Breast-Sparing Proton Therapy for Hodgkin's Disease

According to the National Cancer Institute's Surveillance, Epidemiology, and End Results
Program, there will be an estimated 8,490 new cases of Hodgkin's Lymphoma (HL) in the United
States in 2010, with an estimated 1,320 deaths (Jemal, Siegel et al.). The unadjusted rates
of 5 year overall survival are approximately 95%, and remain among the highest of all
childhood and adult malignancies. With many children and young adults surviving into
advanced age, the impetus has been to develop less toxic yet equally effective treatments.
One of the main approaches taken over the last 25 years to minimize long-term treatment
toxicity has been to limit the amount and volume of radiation received by patients. This
pilot study continues along those lines, attempting to further refine the delivery of
radiation therapy (RT) in order to avoid one of the most notorious long-term side-effects:
secondary breast cancer.

Multiple studies investigating late toxicity in long-term survivors of pediatric Hodgkin's
Lymphoma have shown the risk of breast cancer in young females receiving mediastinal
radiation to be 50 times greater than their age-matched counterparts. The Late Effects
Study Group, with a median follow-up of 17 years, reported a breast cancer incidence of 16%
with a standardized incidence ratio of 55.5 (Bhatia, Yasui et al. 2003). Through
utilization of breast-sparing proton therapy, we hope to provide young female patients with
the benefits of radiation therapy while decreasing their risk of secondary breast cancer,
thus increasing the therapeutic ratio.

In a prior computer-based, in-silico, dose planning study, utilizing the most basic beam
orientation (a single PA beam), we showed that dose to breast tissue was reduced by a
minimum of at least 80% with proton treatment compared to standard AP-PA photon treatment
(in publication). Furthermore, dose to clinical target volume was maintained, and dose to
other normal structures was statistically no worse. We now aim to validate these findings
by verifying the beam range, in-vivo, via post-treatment combined Positron Emission
Tomography-Computer Tomography (PET-CT) imaging in young females undergoing
supra-diaphragmatic radiotherapy for Hodgkin's Disease.

Inclusion Criteria:

- Female sex

- Age >/= 10 years old and < 30 years old

- Pathologically confirmed classical Hodgkin's Lymphoma

- At least one site of disease located above the diaphragm

- Signed study-specific consent prior to initiation of therapy

- Women of child-bearing potential must have a negative pregnancy blood test within 7
days of starting protocol therapy.

Exclusion Criteria:

- Previous radiation therapy to any part of the body.

- Parenchymal lung involvement at initial presentation or any patient that may need
whole lung irradiation as per institutional guidelines.

- Lymphocyte predominant histology not eligible.

- Significant infection or other coexistent medical condition that would preclude
protocol therapy such as:

- History of HIV/AIDS

- History of collagen Vascular Disease

- Symptomatic congestive heart failure

- Unstable angina pectoris or myocardial infarction within 6 months

- Uncontrolled hypertension (systolic blood pressure > 160 mm Hg or diastolic
blood pressure > 100 mm Hg on 2 consecutive measurements separated by 1 week).

- History of uncontrolled diabetes

- Psychiatric illness/social situations that would compromise patient safety or
limit compliance with study requirements