Overview                                                                   

Hematologic malignancies include lymphomas, leukemias and multiple myeloma (MM).  Lymphomas are cancers of the lymphatic system, a network of glands and vessels which are an important component of the body’s immune system. 

Along the lymphatic network are bean-shaped organs known as lymph nodes, which are responsible for the storage and manufacture of infection fighting cells.  Lymph nodes are located throughout the entire body.

Lymphomas have been traditionally divided into two main types: Hodgkin’s Disease and Non-Hodgkin’s Lymphoma (NHL).  NHL consists of a large variety of tumor types occurring in both adults and children. 

Overall, NHL arises in approximately 60,000 patients per year in this country.  Hodgkin’s Disease is considerably less common with less than 8,000 cases per year.  Multiple Myelomas and leukemias are diagnosed in 16,500 and 35,000 patients each year, respectively.

Interested in learning more about leukemias and lymphomas? Check out the American Cancer Society website.

Role of Radiation Therapy                                     

For much of the later part of the 20th Century, Radiation Therapy occupied a primary role in the treatment of a wide variety of lymphomas, notably Hodgkin’s Disease (view article).  Today, however, radiotherapy is more commonly used as an adjunct to chemotherapy, particularly in patients with bulky, residual or refractory disease (view article). 

Radiation therapy may also be used following high dose chemotherapy and autologous stem cell transplantation in both Hodgkin’s Disease (view article) and Non-Hodgkin’s Lymphomas (NHL) (view article).

The primary role of Radiation Therapy in patients with leukemias is in the form of total body irradiation (TBI) as a preparative regimen in patients undergoing high dose chemotherapy and stem cell transplantation (view article). 

Radiotherapy is also often used to treat patients with chronic leukemias (CLL) suffering from large, bulky lymph nodes.

Radiation Therapy Techniques                              

A variety of irradiation techniques have been used in patients with Hodgkin’s Disease and NHL.  One of the most common techniques was a “Mantle Field” which encompassed the mediastinum, bilateral supraclavicular, infraclavicular, axillary and cervical lymph nodes. A “Mini-Mantle” included all the above lymph node chains except the mediastinum.

Mini-Mantle Radiotherapy Fields

Today, more localized ‘involved’ fields are more commonly used, encompassing solely the involved lymph node chains and occasionally the adjacent uninvolved sites.  Total doses range from 20-40 Gy delivered over 2-4 weeks.

Newer radiotherapy techniques, such as intensity modulated radiation therapy (IMRT), are not commonly used in patients with Hodgkin’s Disease and NHL given the low doses required.  However, select lymphoma patients may benefit from IMRT notably patients with tumors arising in head and neck sites (adjacent to radiosensitive salivary glands) and those with bulky tumors in the para-aortic regions (adjacent to the kidneys).

IMRT treatment plan in a patient with stage IA NHL of the right neck Note sparing of the right parotid gland

Total Body Irradiation

As the name implies, total body irradiation (TBI) involves irradiation of the entire body. It is typically used in conjunction with high dose chemotherapy in adult and pediatric patients undergoing stem cell transplantation for leukemias, lymphomas and other hematologic conditions.

The purpose of TBI is to eradicate remaining cancer cells and to cause immunosuppression (depression of the immune system).  Immunosuppresion is required to help reduce the risk of rejection of transplanted tissue.  Since the immune cells of the body are widely dispersed, irradiation of the entire body is indicated.

Although the entire body is irradiated, care is taken to limit the dose to the underlying normal lung tissue.  This is done with the use of customized lung blocks fabricated using low-melting point metal alloy known as “cerrobend”.  These blocks are carefully placed over the lungs at the time of treatment.

Lung Blocks used to reduce dose to lung

TBI treatment typically is delivered twice daily over approximately 3 days.  However, a variety of approaches are used depending on the tumor site and the individual protocol.  A current multiple myeloma TBI regimen, for example, consists of a single fraction of 2 Gy.  In most protocols, however, the total dose is 12 Gy.

Increasing interest has recently been focused on the application of IMRT in patients undergoing TBI, a technique known as intensity modulated TBI (IM-TBI). In this technique, which remains experimental at the present time, sophisticated treatment planning computers are used to focus the radiation dose preferentially on the bone marrow, reducing the dose delivered to adjacent critical tissues. 

Dr. Mundt and his former colleagues at the University of Chicago have explored the feasibility of IM-TBI and it is hoped that clinical trials will evaluate the benefits of this technique in the coming years. Click here to view a copy of their most recent study.

IM-TBI plan.  Note sparing of brain, lung and liver.

UCSD Leukemia & Lymphoma Team                              

The UCSD Leukemia & Lymphoma Team is comprised of dedicated professional with considerable experience in the treatment of patients with hematologic malignancies. 

Arno J. Mundt M.D. is the Chief of the Leukemia & Lymphoma Service in the UCSD Department of Radiation Oncology.

Arno J. Mundt, M.D. Chief, Leukemia & Lymphoma Service Department of Radiation Oncology

Dr. Mundt has considerable experience treating leukemias and lymphomas in both adults and children. 

Working closely with Dr. Mundt in the care of leukemia and lymphoma patients treated in the Department is Radiation Nurse, Michelle Russell, R.N.

Fiona Nasseraddin, R.N. Radiation Nurse Department of Radiation Oncology

The treatment of leukemia & lymphoma patients is a team approach. Dr. Mundt works together with hematologists Edward (Ted) Ball, M.D., Peter Curtain, M.D., Januario Castro, M.D., Peter Holman, M.D. and Catriona Jamieson, M.D., Ph.D.

Edward (Ted) Ball, M.D. Hematologist

Peter Curtin, M.D. Hematologist

Januario Castro, M.D. Hematologist

Peter Holman, M.D. Hematologist

Catriona Jamieson, M.D., Ph.D. Hematologist

Leukemia & Lymphoma Publications by UCSD Radiation Oncology Faculty   

Listed below are Leukemia & Lymphoma Articles published by members of the UCSD Department of Radiation Oncology.  For a full list of published articles by UCSD Radiation Oncology faculty see Research section

Aydogan B, Mundt AJ, et al. Linac-based intensity modulated total marrow irradiation. Technol Cancer Res Treat 2006;5:513

Jose BO, Koerner P, Spanos WJ Jr, Paris KJ, Silverman CL, Yashar CM, et al. Hodgkin's lymphoma in adults--clinical features. J Ky Med Assoc 2005;103:15

Jose BO, Koerner P, Bertolone S, Patel CC, Spanos WJ, Paris KJ, Silverman CL, Yashar CM. Pediatric Hodgkin’s Disease. J Kentucky Med Ass 2004;102:104

Mundt AJ, et al.  What is the optimal treatment volume in Hodgkin's disease patients undergoing high dose chemotherapy, stem cell rescue and adjuvant radiation therapy?  Radiat Oncol Invest 1999;7:353

Mundt AJ, et al.  Patterns of failure and outcome of patients with aggressive non-Hodgkin's lymphoma undergoing high dose chemotherapy and stem cell rescue.  Int  J Radiat  Oncol  Biol  Phys 1997;39:617

Mundt AJ, et al. Patterns of Failure  and Outcome Following High-Dose Chemotherapy and Bone Marrow Transplantation  With Involved Field Radiotherapy for Relapsed and Refractory Hodgkin's Disease. Int  J Radiat Oncol Biol Phys 1995;33:261

Vandermolen L, Rice J, Rose MA, et al. Ringed sideroblasts in primary myelodysplasia: leukemic propensity and prognostic factors. Arch Int Med 1988;148:653-656