NHL

- Epstien-Barr virus - patients who have undergone an organ transplant - congenital or acquired immunosuppression ( EBV, HIV) - Chromosomal aberrations - Patients previously treated for Hodgkin's disease with chemo and radiation. - people exposed to agricultural herbicides || Precursor B-cell neoplasm -Precursor B-lymphoblastic leukemia/lymphoma --(precursor B-cell acute lymphoblastic leukemia) Mature (peripheral) B-cell neoplasms -B-cell chronic lymphocytic leukemia/ samll lymphocytic lymphoma -B-cell prolymphocytic leukemia -Lymphoplasmacytic lymphoma -Splenic marginal zone B-cell lymphoma (__+__ villous lymphocytes) -Hairy cell leukemia -Plasma cell myeloma/ plasmacytoma -Extranodal marginal zone B-cell lymphoma of MALT type -Nodal marginal zone B-cell lymphoma (__+__ monocytoid B cells) -Follicular lymphoma -Mantle-cell lymphoma -Diffuse large B-cell lymphoma --Mediastinal large B-cell lymphoma --Primary effusion lymphoma -Burkitt's lymphoma/Burkitt cell leukemia
 * Epidemiology: || Non-Hodgkin's Lymphoma (NHL) increases in incidence every year. It has increased 65% since the 1970's. It is more common in men than women and whites versus blacks.The median age is 65, with a peak in the 80-84 age group. 3 ||
 * Etiology: || The cause of NHL is unknown. Researchers have discovered that lymphomas are genetic alterations of the B or T lymphocyte cells. 3 NHL can occur any where in the body that lymphoid cells circulate including; lymph nodes, spleen, Waldeyer's ring, bone marrow, and the GI tract. 2 Risk factor for NHL include: 4
 * Signs & Symptoms: || The signs and symptoms of Non-Hodgkin's Lymphoma (NHL)are similar to those of Hodgkin's lymphoma: enlarged lymph nodes, fever, night sweats, fatigue, itching, and weight loss. Unlike Hodgkin's, however, NHL may arise in a wide variety of sites, most commonly in the lymph nodes, GI tract, and Waldeyer's ring. Clinically, lymphomas can appear as enlarged nodes or are discovered when the patients has symptoms related to the site and extent of the tumor involvement. For example, shortness of breath or a cough is symptomatic of lung involvement. Abdominal pain or a change in bowel habits may indicate pelvic disease. Symptoms of brain involvement may include headaches, vision problems, and seizures. Systemic symptoms are rare, occuring in only 10 to 15% of the patients at the time of presentation. 3 ||
 * Diagnostic Procedures: || The history and physical examination are the first standard steps along with the cytologic evaluations. Blood tests include a complete blood count (CBC), an HIV test, a blood chemistry, an urinalysis, serum lactate dehydrogenase (LDH), liver function tests, and serum alkaline phosphatase. A bone marrow biopsy is necessary because bone marrow involvement is common in many lymphomas; however, a MRI may be just as sensitive, if not more sensitive, than a biopsy. The MRI can also identify CNS involvement. A chest radiograph; a CT of the abdomen, pelvis, neck and chest; and a bone scan are also part of the first line of diagnostic tests. PET scans have been increasingly used for staging as well. Further diagnostic tests may include a gallium whole-body scan and upper GI or small bowel series. A CT scan of the brain may be recommended if previous tests or symptoms indicate possible disease at these sites. A lymphangiogram of the pelvis and abdomen are done if the CT scan shows abnormal results. 3  The initial diagnosis of NHL usually requires an excisional lymph node biopsy for precise classification. 8 ||
 * Histology: || **__B-cell Neoplasms__**

Precursor T-cell neoplasm -Precursor T-lymphoblastic lymphoma/leukemia --(precursor T-cell acute lymphoblastic leukemia) Mature (peripheral) T-cell neoplasms -T-cell prolymphocytic leukemia -T-cell granular lymphocytic leukemia -Aggresive NK-cell leukemia -Adult T-cell lymphoma/ leukemia (HTLV-1+) -Extranodal NK/T-cell lymphoma, nasal type -Enteropathy-type T-cell lymphoma -Hepatosplenic gamma-delta T-cell lymphoma -Subcutaneous panniculitis-like T-cell lymphoma -Mycosis fungoides/ Sezary syndrome -Anaplastic large-cell lymphoma, T/null cell, primary cutaneous type -Peripheral T-cell lymphoma, not otherwise characterized -Angioimmunoblastic T-cell lymphoma -Anaplastic large-cell lymphoma, T/null cell, primary systemic type
 * __T-cell and NK-cell neoplasms__**

MALT= mucosa-associated lymphoid tissue NK= natural killer HTLV= human T-cell lymphotropic virus 8 || Figure 1: Lymph Node areas.  7 || -Waldeyer's ring is commonly involved -Epitrochlear and brachial nodes are often involved (especially in follicular lymphoma) -Bone marrow and mesenteric lymph node envolvement is not uncommon in latter groups 2 || Figure 2: Grading for NHL.  2 || The staging system most often used to describe the extent of non-Hodgkin lymphoma in adults is called the Ann Arbor staging system. The stages are described by Roman numerals I through IV (1-4). Lymphomas that affect organs outside of the lymph system (extranodal organs) have E added to their stage (for example, stage IIE), while those affecting the spleen have an S added. If either of the following is present it means the disease is stage I: **Stage II** If either of the following is present it means the disease is stage II: **Stage III** If either of the following is present it means the disease is stage III: **Stage IV** If either of the following is present it means the disease is stage IV: Along with the Roman numeral, each stage is also assigned an A or B. The letter B is added (stage IIIB, for example) if any of the following "B symptoms" are present: These symptoms usually mean the disease is more advanced. If none of these B symptoms is present, the letter A is added to the stage. The type and stage of the lymphoma provide useful information about a person's prognosis, but for some types of lymphomas (especially fast-growing ones) the stage is not too helpful on its own. In these cases, other factors can give doctors a better idea about a person's prognosis (outlook). 1 ||
 * Lymph Node Drainage: || -Tumors may arise in any area of lymphoid aggression, such as lymph nodes, spleen, waldeyer's ring, bone marrow, Gastrointestinal tract, and other areas where lymphoid tissues circulate. 2
 * Metastatic Spread: || <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif;">Because lymph tissue is found in many parts of the body, non-Hodgkin’s lymphoma can start and spread to almost anywhere in the body.
 * Grading: || [[image:nhlgrade.jpg]]
 * Staging: || **Ann Arbor staging system**
 * Stage I**
 * The lymphoma is in a lymph node or nodes in only 1 region, such as the neck, groin, underarm, and so on.
 * The cancer is found only in 1 area of a single organ outside of the lymph system (IE).
 * The lymphoma is in 2 or more groups of lymph nodes on the same side of (above or below) the diaphragm (the muscle that separates the chest and abdomen). For example, this might include nodes in the underarm and neck area but not the combination of underarm and groin nodes.
 * The lymphoma extends locally from a single group of lymph node(s) into a nearby organ (IIE). It may also affect other groups of lymph nodes on the same side of the diaphragm.
 * The lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm.
 * The cancer may also have spread into an area or organ next to the lymph nodes (IIIE), into the spleen (IIIS), or both (IIISE).
 * The lymphoma has spread outside of the lymph system into an organ that is not right next to an involved node.
 * The lymphoma has spread to the bone marrow, liver, brain or spinal cord, or the pleura (thin lining of the lungs).
 * unexplained weight loss (more than 10% of weight)
 * soaking night sweats
 * unexplained fever of at least 101.5°F
 * Radiation Side Effects: || Acute Effects

-Acute side effects most often associated with mantle irradiation include temporary loss of change in taste, xerostomia, sore throat, esophagitis, low posterior scalp epilation, skin erythema, and occasionally dyspepsia and nausea and vomiting. -Acute effects of paraaortic irradiation include early-onset nausea and vomiting, which usually abates after the second or third treatment without antiemetic therapy.

Long-term Effects

-Second maligany neoplasms are the most clinically significant complications of treatment. -Long term sequelae specific to irradiation include impairment of muscle and bone evelopment and injury to lung,heart, thyroid gland, and reproductive organs. -Height reduction is most severe in prepubertal children treated with full-dose irradiation. -Slipped capital femoral epiphysis occurs in up to 50% of young children whose femoral heads have been irradiated. A threshold dose of 35Gy for the slippage was reported. -Radiation doses of 20-40 Gy to the mandible may result in dental abnormalities. -Cardiac sequelae, including pericarditis, valvular thickening, and coronary artery disease, are observed with irradiation to the heart. -Pulmonary complications, most typically pneumonitis, occur in up to 5% of patients treated with standard-dose irradiation. -Thyroid dysfunction, which may result from neck, mediastinal, or mantle field irradiation. -Infertility and impaired secretion of sex hormones are potential complications of pelvic irradiation. -Small bowel obstruction may be observed in patients who recieve paraaortic irradiation, particularly after surgical exploration. 2 || 1. Age (less than 60 years versus greater than 60 years) 2. Serum LDH ( less than normal versus greater than normal) 3. performance status ( 0, 1, versus 2 to 4) 4. stage ( I to II versus III to IV) 5. Extra-nodal site involvement ( less than 1 versus greater than 1) The 5 year survival rate is less than 50% for patients exhibiting 2 or more of thes significant factors. 2 ||
 * Prognosis: || There are 5 significant factors affecting the overall survival rate for NHL patients. 2
 * Treatments: || <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 113%;">"The main modalities used to treat NHL are radiation therapy and chemotherapy, with surgery limited to secure the diagnosis or manage selected extranodal sites." The first decision that has to be made in curative situations is between local treatment alone versus an approach that features local and systemic therapy. The decision is based on the "potential for local control, inherent risk of occult distant disease, and availability of curative chemotherapy."

There are three common terms used when describing the extent of radiation therapy in NHL treatment. The first is involved-field. This refers to treatment to the involved nodal regions with adequate margins or to the extranodal site and the immediate lymph node drainage. This type is most commonly used with localized lymphomas. The second term commonly used is extended-field radiation therapy. This "is a treatment plan including radiation therapy to the next-echelon lymph nodes." The third term is total-lymphoid irradiation. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 106.48%; vertical-align: super;">2 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 113%;"> Figure 3. Fields for total lymphoid irradiation. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 106.48%; vertical-align: super;">5 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 113%;"> Data from a large institutional experience has indicated that doses of 35 to 45 Gy are usually adequate to ensure high local control rates. The most frequent prescription used in the data was 35 Gy in 15 to 20 fractions over 3 to 4 weeks. For intermediate-grade lymphomas, especially the diffuse large cell type, doses are increased to 40 to 50 Gy. When these high doses are used for diffuse lymphomas, local recurrence rates vary from 15% to 20%.
 * __Radiation Therapy__**

For chemo, the majority of patients with intermediate-grade lymphomas are treated with cyclophosphamide, doxorubicin, vincristine sulfate, and prednisone (CHOP) chemotherapy. This would then be followed by involved-field irradiation. In patients who respond to the chemo, the data suggests that there doses can be limited to 30 to 35 Gy. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">

<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 122.1%;">For stage I and II limited disease, the appropriate margin consists of covering the contiguous lymphatic region. For stage II extensive disease, an appropriate margin consists of all lymphatic regions on the ipsilateral side of the diaphragm. For stage I disease involving the right upper cervical lymph nodes, the entire right neck and supraclavicular fossa should be irradiated. For patients that have disease involving the left inguinal and pelvic lymph nodes, the ipsilateral pelvic and paraaortic lymph nodes should be included in the irradiated volume.

"If radiation therapy is to be delivered on both sides of the diaphragm, an appropriate gap must be calculated between the fields at the surface of the skin on both the anteroposterior (AP) and posteroanterior portals to account for the normal divergence of the beam from each of the two fields. The objective of this calculation is to have the 50% isodose lines of the superior and inferior fields match exactly at the midplane."

__Treating the abdomen__: In NHL, the mesenteric lymph nodes are often involved and the GI tract is a common site for primary extranodal lymphoma. As a result, the entire abdominal cavity is often treated. When doses over 20 Gy are used, the dose to the anterior surface of the kidney is limited to 20 Gy by using posterior renal shielding. When treating the whole abdomen, "initial treatment consists of simple anterior and posterior fields from the dome of the diaphragm to approximately the level of the iliac crests (assuming that the inferior margin does not cut across known tumor)." When large tumors occur at this level, the fields contain the entire abdominal contents in one field, starting at the diaphragm and extending to the floor of the pelvis. When it is possible, in order to protect the iliac bone marrow, lead blocks are placed over the lateral portions of each ileum. With these large fields, the dose should not be greater than 1.5 Gy per day. The tumor dose is approximately 15 Gy given over 2 to 3 weeks. During the first part of the treatment, the right lobe of the liver is blocked anteriorly to minimize the dose it receives. This is compensated for in the second part of the treatment which continues treating the upper abdomen with lateral fields. When there is massive abdominal disease, the pelvic irradiation may continue by opposing AP techniques. "The upper abdominal field receives opposing cross-table lateral fields with the patient in the supine position and with blocks to protect both kidneys." The margins of the field include: posterior margin--anterior to the kidneys but posterior to the periaortic nodes; anterior margin--extends to the anterior abdominal wall. By using these lateral fields with the kidney blocks, the upper abdomen is able to recive another 15 Gy in approximately 2 weeks bringing the nodal dose to 30Gy in 4 to 5 weeks. "When kidney location prevents the use of lateral field technique, AP irradiation techniques are required, and the use of 5-cm-thick lead kidney blocks is necessary posteriorly to keep the total renal dose under 25 Gy." The last part to the abdominal irradiation consists of a wide paraaortic field using AP and PA fields. "The lateral width of the upper portion of this wide paraaortic field extends from the lateral margin of one kidney to the lateral margin of the opposite kidney. The total dose delivered to the central abdomen is 45 Gy over approximately 6 to 7 weeks." It is very important to watch the blood counts during this course of irradiation. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 106.48%; vertical-align: super;">2 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> Figure 4. AP/PA field used to treat to 1500cGy because of kidney inclusion. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">3 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> Figure 5. Second part of abdominal treatment excluding the kidneys. Dose given to the lateral fields is 1500 cGy. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 96.8%; vertical-align: super;">3 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> Figure 6. Third portion of abdominal treatment. AP/PA fields with 5 HVL Kidney blocks. Total dose to all 3 fields is 4500 cGy. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">3 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 111%;"> "In patients with advanced follicular lymphocytic lymphoma or follicular mixed lymphoma, total-body irradiation (TBI) may be used for palliation." There are several fractionations in which the dose can be delivered but usually 1.5 Gy is delivered to midplane over a period of 5 weeks at a rate of 30 cGy per week in 2 or 3 fractions per week.

Chemo regimen choices are made based on histology, regardless of the site of disease. Most of the time when chemo and radiation are combined, chemo is given first so that the patient can be assessed for their response and reduction of disease bulk. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">
 * __Chemotherapy and Combined-Modality therapy__**

__**Treatment by Stage and Grade **__ Figure 7. Treatment decisions based on stage and grade. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">2 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">

__**Primary Extranodal Lymphomas**__ __Gastric Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Intestinal Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Waldeyer's Ring Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Salivary Gland Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Thyroid Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Orbital Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Breast Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Testicular Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Bone Lymphom__ __<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">a __ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> __Primary CNS Lymphoma__ <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Figure 8. TD5/5 for many possible organs exposed in NHL irradiation. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">6,3 || 1. American Cancer Society. How is Non-Hodgkins Lymphoma Staged?. Available at: []. Accessed: February 10, 2010. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">2. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 111%;">Chao KS, Perez CA, Brady LW. //Radiation Oncology Management Decisions.// 2nd edition//.// Philadelphia, PA: Lippincott Williams & Wilkins. 1999, 2002; 589-598, 674-675 . 3.Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. Second Edition. St. Louis, Missouri: Mosby, Inc. 2004; 602-603, <span style="color: #008000; font-family: 'Times New Roman',Times,serif;">80, 607, <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">603-604 <span style="color: #008000; font-family: 'Times New Roman',Times,serif;">. 4. Rubin P. //Clinical Oncology A Multidisciplinary Approach for Physicians and Students.// 8th Edition. Philadelphia, PA: W.B. Saunders Company. 2001; 318-325. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">5. Khan FM. //Treatment Planning in Radiation Oncology.// 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2007; 350. 6. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 111%;">Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">[]. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 111%;">Accessed February 13, 2010. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 111%;">7. Waldeyer's Tonsillar Ring. (n.d) In Wikipedia. Retrieved February 12, 2010, from [|http://en.wikipedia.org/wiki/Waldeyer's_tonsillar_ring]. <span style="color: #008080; font-family: 'Times New Roman',Times,serif;">8. Lenhard RE, Osteen RT, Gansler T. The American Cancer Society's Clinical Oncology. 1st edition. Atlanta, GA: The American Cancer Society, Inc. 2001: 503-504.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Most common primary extranodal lymphoma.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Antibiotic therapy is recommended.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Surgery has not been found to alter overall survival rates.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Surgical resection is standard with intestinal lymphoma.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">If resection cannot be achieved in advanced disease, the treatment is anthracycline-based chemotherapy, sometimes followe by radiation.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Prognosis is poor.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">This includes tonsil, base of tongue, and the nasopharynx
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">With traditional treatment, involved-field irradiation (which is the primary tumor and its draining neck nodes), and moderate radiation doses have been used producing survival rates of 50% to 60% for stage IE lesions and 25% to 50% for IIE lesions.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">A combination of doxorubicin-based chemo and radiation to the primary tumor and neck nodes has been used and resulted in control rates of 80% and survival rates of 60% to 75%.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"Radiation therapy offers excellent local control for limited-stage salivary gland lymphomas."
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Local control is achieved in over 75% of these patients with locoregional, moderate-dose irradiation (40 to 45 Gy).
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">These lesions are easily controlled with low-to-moderate radiation doses.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"Treatment with an anterior orthovoltage x-ray field or electron beam provides satisfactory therapy for anterior lesions limited to the eyelid or bulbar conjunctiva, with the advantage of sparing orbital structures compared with use of a photon beam."
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">When an anterior orthovoltage field is used, the use of a lead eye shield can reduce the lens dose to less than 5% to 10%.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"For unilateral bulbar tumors, a two-field technique is used (4- to 6- MV photons), with a corneal shield placed in the anterior and lateral fields, angled posteriorly, to spare the lens in both eyes."
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">A different option uses an isocentric treatment with two oblique, wedged fields and the eye shield.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Local control rates of 95% for patients with low-grade orbital and conjunctival lymphomas are achieved with radiation therapy doses of 20 to 30 Gy in 10 to 20 daily fractions.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"Fewer data are available for intermediate- and high-grade lymphomas, but dose-control data for lymphoma suggest that for patients with small bulk tumors, a dose of 35 GY provides excellent local control. For patients wit larger intermediate- and high-grade tumors, short-duration doxorubicin-based chemotherapy followed by radiation therapy is recommended."
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Preserving the breast is possible most of the time.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Radiation doses of 45 to 50 Gy are given to the whole breast, 40 to 50 Gy to the ipsilateral axillary nodes. This results in local control of 75% to 78%.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Patients that have low-grade lymphomas are treated with radiation alone. Patients with intermediate- and high-grade lymphomas are treated with combined-modality therapy.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">CNS prophylaxis should be given to all patients that have high-grade histology.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"Traditional postorchiectomy therapy involves radiation therapy to the periaortic and ipsilateral pelvic lymph nodes, with cure rates of 40% to 50% for Stage I and 20% to 30% for stage II disease."
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Improved survival to 93% at 4 years for patients with localized testicular lymphomas is achieved by doxorubicin-based chemotherapy.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">The role of radiation isn't clear.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"Low-dose irradiation (25 to 30 Gy in 10 to 15 daily fractions) to the contralateral testis eliminates the risk of failure at this site, carries little morbidity, and is recommended for all patients with primary testicular lymphoma."
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">CNS prophylaxis is an important part of this treatment.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">This should be treated with anthracycline-based chemo and radiation afterwards to the whole bone with a minimum dose of 35 Gy.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Radiation helps improve the median survival by only 15 months.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">The treatment fields are usually whole brain fields with an extension to include the upper cervical spine and sometimes the orbit.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Studies have shown that chemo followed by radiation did not improve results over using radiation alone.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">"Radiation doses above 50 Gy may lead to longer survival." <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">2 ||
 * TD5/5: || [[image:NHLTD5.5.jpg]]