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Radiation therapy for the mediastinum and hilum of lung for malignant lymphoma

General

In the Ann Arbor system the mediastinum is one region and is separated fromthe hilar lymph nodes on each side.

For radiation therapy, it is common to view the mediastinum as:

  • the upper region above the carina.
  • the middle region around the carina which includes tracheobronchial and bronchopulmonary lymph nodes (lung hilum on both sides). 
  • lymph nodes immediately subcarinal and at the base of the heart.
  • Posterior/lower region with lymph nodes below the carina behind the heart along the esophagus, descending aorta, thoracic column, and in the carciophrenic angles.  

Lymphoma involvement in the mediastinum occurs normally as large conglomerate tumors in close proximity to the heart. In addiion to involvment in the middle and posterior mediastinum, there is often paracardial involvement along and and in the pericardium ventrally, ventrolaterally on the right or left side and in the cardiophrenic angles. Lymphoma involvement near the heart is often a challenge for planning radiation therapy. 

Indications

Curative radiation therapy

  • For localized stages of classical Hodgkin's lymphoma (stage IA/IIA), radiation therapy is given to the original area involved with margin (involved field) after chemotherapy (ABVD or equivalent). The initial tumor volume before chemotherapy is critical for field modeling, but it is important to take into account tumor reduction after chemotherapy where the lung was pushed to the side, but not infiltrated by lymphoma before chemotherapy (the balloon effect).  
  • For localized stages of nodular lymphocyte-rich Hodgkin's lymphoma (stage IA/IIA) without risk factors, radiation therapy alone is given to the involved area with margin (involved field) without previous chemotherapy. Isolated involvment of NLPHL in the mediastinum is rare.
  • Special guidelines apply for children and adolescents up to 18 years with Hodgkin's lymphoma.
  • For residual tumor of Hodgkin's lymphoma after full chemotherapy for advanced Hodgkin's lymphoma (6-8 ABVD, 8 BEACOPP or equivalent), consolidative radiation therapy to the residual tumor with margin is considered.
  • For localized stages of aggressive lymphomas (stage I-II1), consolidative radiation therapy after chemotherapy (CHOP-based or equivalent) to the original tumor-involved area with margin (involved field) is given. The initial tumor volume before chemotherapy is critical for field modeling, but it is important to take into account tumor reduction after chemotherapy where the lung was pushed to the side, but not infiltrated by lymphoma before chemotherapy (the balloon effect). With residual tumor of aggressive lymphomas after full chemotherapy (6-8 CHOP-based cycles or equivalent), consolidative radiotherapy to the residual tumor with margin is considered.
  • With residual tumor of aggressive lymphomas after full chemotherapy (6-8 CHOP-based cycles or equivalent), consolidative radiotherapy to the residual tumor with margin is considered.
  • Mediastinal tumors from lymphoblastic lymphomas/ALL, Burkitt's lymphoma and primary mediastinal B cell lymphomas are always considered for radiation therapy, even after intensive chemotherapy. This is usually done by irradiating the original tumor volume in the craniocaudal direction, but with consideration for the balloon effect in the transversal plane.
  • For indolent lymphomas with localized disease (stadium I-II1), radiation therapy alone is given to the involved area with margin (involved field).

 

 

Palliative radiation therapy

  • As palliative radiation therapy, the method is based on guidelines for curative treatment with individual modifications.

       

       

       

       

       

       

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