馬偕紀念醫院新竹分院淋巴癌放射治療指引

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馬偕紀念醫院新竹分院

淋巴癌放射治療指引

2010.05.12 新增

2013.06.03 四版

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前言

• 新竹馬偕醫院放射腫瘤科藉由跨院聯合會議

機制進行討論，以制定符合現狀之『淋巴癌

放射治療指引』。

• 本院淋巴癌放射治療指引的建立，係參考國內

外文獻報告及台北總院臨床指引，彙整而

成。

• 本院淋巴癌放射治療流程，以實證醫學方式並

參考國內外醫學中心治療指引，彙集而成。

『淋巴癌放射治療指引』的目的，為提供醫師在

臨床處理之建議。醫師應秉其專業，解釋治療之

損益，更要以病人及家屬的意願與選擇為主，讓

病人獲得最恰當的治療。

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Non-Hodgkin’s Lymphoma

Radiotherapy guideline

NCCN guideline subtype

Cotswolds Modification of Ann Arbor Staging System

I

Single lymph node group

II

Multiple lymph node groups on same side of diaphragm

III

Multiple lymph node groups on both side of diaphragm

IV

Multiple extranodal sites or lymph nodes and extranodal disease

X

Bulk > 10cm

E

Extranodal extension or single isolated site of extranodal disease

A/B

B symptoms：weight loss> 10%，fever，drenching night sweats

Indolent

B-cell lymphoma

CLL/SLL

Follicular lymphoma

Marginal zone lymphoma (MALToma, Splenic MZL Nodal MZL)

Aggressive

B-cell lymphoma

Diffuse large B-cell lymphoma

Mantle cell lymphoma

Highly aggressive

B-cell lymphoma

Burkitt lymphoma

Lymphoblastic lymphoma

AIDS-related B-cell lymphoma

T-cell lymphoma

Peripheral T-cell lymphoma

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Treatment Recommendations

Non-Hodgkins’Lymphoma RT indication

Low grade non-Hodgkins’lymphoma

CLL/SLL (chronic lymphocytic leukemia/small lymphocytic lymphoma)

SLL

Stage I

Locoregional RT if indicated => observation and follow up

Follicular lymphoma (FLIPI: age>60, stage IIIIV, Hb<12, LN area>4, elevation of LDH)

Follicular lymphoma

Stage I / II

1. IFRT (prefer for stage I or contiguous stage II; 24-30 Gy;

Bulky: 36 Gy)

2. Immunotherapy ± chemotherapy ± RT

3. Observation (Toxicity of IFRT outweights potential clinical

benefit.)

Marginal zone lymphoma

MALToma-gastric

Stage I / II

with H.P. negative

1. RT (30Gy)

2. Rituximab

Restage at 3-6 months with endoscopy and biopsy after RT.

MALToma-nongastric

Stage I / II

1. IFRT (24~30Gy)

2. Surgery (lung, breast, thyroid or bowel) and consider

adjuvant RT if positive margin

3. Observation (IFRT or systemic treatment could result in

significant comorbility)

MALToma-nongastric

extranodal

1. RT

2. observation (IFRT or systemic treatment could result in

significant comorbility)

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Mantle cell lymphoma

Stage I / II

1. Chemotherapy ± RT

2. RT (30~36Gy)

Intermediate and high grade NHL (IPI: age>60, stage III/IV, elevation of LDH, ECOG≧2,

more than one site of extranodal involvement)

DLBCL

Stage I / II

Nonbulky (<10cm)

RCHOP x 3 cycles + locoregional RT (30~36Gy)

RCHOP x 6 cycles ± locoregional RT (30~36Gy)

‧Adverse risk factor：elevated LDH、Stage II、Age>60y、PS≧2

‧If partial remission after RCHOP, RT could escalate to 40~50 Gy

DLBCL

Stage I / II

Bulky (>10cm)

RCHOP x 6 cycles ± RT (30~40Gy)

Hodgkins’Lymphoma RT indication

Classic Hodkin lymphoma (nodular sclerosis, mixed cellularity, lymphocyte-depleted and

lymphocyte-rich)

Unfavorable factor: bulky mediastinal or > 10 cm disease, B symptoms, ESR > 50, > 3 sites

of disease.

Stage IA/ IIA

favorable

ABVD x 2-4 cycles or Stanford V x 8 weeks + IFRT

Stage I/II, unfavorable

1. ABVD x 6 cycle + IFRT

2. Stanford V x 12 weeks + IFRT

Stage III/IV

1. ABVD x 6 cycle + RT to residual disease ± initial bulky

site.

2. Stanford V x 12 weeks + RT to initial site > 5 cm, involved

spleen, residual PET positive site.

3. escalated BEACOPP ± RT to initial site > 5 cm

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Radiation Delineation

Involved-Field

Radiotherapy

(IFRT)

GTV = Grossly involved lymph nodes

CTV =

the involved lymphatic region:

Cervical region: level Ib-V and SCF, extend to skull base.

Axillary region: SCF to infraclavical nodes; borders: sup.: C5-6, inf.:

tip of scapula or 2 cm below the most inferior node, med.:

ipsilateral transverse process, lat.: flash axilla.

Epitrochlear region.

Mediastinal region: SCF + mediastinum + hilar

Paraaortic LN +/- spleen: 7 mm around vessel.

Mesenteric region: splenic hilar, portal, celiac

Inguinal region.

Popliteal region

PTV: CTV with 1-1.5 cm margin

Involved-Nodal

Radiotherapy

(INRT)

GTV = Grossly involved lymph nodes

CTV =

initial volume of lymph node before chemotherapy or

encompassing pre-chemo length and post-chemo width.

PTV: CTV with 1-1.5 cm margin

Option: fusion with PET-CT or pre-treated image

Radiation Dose

Follicular lymphoma

24 – 30 Gy

Bulky lesion: 36 Gy

MALT lymphoma

Stomach: 30 Gy

Other organ: 24 – 30 Gy

Early stage mantle cell lymphoma

30 – 36 Gy

Consolidation RT of DLBCL

30 – 36 Gy.

Residual disease: 40 – 50 Gy

Mini-RT for palliation of advance stage of

low-grade lymphoma (FL, SLL, MZL, MCL)

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Nonbulky Hodkin lymphoma (stage I-II)

20-30 Gy

Nonbulky Hodkin lymphoma (stage IB-IIB)

and stage III-IV

30-36 Gy

Bulky Hodkin lymphoma

30-36 Gy post ABVD; 36 Gy post

Stanford V

LPHL

Involved region: 30-36 Gy

Uninvolved region: 25-30 Gy

Radiation constraints (

QUANTEC IJROBP 2010;76:S10-S19

)

OAR

constraint

Brain stem

Dmax

＜

54 Gy

Optic nerve

Dmax

＜

55 Gy

Chiasm

Dmax

＜

55 Gy

Cochlea

Mean

≦

45 Gy

Parotid

Bilateral: Mean

≦

25 Gy

Unilateral: Mean

≦

20 Gy

Pharynx

Mean

≦

50 Gy

Larynx

Mean

≦

50 Gy

Esophagus

Mean

≦

34 Gy

lung

V20

≦

30 %

Heart

Mean < 26 Gy

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Liver

Mean < 30 Gy

Rectum

V50 ≦ 50%

Bladder

Dmax < 65 Gy (V40 ≦ 40%)

Kidney

Mean ≦ 15 Gy

Spinal cord

Dmax ≦ 50 Gy

Small bowel

V40 ≦ 195 cc. (V40 ≦ 30%)

Patient Set-up:

1. 建議以電腦斷層影像作為治療計畫的基礎，若治療照野包括巨觀腫瘤或有問

題淋巴腺時，建議該電腦斷層影像要注射顯影劑。

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Reference:

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2005;352:1250-1252.

3. Ballonoff A, McCammon R, Schwer A, et al. Increased overall survival in patients with stages I and ii diffuse large b-cell lymphoma treated with radiation therapy: a surveillance, epidemiology, and end results (SEER) analysis. Int J Radiat Oncol Biol Phys 2007;69S:S15-S16.

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