Image-Guided Radiation Therapy in Lymphoma Management: The Increasing Role of Functional Imaging

Overview

An ideal text for radiation oncologists, hematologist-oncologists, and radiologists, Image-Guided Radiotherapy and Functional Imaging in Modern Lymphoma Management is the foremost source for information on the increasingly important subject of image guided radiation therapy (IGRT) and its crucial role in the clinical evolution of high-precision ionizing beam therapy. An understanding of IGRT allows clinicians to improve targeting accuracy and safely increase dosage administration without increasing toxicity in normal, healthy tissue areas, resulting in better lymphoma patient outcomes.

Contents

Section A: Background for incorporation of functional imaging approaches into IGRT planning for lymphoma

• Functional imaging in IGRT treatment planning: The next big step in lymphoma radiotherapy -Nidhi Sharma and Roger Macklis
• Role of 18F-FDG PET/CT in the evaluation of lymphoma - Dominique Delbeke, Angelika Bischof Delaloye and Peter S Conti
• PET-CT in radiotherapy treatment planning - Stephanie A. Terezakis and Joachim Yahalom

Section B: General concepts in modern lymphoma management

• Overview of systemic management options for hodkin's and non-hodgkin's lymphoma - John W Sweetenham
• Risk and response-adjusted consolidative treatment fields - Nidhi Sharma and Roger Macklis
• Hodgkin's lymphoma - Nidhi Sharma and Roger Macklis
• Low grade and follicular histologies - Nidhi Sharma and Roger Macklis
• Aggressive B cell NHL - Henry Blair and Nidhi Sharma

Section C: Other Specific Anatomic Sites

• Primary central nervous system lymphomas - Erin S. Murphy and Samuel T. Chao
• Orbital B cell lymphoma - Kevin Stephans, Nidhi Sharma, Mohammad Khan and Roger Macklis
• B cell NHL of the stomach - Tony Y. Eng and Chul S. Ha

Reviews

J. Daniel Bourland, Ph.D.(Wake Forest University School of Medicine)

**Description**

This book, described by the authors as an introductory manual, reviews the roles for conventional and advanced imaging and radiation treatment for the management of lymphomas. Lymphomas are relatively radiosensitive and radiation treatment has an important role, but most lymphomas, which are a diverse cohort of disease types and anatomical locations, are primarily treated through the use of chemotherapeutic agents. At the same time, imaging is used for diagnosis and especially staging, and image-based radiation treatment using lymphoma target volumes defined on anatomic and functional (e.g., biological) imaging is a developing technique. Thus, the presentation of image-based radiation treatment of lymphomas makes this manual a niche reference for clinically oriented individuals with an interest in lymphomas as well as the developing roles for radiation treatment.

**Purpose**

The premise is that "functional imaging," that is, imaging that shows both biology and anatomy ("bioanatomic imaging"), has a growing role in diagnosis, staging, radiation treatment, and response monitoring for lymphomas. The challenging issues for lymphoma are that, while nodal regions can be identified as radiation targets, lymphomas tend to be heterogeneous with poorly defined borders that appear diffuse on anatomical as well as functional imaging. The focus is mainly on FDG-PET (PET/CT) and its uses in staging and treatment planning, although non-FDG PET is mentioned. The title of the book, Image-Guided Radiation Therapy is somewhat misleading, because image-based treatment of lymphoma is presented (e.g., staging, treatment planning), but image-guidance for verification of individual treatment fractions is not covered. This limitation likely agrees with the editor's statements that the book may stimulate technologies for better radiotherapy of lymphomas. In this sense, this book may be ahead of its time.

**Audience**

Clinically-oriented individuals such as residents and clinicians, as well as those seeking background information on lymphomas, will find this relatively short book (10 chapters, 80 pages) of use, particularly if they are interested in lymphoma multidisciplinary treatment regimens. The editors and authors are from Cleveland Clinic, and the book summarizes their treatment approaches.

**Features**

Anatomic (CT and MR) and functional (FDG-PET, PET/CT, and non-FDG PET) imaging are presented, with relevance for diagnosis and staging. The authors note that uses in treatment planning and treatment response for PET imaging are still developing, including qualitative vs. quantitative PET image assessment for detection of cancer (e.g., SUV > 2.2 indicates malignancy). After a nice chapter on FDG PET imaging for oncology, approaches with PET imaging and radiotherapy are described for Hodgkin's, Non-Hodgkin's, orbital, primary CNS, and other lymphomas. These chapters include good clinical reviews for each lymphoma type, and sometimes include example radiation treatment plans. A weakness is that, given the emphasis on functional imaging, there are relatively few images showing CT, PET, and PET/CT presentations for each type of lymphoma, although the challenges of lymphoma target definition are discussed. And, as stated earlier, there is no discussion of image-guided radiation therapy (IGRT) (e.g., daily, in-room imaging for treatment validation). Essentially, the editors have put forward a summary to stimulate work in imaging and radiation treatment for the benefit of future lymphoma patients.

**Assessment**

In this introductory manual, the editors and authors share their imaging and radiation oncology expertise for the management of lymphomas, with hopes of encouraging new radiation approaches and multidisciplinary care for patients with this diverse disease. While imaging has its place for diagnosis, staging, and evaluation of treatment response for lymphoma, image-based target definition and daily in-room imaging for IGRT of low contrast and diffuse-boundary lymphomas remain to be developed, especially given that lymphomas tend to be radiosensitive and do not need to be treated to high doses that could also have morbidity for adjacent tissues. Thus, this manual reflects the current status for radiotherapy of lymphomas in the modern era, and is a niche book intended for a specialized audience with clinical interests in the management of lymphoma.

Weighted Numerical Score: 56 - 2 Stars

Authors

Roger M. Macklis, MD, is a Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio, USA. He has authored more than 100 articles, book chapters, and textbooks. In addition, he is an active member of numerous professional societies including the American Society for Therapeutic Radiology and Oncology and the American Society of Clinical Oncology. Dr. Macklis’s research interests are focused on new approaches to increasing precision in radiotherapy including biological tumor targeting and automated aspects of focal radiotherapy. He also is involved in research on automated systems for error prevention and quality assurance in medicine.

Peter S. Conti, MD, PhD is a Professor and Director of Nuclear Medicine at the University of Southern California, Los Angeles, California, USA. He is board certified in Nuclear Medicine specializing in diagnostic imaging applications in oncology. He is a member of the Society of Nuclear Medicine, American College of Radiology, and the American College of Nuclear Physicians. He is an expert in the clinical use of positron emission tomography (PET) in the diagnosis, staging and treatment monitoring of cancer. His research interests include the development of new radiolabeled imagining agents for use in the diagnosis of cancer and infectious disease and evaluation of the effects of gene therapy on tumors.