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Lymphoma is one of the most radiation-sensitive cancers there is, so the doses are low and the fields are small. Two doses of 2 Gy can shrink a painful node in a fortnight; 24 Gy can cure a stage I follicular lymphoma.
Fields have shrunk twice in living memory: from mantle and inverted-Y fields covering whole regions, to involved-field radiotherapy covering a nodal region, to involved-site radiotherapy covering the pre-chemotherapy tumour volume with a margin. The change is the single largest reason late cardiac disease and second cancers after Hodgkin lymphoma are falling.
Doses, by purpose. Curative radiotherapy for stage I to II follicular or marginal zone lymphoma is 24 Gy in 12 fractions. The FoRT trial randomised 4 Gy in two fractions against 24 Gy in indolent lymphoma and found 4 Gy clearly inferior for local control (21 local progressions after 24 Gy against 70 after 4 Gy; hazard ratio 3.42), so 4 Gy is palliative, not curative. Palliative 4 Gy in two fractions, sometimes repeated, is remarkably effective for a symptomatic node, an orbital mass or a skin plaque and can be given to a frail patient in two visits. Consolidation after chemotherapy in Hodgkin lymphoma is 20 to 30 Gy to an involved site. Gastric MALT lymphoma that does not respond to antibiotics is treated with about 24 Gy to the stomach. Total skin electron beam therapy, at conventional 30 to 36 Gy or low-dose 10 to 12 Gy, treats the whole skin surface in mycosis fungoides.
When radiotherapy is left out. IELSG37 showed consolidation radiotherapy can be omitted in primary mediastinal B-cell lymphoma after a negative end-of-treatment PET (30-month progression-free survival 96.2 per cent observed against 98.5 per cent irradiated). In early Hodgkin lymphoma, HD16 and EORTC H10 both found that omitting radiotherapy from PET-negative patients costs some disease control without costing survival, which is why the decision differs by country and by patient age.
Proton therapy and deep-inspiration breath hold are used in young patients with mediastinal disease to keep dose off the heart, breasts and lungs.
Showing the technology this term belongs to: IMRT / IGRT (modern external beam).
End-of-treatment PET now decides radiotherapy in primary mediastinal B-cell lymphoma: a negative scan means no radiotherapy, whichever chemotherapy regimen was used.
24 Gy in 12 fractions is the standard radiotherapy dose for indolent lymphoma when durable local control is the aim; 4 Gy remains useful for palliation.
Shares PET-adapted (response-adapted) therapy, Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, FDG PET.
Shares FoRT: 4 Gy versus 24 Gy radiotherapy for indolent lymphoma, a randomised phase 3 non-inferiority trial, Nodal marginal zone lymphoma, Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), Palliative radiotherapy.
Shares IELSG37: omission of radiotherapy in primary mediastinal B-cell lymphoma after a negative PET scan, Lugano classification / Ann Arbor staging, PET-adapted (response-adapted) therapy, FDG PET.
Shares Helicobacter pylori eradication as cancer treatment in gastric MALT lymphoma, Nodal marginal zone lymphoma, Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma).
Shares Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma), Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV).
Shares Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma), Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV).
Shares Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Primary mediastinal (thymic) large B-cell lymphoma.
Shares Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Primary mediastinal (thymic) large B-cell lymphoma.