
- Most patients present with painless
peripheral lymphadenopathy
- Stage IV disease – 80 %
- Principle extra-nodal organ involved –
bone marrow
- Extra nodal presentation – 6 %
- Transformation to large cell – 30 %
patients, 2 % per year

21. Treatment protocol
Stage I, II
Stage I (< 7cm) or
Contiguous Stage II
Stage I (>=7cm) or
Non-contiguous Stage II
ISRT
CR/ PR
NR
- Anti-CD 20 immunochemotherapy
- Anti-CD20 immunochemotherapy
+ ISRT
- Observation
Follow up
CR
Follow up
PR
ISRT
CR/ PR
Follow upTreat as stage III, IV

22. Treatment protocol
Stage III, IV
Candidate for treatment
Yes
No
Follow up
- Chemotherapy
- Palliative ISRT
CR/ PR
Consolidation
chemotherapy
or observe
NR
Follow up
Rebiopsy
(A biopsy of the new
disease must be performed
to rule out transformation.)

23. • As follicular lymphoma is a relatively indolent disease –
Treatment – stage III and IV
Category I Observation for low tumor burden
Indications for treatment
Bulky disease
- 3 distinct nodal sites each >= 3 cm
- Single nodal site > 7 cm
Symptomatic disease
- Organ compression
- Pleural effusion or ascites

24. • Chemotherapy
Treatment – stage III and IV
Chemotherapy Response rate
Bendamustine + Rituximab 80 to 90 %
R-CHOP 86 %
R-CVP 81 %
Rituximab alone 70 %, CR – 30 %
Maintenance Rituximab 72 %
Lenalidomide + Rituximab ORR – 98 %, ongoing trial
90Y-ibritumomab ORR – 94 %, CRR – 58 %
The preferred strategy is Rituximab in combination with chemotherapy

25. Chemotherapy
R-B
Rituximab 375 mg/m2 i/v – day 1
Bendamustine 90 mg/m2 i/v – days 1 & 2
Repeated every 4 weeks, x 6 cycles
R-CVP
Rituximab 375 mg/m2 i/v – day 1
Cyclophosphamide 750 mg/m2 i/v – day 1
Vincristine 1.4 mg/m2 i/v – day 1
Prednisolone 40 mg/m2 PO – days 1 to 5
Repeated every 3 weeks, x 6 cycles
Rituximab-Fludabirine
Rituximab 375 mg/m2 i/v – day 1
Fludabirine 25 mg/m2 i/v – days 3 & 5
Repeated every 4 weeks, x 6 cycles
Rituximab maintenance
Rituximab 375 mg/m2 i/v every 8 weeks for
2 years

26. Chemotherapy
Obinutuzumab + Bendamustine
- Cycle 1 – Obinutuzumab 1000 mg i/v on day 1, 8 & 15 + Bendamustine 90 mg/m2/day on
days 1 & 2
- Cycle 2-6 – Obinutuzumab 1000 mg i/v on day 1 + Bendamustine 90 mg/m2/day on days
1 & 2
- Monotherapy – patients who achieve stable disease, CR or PR to first 6 cycles should be
continued on Obinutuzumab 1000 mg i/v every 2 months for 2 years
PI3K delta inhibitors
Idelaisib – 150 mg PO BID
Copanlisib – 60 mg i/v on days 1, 8 & 15, every 4 weeks

27. Radiation in FL
• Radiation dose used varies from
16 to 50Gy  >90% local control
with doses in the range of 30Gy
• Majority of relapses were at
distant sites , radiation gave
excellent local controlthis led
to ISRT and INRT

28. Marginal zone lymphomas
• They account for 10 % of all cases of NHL.
• MZL entities include - - Nodal MZL
- Splenic MZL
- Extra nodal MZL
Immuno-histochemistry
- CD 20, 19
- CD 22
- CD 79a
- CD 5, CD 10, CD 23, cyclin D1 – negative
Genetics
- T(11;18) – most common
- t(1;14)
- t(3;14)
- Trisomy 8

29. Marginal zone lymphomas
Clinical features
- 2/3rd to 3/4th patients present in
stage I and II
- Most common locations for extra-
nodal MZL – stomach, orbit &
lung
Extra-nodal site Agent
Stomach H. pylori
Ocular C. psittaci
Skin B. burgdorferi
Small intestine C. jenuni
Prognostic factors
- Primary prognostic factor – disease site
- Paired organs – higher risk of relapse

30. • Treatment of localized MALT- Radiotherapy
• Gastric MALT - antibiotics
Marginal zone lymphomas - treatment
Complete response rate 100 %
5-year survival > 90 %
Relapse rate 25 %
Recommended regime
- Omeprazole – 20 mg
BID x 21 days
- Response rate – 80 %
- Metronidazole – 500
TDS x 21 days
- Relapse rate – 30 %
- Clarithromycin – 500 mg
TDS x 21 days
- H . Pylori negative - RT
Long term progression free OS – 90 %
• Ocular lymphoma
- Incidence of C. psittaci – 23 %
- Antibiotics can be considered
- A reasonable strategy is observation
Single agent doxycycline – 100 mg
BID x 3 weeks
RR – 83 %
Antibiotic treatment contra-
indications
- Deep gastric wall invasion
- Nodal involvement
- t(11;18) translocation

31. Relapsed disease
- Oral low dose chlorambucil – 8 mg/m2 or Cyclophosphamide – CRR - 75 %
- Single agent Rituximab – RR – 73 %
- Rituximab + Fludabarine – RR – 85 to 100 %
Marginal zone lymphomas - treatment

32. Nodal MZL
Clinical features
- 70 % patients present with stage IV disease
- Bone marrow involvement – 45 %
- 5-year survival in local MZL – 55 to 79 %
Treatment
- Chemo-immunotherapy – RR – 80 %
- RCHOP vs BR in PFS – 47 vs 57 months
- Ibrutinib – 560 mg OD – in relapsed MZL – RR -
48 %
• For a rare patient with localised
disease 24 to 30Gy is
recommended
Perez

33. Splenic MZL
Clinical features
- Splenomegaly, lymphocytosis, cytopenias
- > 90 % have stage IV disease
- 10-year OS - > 70%
Prognostic factors
- Hemoglobin < 12 g/dl
- LDH > normal limit
- Albumin level < 3.5 g/dl
Number of risk factors
present
5-year cause specific
survival
0 88 %
1 73 %
2 or 3 50 %

34. Treatment
Asymptomatic patients Observation
Symptomatic splenomegaly or significant cytopenias
Splenectomy
- RR – 85 %
- 5-year PFS & OS – 58 % & 77 %
Non-surgical candidates – RT
24-30 Gy is the ideal dose
Single agent Rituximab – induction & maintenance
- RR – 95 %
- 5-year OS &PFS – 92 % & 75 %

35. Mantle cell lymphoma
• MCL lymphoma represents 7 % of all NHL.
• Pathology
IHC Genetics
CD 5 positive T(11;14)
CD 23 negative Cyclin D1 over
expression
CD 20 positive
CD 10 negative
Clinical features
- 80 % patients present with stage
IV disease
- Indolent disease – 10 to 15 %
cases
- Most common organ to be
involved – bone marrow – 2/3rd
patients
- 5 year survival rate – 27 %
Treatment
- Standard of care – chemoimmunotherapy
- Rituximab is generally combined with
chemotherapy
- There is no standard treatment regime for
MCL

36. Treatment protocol
Stage I/ II
Chemoimmunotherapy
CR
Follow up
PR
2nd line chemotherapy
Relapse
2nd line chemotherapy

37. Treatment protocol
Stage III/ IV
Aggressive
Aggressive chemotherapy
regimes
Candidate for
ASCT
Non-candidate for
ASCT
Chemotherapy
regimes
CR PR
HDT+ASCT
Maintenance
Rituximab
(Category 1)
2nd line
chemotherapy
CR
Maintenance
Rituximab
(Category 1)
PR
2nd line
chemotherapy
Indolent
Observation

38. Mantle cell lymphoma

39. • Prognostic model
Primary CNS lymphoma
- Standard systemic chemotherapeutic regimes are ineffective
• Median age of presentation – 55 years
• Imaging modality of choice – MRI
• Leptomeningeal & ocular involvement – 33 % and 20 %

41. Primary CNS lymphoma

42. Primary CNS lymphoma
Induction chemotherapy
HDT + ASCT – CR – 96 %
CR
Induction chemotherapy
CR
RT – 23.4 Gy, 5-year OS – 80 %
Perez

43. Primary CNS lymphoma
Regime Response rate
High dose methotrexate - Rituximab 91 %, CR - 58 %
MATRix regimen (methotrexate,cytarabine,
thiotepa,rituximab)
CR - 49 %
Methotrexate + cytarabine CR - 23 %
MTX MTX-R
ORR – 36 % OR – 73 %

44. MATRix regime
Methotrexate 3.5 g/m2 i/v - day 2
Cytarabine 2g/m2 i/v - days 3 & 4
Thiotepa 30 mg/m2 – day 5
Rituximab 375 mg/m2 – day 1
3 weekly x 4 cycles
Primary CNS lymphoma
Methotrexate + Rituximab
Methotrexate 8 g/m2 i/v - day 1
Rituximab 375 mg/m2 – day 1
2 weekly x 4 cycles
Methotrexate + Cytarabine
Methotrexate 3.5 g/m2 i/v - day 1
Cytarabine 2 g/m2 – days 2-3
3 weekly x 4 cycles

45. Peripheral T-cell lymphoma
• Along with NK cell lymphoma they make up 10 % of all NHL.
• Pathology
NOS Anaplastic large-cell
lymphoma – 2 %
CD 2 CD 30
CD 3 CD 25
CD 4
CD 4+/ CD 8-
phenotype is typical in
nodal cases
Clinical features
- Stage III/ IV – 70 %
ALK + ALK -
- Young men - Older patients
- Despite advanced
stage respond well to
chemotherapy
- 10 year OS – 70 % - 10 year OS – 20 %
- Cutaneous – excellent
prognosis

46. • Treatment -
Peripheral T-cell lymphoma
Stage Treatment
I & II - Chemotherapy x 6 cycles
- Chemotherapy x 3 cycles + RT
II & IV - Chemotherapy x 6 cycles

47. • Salvage chemotherapy and ASCT have limited benefit
Peripheral T-cell lymphoma
CHOEP – 3 weekly
Doxorubicin – 50 mg/m2 i/v Day 1
Vincristine – 1.4 mg/m2 i/v Day1
Cyclophosphamide – 750 mg/m2 i/v Day 1
Etoposide – 200 mg/m2 PO Days 2 to 3
Prednisolone – 100 mg PO Days 1 to 5
A+ CHP - 3 weekly
Doxorubicin – 50 mg/m2 i/v Day 1
Brentuximab 1.8 mg/kg Day 1
Cyclophosphamide – 750 mg/m2 i/v Day 1
Prednisolone – 100 mg PO Days 1 to 5
GEMOX
Gemcitabine - 1000 mg/m2 days 1
Oxaliplatin 100 mg/m2 – day 1
2 weekly
GDP
Gemcitabine - 1000 mg/m2 days 1 & 8
Dexamethasone – 20 to 40 mg days 1 to 3
Cisplatin 25 mg/m2 – day 1 to 3
3 weekly

48. Treatment protocol
Stage I, II Stage III, IV
- Multi agent chemotherapy x 6 cyles
+- ISRT
- Multi agent chemotherapy x 3-4 cyles
+- ISRT
CR/ PR
Follow up
NR
Relapsed disease
- Multi agent chemotherapy x 6 cyles

49. Treatment protocol
Relapsed
Intention to transplant
No intention to transplant
2nd line chemotherapy
CR/PR
HDT+ASCT
NR/ Progressive disease
- Alternative 2nd line
Chemotherapy
- ISRT
CR/ PR
Observe
NR/ Progressive disease
- Alternative 2nd line
Chemotherapy
- ISRT

50. Small lymphocytic lymphoma/ B-cell chronic lymphocytic leukemia
• SLL is synonymous with CLL.
• The diagnosis is made by clinical presentation
• Pathology -
IHC
CD 5
CD 20
CD 23
CD 5 - characteristic
Clinical presentation
- Painless generalized lymphadenopathy
- Absolute lymphocyte count < 5000
- Hypogammaglobinaemia – 40 %
Treatment
- Stage I or II – RT – 40 to 44 Gy,
Freedom from relapse free survival
– 80 % & 62 %
- Advanced stage – low dose
radiation – 200 cGy x 2 #
(palliation)

51. EVOLUTION OF RADIATION THERAPY IN
NON HODGKIN’S LYMPHOMA
Total Lymphatic Irradiation
Subtotal Nodal Irradiation
Extended Field Nodal Irradiation
(Mantle, para-aortic, spleen, inverted Y)
Involved Field Radiation Therapy (IFRT)
( adjacent area are taken +field border are determined by anatomical
landmarks)
Involved Nodal Radiation Therapy (INRT)
( pre treatment PET imaging in RT treatment position )
Involved Site Radiation Therapy (ISRT)
( after CT, depending upon type of lymphoma,
either just lesion + margin or whole organ +
margin)
Treatment
volume
reducing
Introduced for
patients
For whom optimal
imaging is available
Introduced for
patients where
optimal Imaging is
not available

52. Radiotherapy
• IFRT (Involved field RT)- defined as the involved nodal group and one or more immediately adjacent
uninvolved nodal groups.
• (INRT) Involved nodal RT- the clinical target volume (CTV) is based on the prechemotherapy and
postchemotherapy nodal volumes, with exclusion of normal displaced structures based on the
postchemotherapy scan. The use of PET scanning in the treatment position is encouraged but is not
mandated.
• ISRT ( Involved site RT)- targets the originally involved lymph nodes. ( prechemo or pre surgery
volume), but it spares uninvolved organs (like lungs, bone, muscle or kidney) when lymphadenopathy
regresses following chemotherapy- Current standard

53. Extended field nodal irradiation:
MANTLE FIELD
Borders of Mantle field
• Superior: chin-mastoid process tip line
• Inferior : axillary margin : at the level of inferior tip of
scapula
• Inferior :mediastinal border: at the level of T10-11 space
• Lateral: includes axilla
lung blocks, laryngeal block, humeral head blocks, spinal
cord block used
Patient treated in supine position and head fully extended Modified mantle field
Mini mantle field

54. Extended field nodal irradiation
Inverted Y field
Borders: ( invertedY)
Superior : above T11
vertebrae
Inferior : includes
inguinal lymph nodes
Lateral ; iliac spines
Midline block used Para-aortic field
Splenic field

55. INVOLVED FIELD RADIATION
THERAPY
• 1. IFRT is treatment of a region, not of an individual lymph node.
• 2. The main involved-field nodal regions are :
• Neck
• Mediastinum ( including the hilar regions bilaterally)
• Axilla ( including the supraclavicular and infraclavicular lymph nodes
• Spleen
• Para-aortic lymph nodes
• Inguinal lymph nodes ( including the femoral and iliac nodes )

56. Involved field Radiotherapy
3. Fields include the involved pre-chemotherapy sites and volume except for transverse diameter of the
mediastinal and para-aortic lymph nodes, it is recommended to use the reduced post-chemotherapy
diameter.
4. The supraclavicular lymph nodes are considered part of the cervical region. If involved alone (based on
CT and PET imaging, when appropriate), only the low neck need be treated (to the top of the larynx). This
is to avoid irradiating the salivary glands when the risk for the area is low. If other cervical nodes are
involved, the whole neck is treated unilaterally.

57. INVOLVED FIELD RADIATION
THERAPY: NECK
Upper Border: 1 to 2 cm above the lower tip of the mastoid process. If only the supraclavicular nodes are
involved, the upper border of the field may be placed at the top of the larynx.
Lower Border: 1 to 2 cm below the bottom of the clavicle.
Lateral Border: To include the medial two-third of the clavicle
Medial Border: ( if unilateral LN involved)
If the supraclavicular nodes are not involved, the border is placed at the ipsilateral transverse processes.
(For medial nodes, the entire vertebral body is included.)
When the supraclavicular nodes are involved, the border should be placed at the contralateral
transverse processes.
unilateral
bilateral

58. IFRT : MEDIASTINUM
Arm Position: Akimbo or at sides.
 Upper Border: C5-C6 interspace. If supraclavicular nodes also involved, the upper border
should be placed at the top of the larynx.
 Lower Border: The lower of (a) 5 cm below the carina or (b) 2 cm below the pre-
chemotherapy inferior border.
 Lateral Border: The post-chemotherapy volume with a 1- to 1.5-cm margin.
 Hilar Area: To be included with 1-cm margin unless initially involved, in which case the
margin should be 1.5 cm.
If paracardiac lymph nodes are involved, they should be treated either as an extension of
the mediastinal field, or as a separate targeted involved lymph node area. Irradiation of the
whole heart (for even a lower dose) is not recommended in most cases.
Involved-field irradiation for a
patient Non Hodgkin lymphoma
who has a large mediastinal mass
and involvement of the right neck,
right hilum, and right
cardiophrenic region.

59. IFRT: AXILLA
The ipsilateral axillary, infraclavicular, and supraclavicular
areas are treated when the axilla is involved.
Upper Border: C5-C6 interspace or bottom of the larynx.
Lower Border: The lower of (a) the tip of the scapula or
(b) 2 cm below the lowest axillary node.
Medial Border: Ipsilateral cervical transverse process.
Include the vertebral bodies only if the SCL are involved.
Lateral Border: Flash axilla.
Involved-field
irradiation for a patient
with stage I Hodgkin
lymphoma involving the
left axilla. The image
shows the field
configuration with
patient in an arms-up
position.

60. IFRT:
INGUINAL/FEMORAL/EXTERNAL ILIAC
REGION
These ipsilateral lymph node groups are treated together if any of the nodes are involved.
Upper Border: Middle of the sacroiliac joint
Lower Border: 5 cm below the lesser trochanter.
Lateral Border: The greater trochanter and 2 cm lateral to initially involved nodes.
Medial Border: Medial border of the obturator foramen with at least 2 cm medial to
involved nodes. If common iliac nodes are involved, the field should extend to the L4-L5
interspace and at least 2 cm above the initially involved nodal border.

61. IFRT: PARA-AORTIC
Upper Border: Top of T11 and at least 2 cm above pre-
chemotherapy volume.
Lower Border: Bottom of L4 and at least 2 cm below pre-
chemotherapy volume.
Lateral Borders: The edge of the transverse processes and
at least 2 cm from the post-chemotherapy volume.

62. INVOLVED FIELD RADIATION
THERAPY
Waldeyer field RT
BORDERS
Two lateral fields
Superior : 1 cm above zygomatic arch
Posterior : spinal process
Anterior : anterior to 2nd molar teeth
Inferior : thyroid notch
Brain, teeth, maxillary sinus within the field is shielded
Single field may be used in case of U/L preauricular LN
involvement

63. INVOLVED SITE RADIATION THERAPY
- TREATMENT VOLUMES
GTV :-
Pre CT or Treatment volume
Post therapy GTV, which represents residual macroscopic abnormality after treatment
CTV:- microscopic extend may occur within pretherapy GTV
Adjacent involved structures should be included
Uninvolved structures or lymph nodes should not be included
1st echelon nodes of uncertain status close to primary may be included
In many organs ( stomach, CNS , salivary gland) lymphoma is multifocal , organ is treated even if
it initially appeared to be partially involved

64. ISRT – Treatment volumes
ITV:- CTV+ margin
ITV is determined by 4D – CT simulation or fluoroscopy
PTV :-
CTV + 0.5 – 1 cm (as per departmental protocols)
If involved nodes > 5 cm apart, they can be treated with separated fields

65. Radiotherapy

66. ThankYou!