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Hodgkin Lymphoma



Radiation Therapy (RT)


RT was previously used to treat Hodgkin lymphoma alone - but is now used to reduce the risk of recurrence in areas of bulky disease at presentation.

Hemoglobin should be kept above 10 gm/dL during RT.

Standard therapy for all intermediate risk category patients (not on protocol) would be to give involved field radiotherapy (21 Gy in 14 fractions of 1.5 Gy per day).


Treatment volumes:

GTV = Gross Tumor Volume = Areas of disease involved at presentation. Includes any lymph node measuring > 1.5 cm in a single axis on CT scan.

CTV = Clinical Target Volume = Anatomical compartment.

PTV = Planning Target Volume = 1.0 cm margin around the CTV to account for patient motion and set-up variability.

Anatomical compartments that are contiguous to involved compartments will also need to be treated if they contain  lymph nodes > 1.0 cm on CT.


Definitions of Terms for Historical and Current Radiation Therapy (RT) Volumes:


Irradiated Regions

Involved field

Entire lymph node area

Extended field

Involved nodal area and uninvolved contiguous region

Mantle field

Cervical, supraclavicular, infraclavicular, axillary and mediastinal, hilar and inferior mediastinal nodes

Inverted Y

Paraaortic, pelvic and inguinal nodes ± spleen

Total nodal

All involved nodal areas

Subtotal nodal

Mantle and paraaortic node


Liver ± paraaortic node

Preauricular field

Small volume with preauricular nodes

Waldeyer’s ring field

Pre- and postauricular nodes, occipital nodes and lymphoid structures in base of tongue and nasopharynx


Treatment Technique

Different factors should be taken into account when planning RT for Hodgkin lymphoma to minimize:

  • Organ/normal tissue damage
  • Impairment of future growth and development

Precise treatment achieved using:

  • Immobilization devices
  • CT simulation and planning
  • Using a compensator or other technique to ensure RT dose homogeneity
  • Partial transmission blocks can be used. For example, if treating the liver, this technique can be used as a mechanism to reduce dose that reaches liver but still maintain full dose to adjacent nodes.
  • Treatment using a linear accelerator with beam energy of 6mV
  • Portal imaging to verify that the actual treatment field matches the planned treatment field

Protection of reproduction organs is important in pediatric patients.

For females:

  • Transposition of ovaries to central midline position and then using a pelvic block is possible during pelvic irradiation. 

For males:

  • Testicular shielding should be used whenever possible. 


Techniques for different RT fields:


Mantle field

Anterior field simulation:

  • elevate arms to raise axillary and infraclavicular lymph nodes to reduce lung irradiation

Posterior field simulation:

  • arms abducted to 90˚ and hands placed on iliac crest
  • does not include infraclavicular lymph nodes

Transmission blocks to shield:

  • cardiac and lung area, larynx, mandible, humeral heads and spinal cord

Waldeyer’s Ring

For unilateral bulky upper neck disease:

  • weighted fields used

Paraaortic field

Equally weighted anterior and posterior portals

2 cm lateral borders to transverse processes

Inferior border – bottom of fourth lumber vertebra

Gap placed between mantle and paraaortic field

Spleen field

If treated separate from paraaortic field a 1 cm gap on skin is required

Splenic Hilar nodes

Needs to be treated if patient had laparotomy – surgeon marks splenic hilum during surgery

Can be included in paraaortic field

Pelvic field

Iliac crests and midline structures are shielded

Fertility preservation:

  • testicular shield for male patients
  • transfix ovaries to midline and shield for female patients





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