Perspective

Evolution of Radiation Fields from Involved Field to Involved

Site—A Summary of the Current Guidelines by the
International Lymphoma Radiation Oncology Group
Hans Theodor Eich *, Niklas Benedikt Pepper and Michael Oertel

Department of Radiation Oncology, University Hospital Muenster, 48149 Muenster, Germany;

[email protected] (M.O.)
* Correspondence: [email protected]

Abstract: Radiation therapy has been proven to be highly effective in the treatment of lymphoma.
With increasing rates of long-term survival, the reduction in toxicity has gained importance. The
evolving understanding of the diseases’ biology, as well as technical and conceptual advances, allows
for a precise and individualized application of irradiation. Smaller treatment fields and safety margins
make it possible to spare healthy neighbouring tissue (organs at risk). The International Lymphoma
Radiation Oncology Group (ILROG) has developed several guidelines to optimize radiotherapy
treatment in lymphoma patients. Since its introduction in 2013, involved site radiotherapy (ISRT) has
been adopted as the standard of care in most treatment regimens in adult lymphoma. This article
serves as a summary of the current ILROG guidelines, also considering contemporary developments
and possible future directions.

Keywords: lymphoma; radiation therapy; ISRT; IFRT

1. Introduction
Citation: Eich, H.T.; Pepper, N.B.;
Oertel, M. Evolution of Radiation
Most lymphatic malignancies are sensitive to radiotherapy (RT), prompting the intro-
Fields from Involved Field to
duction of RT for lymphoma treatment. Curative treatment for this complex spectrum of
Involved Site—A Summary of the diverse entities was made possible by the development of the linear accelerator by Henry
Current Guidelines by the Kaplan in the 1960s, using large extended fields such as “mantle field” or “inverted y”
International Lymphoma Radiation as part of total lymphoid RT for Hodgkin’s lymphoma (HL). The underlying treatment
Oncology Group. Lymphatics 2023, 1, volumes have since been adapted for other lymphoma entities (non-Hodgkin’s lymphoma,
262–272. https://doi.org/10.3390/ NHL) and have been subject to considerable change over time [1].
lymphatics1030017 Scientific effort and technical advances have led to improved outcomes in lymphoma
patients, with high rates of disease control and long-term survival for a group of diseases
Academic Editor: Varsha Gandhi
previously considered fatal. Because of possible short- and long-term toxicity, the risk–
Received: 29 August 2023 benefit ratio of RT as a single- or part of a combined-modality treatment was constantly
Revised: 14 October 2023 reevaluated in a series of treatment de-escalation trials. In addition to lower doses, the
Accepted: 30 October 2023 reduction in side effects was achieved via the use of smaller treatment fields, sparing
Published: 8 November 2023 normal tissue. Involved field radiotherapy (IFRT) replaced extended field RT (EFRT),
marking the first step from uniform treatment towards individually tailored planning. De-
lineation of specific sites of disease necessitated the definition of corresponding anatomical
Copyright: © 2023 by the authors.
landmarks [2].
Licensee MDPI, Basel, Switzerland.
Since then, further technological advances have increased the safety and accuracy
This article is an open access article of application of RT, rendering even smaller target volumes possible. Identification of
distributed under the terms and lymphoma infiltration and monitoring of response via metabolic PET/CT-imaging, giving
conditions of the Creative Commons a precise representation of disease extension, has proven to be a valuable basis for RT and
Attribution (CC BY) license (https:// encouraged aspirations of achieving the smallest possible field size.
creativecommons.org/licenses/by/ The International Lymphoma Radiation Oncology Group (ILROG), a board of experts
4.0/). founded in 2010, has devoted itself to the improvement as well as the harmonization and

Lymphatics 2023, 1, 262–272. https://doi.org/10.3390/lymphatics1030017 https://www.mdpi.com/journal/lymphatics

 Lymphatics 2023, 1, FOR PEER REVIEW

Lymphatics 2023, 1 The International Lymphoma Radiation Oncology Group (ILROG), 263 a boa
experts founded in 2010, has devoted itself to the improvement as well a
harmonization and standardization of RT lymphoma treatment by conducting cl
trials
standardization of RTand developing
lymphoma guidelines
treatment for state-of-the-art
by conducting treatment
clinical trials [3–10]. In 2014,
and developing
guidelines for state-of-the-art treatment [3–10]. In 2014, their proposal of involved fields.
proposal of involved site radiotherapy (ISRT) further decreased IFRT site Today
principle has become the standard of care for most lymphoma entities
radiotherapy (ISRT) further decreased IFRT fields. Today, this principle has become the [11–13]. This
serves
standard of care as a lymphoma
for most summary ofentities
the underlying guidelines,
[11–13]. This the status
paper serves quo, andofpossible f
as a summary
the underlyingdevelopments
guidelines, theregarding theand
status quo, usepossible
of ISRT.future developments regarding the
use of ISRT.
2. From Involved Field to Involved Site
2. From Involved Field
IFRTtowasInvolved Site to EFRT in a series of trials that combined RT with comp
non-inferior
IFRT waschemotherapy
non-inferior toregimens.
EFRT in a Whileseries of trials that
disease combined
control RT with compati-
was unchanged, combined-mo
ble chemotherapy regimens.
settings While disease
with de-escalated RTcontrol
resultedwasin unchanged,
reduced treatment combined-modality
toxicity [2,14–16], but
settings with de-escalated RT resulted ininreduced
continuing improvements imagingtreatment
(especiallytoxicity [2,14–16],
the emergence but with and trea
of PET/CT)
continuing improvements in imaging (especially the emergence of PET/CT) and
delivery, further de-escalation seemed achievable: the origin of ISRT lies in the conctreatment
delivery, further de-escalation
involved seemed achievable:
node radiotherapy (INRT),thewhich
origin wasof ISRT lies in theby
introduced concept of
the EORTC gro
involved nodeGirinsky
radiotherapy
et al.(INRT),
in 2006which[17], was introduced
adapted by theby the EORTC
German groupStudy
Hodgkin of Girin-
Group [18]
sky et al. in 2006 [17], adapted
successfully by theinGerman
applied Hodgkin Study
the corresponding EORTCGroup [18], and
H10-trial successfully
[19] and the HD17 tria
applied in the corresponding EORTC H10-trial [19] and the HD17-trial [20]
on patients with early-stage HL. This concept marks the furthest reduction on patients within RT fiel
early-stage HL. This concept marks the furthest reduction in RT field size
for lymphoma treatment to date. Leveraging pre-treatment imaging in the rad for lymphoma
treatment to date. Leveraging
application pre-treatment
position allowed for imaging in theof
delineation radiation application
small margins around position
initial tumour
allowed for delineation of small margins around initial tumour mass
and lymph node remnants with sharp exclusion of organs at risk (OARs). and lymph nodeThe limi
remnants withof sharp exclusion of organs at risk (OARs). The limitation of this
this concept lies in the ambitious prerequisites for baseline imaging requiring concept lies op
in the ambitious prerequisites for baseline imaging requiring optimal co-registration
co-registration of pre- and post-chemotherapy scans with the planning CT. of pre-
and post-chemotherapy Whenscans with theclinical
comparing planning CT. to real-world scenarios, radiation oncologis
trials
When comparing
oftentimes confronted with a number scenarios,
clinical trials to real-world of limitations radiation oncologists
concerning are mainl
this concept,
oftentimes confronted with a number of limitations concerning this concept,
to differences in patient positioning (such as head and arm positioning, missing comainly due
to differences in patient positioning (such as head and arm positioning, missing contrast
enhancement, or divergent breathing). As a compromise, the ILROG introduce
enhancement, or divergent breathing). As a compromise, the ILROG introduced the
concept of ISRT [4,5], recommending small treatment volumes of initially affected s
concept of ISRT [4,5], recommending small treatment volumes of initially affected sites of
disease with a high degree of normal tissue sparing, but slightly more generous ma
disease with a high degree of normal tissue sparing, but slightly more generous margins to
to make up for uncertainties in image fusion. Figure 1 illustrates the reduction in s
make up for uncertainties in image fusion. Figure 1 illustrates the reduction in size of the
the treatment fields.
treatment fields.

(A) (B) (C) (D)

Figure 1. Exemplary depiction
Figure of lymphoma
1. Exemplary sitesof(red)
depiction and different
lymphoma sites radiation
(red) andtreatment
differentfields (blue).treatment
radiation
(A) Disease location
(blue).of(A)
mediastinal and cervical
Disease location lymphoma
of mediastinal andmanifestation;
cervical lymphoma (B) field extension for
manifestation; (B) field ext
EFRT; (C) field extension
for EFRT;for (C)IFRT;
field(D) field extension
extension for IFRT; for (D)
ISRT. Image
field courtesy
extension of ISRT.
for NiklasImage
Schwartz
courtesy of
Schwartz Illustration & Design.
Illustration & Design.

3. Target Volume Definition

3. Target for Definition
Volume ISRT (Summary of ILROG
for ISRT Guidelines)
(Summary of ILROG Guidelines)
Today, ISRT isToday,
used inISRT
several settings:
is used as part
in several of combined-modality
settings: treatment or treatm
as part of combined-modality
definitive RT (with no systemic treatment) in curative intent (i.e., early-stage
definitive RT (with no systemic treatment) in curative intent (i.e., follicular
early-stage foll
lymphoma, early-stage nodular lymphocyte-predominant Hodgkin’s lymphoma
lymphoma, early-stage nodular lymphocyte-predominant Hodgkin’s lymphoma (L(LPHL),
marginal zone lymphoma, low-risk NK/T-cell nasal type lymphoma, and mantle cell lym-
phomas), as salvage treatment after failure of systemic therapy, or in palliative settings [21].
Lymphatics 2023, 1 264

The ILROG guidelines specify dose and volume definitions for HL as well as NHL of
nodal or extranodal location, but also give specific recommendations regarding NK/T-cell
lymphoma. Underlying volume definitions as defined by the International Commission
on Radiation Units [22] include the gross tumour volume (GTV) as a representation of
macroscopic disease, the clinical target volume (CTV), also considering areas of subclinical
infiltration, the internal target volume (ITV), and planning target volume (PTV), consisting
of an additional margin to account for organ movement, set-up, and internal uncertainties.
The creation of these volumes relies heavily on FDG-PET/CT-imaging for lymphoma
treatment. Metabolic imaging has not only demonstrated high value in diagnosis and
response assessment [23–25], but is now the basis for RT planning in most lymphoma
entities [20,26–28] even though some limitations remain [21,29]. Uncertainties in image
interpretation can be a concern and should be discussed in an interdisciplinary setting since
they may require additional extension of safety margins based on clinical judgment [3–5,21].
It is important to note that the definition of treatment volumes for ISRT as well as dose
considerations (which are not discussed in this summary) do not solely depend on PET/CT-
imaging data, but also consider factors like histology, stage, location, and extent of prior
therapy in an individual assessment [21]. The requirements needed for planning of ISRT
are summarized in Table 1.

Table 1. Requirements for planning/simulation of ISRT.

Requirements for Planning/Simulation of ISRT

• Mandatory fusion of initial, pre-therapeutic imaging (PET/CT, MRI) with the simulation
study (of which at least one should be contrast-enhanced, in cases of GI lymphoma with and
without additional oral contrast medium < 50 mL).
• If possible, acquire baseline imaging already in treatment position.
• Use respiratory motion management (i.e., 4D-CT simulation or deep inspiration breath hold)
in areas of high mobility (e.g., mediastinum, abdomen).
• Use appropriate immobilization (e.g., thermoplastic mask).
• In cases of abdominal lymphoma, fasting for at least 4 h might be necessary.
• Slice thickness of planning study should be 3–5 mm.
• In cases of extranodal lymphoma, additional information of locoregional assessments such as
slit lamp examination, ear, nose, and throat examination, esophago-gastroduodenoscopy, or
MRI (especially in cases of cerebral and skull base involvement) should also be considered.
• In cases of exposed structures, consider special precautions (e.g., lens shield or bolus for
ocular lymphoma, feeding tube for large cervical involvement, bite block, side-by-side renal
function test in abdominal lymphoma).

Essentially, the GTV is defined as the initial extent of disease (pre-chemotherapy) while
the CTV includes the sites of initial or remaining disease with consideration of anatomical
changes after application of chemotherapy. In cases of definitive RT (without systemic
treatment), adjacent visible nodes (even if not enlarged) might be included. In this setting,
more generous margins are also advisable given the absence of systemic therapy to treat
microscopic disease. Special caution is needed when defining pericardial or pleural disease
extension [21,30]. The margin for the PTV should reflect institutional setup errors, with an
extension of up to 10 mm being sufficient in most cases. Smaller margins can and should be
used depending on the anatomical location as well as the availability and implementation
of image guidance, tracking, and patient immobilization to reduce toxicity to organs at risk.
CTV-to-PTV-margins should be as small as reasonably achievable without compromising
treatment quality. Considering modern developments and increasing precision, they may
be smaller than the exemplary margins given in this summary of the existing guidelines.
Figure 2 gives an example of the target definition process with the resulting beam setup
and dose distribution.
 Additionally, the effectiveness of systemic therapy in ENKTCL is low compared to other
lymphoma entities [9]. Here, the CTV comprises all involved primary sites and adjacent
anatomic sites where infiltration is likely. Contrary to other lymphoma types, in cases of
lymph node involvement, all regional lymph nodes are included, resulting in treatment
fields that appear unusual in the context of lymphoma radiation, but reminiscent of solid
Lymphatics 2023, 1 265
head and neck tumours. Consulting the detailed ILROG guidelines by Qi et al. [9] is
advised.

Figure 2. Target volume definition and field setup for ISRT in the thoracal region. (A) Initial PET/CT
Figure 2. TargetFDP
scan showing volume
avid definition and field
manifestations in a setup
patientfor ISRT
with in the
stage thoracal
II HL. region.of(A)
(B) Fusion Initial
initial PETPET/CT
with
scan showing FDP avid manifestations in a patient with stage II HL. (B) Fusion of
planning CT scan for ISRT after two cycles of BEACOPPesc and ABVD with residual PET activity. initial PET with
planning CT scan for ISRT after two cycles of BEACOPPesc and ABVD with residual
Target volumes are defined as GTV = red, CTV = blue, PTV = orange. Notice the difference in arm PET activity.
positioning
Target andare
volumes table surfaceasbetween
defined initial
GTV = red, CTVPET/CT and
= blue, planning
PTV CT; Notice
= orange. lymph nodes on the left
the difference in are
arm
>5 cm apart,
positioning andsotable
theysurface
are treated
betweenindividually. (C) Beam
initial PET/CT setup for
and planning CT;sliding-window
lymph nodes onIMRT. the left(D)
are
Resulting
>5 cm apart,colour wash
so they areof dose distribution.
treated individually. (C) Beam setup for sliding-window IMRT. (D) Resulting
colour wash of dose distribution.

In the special case of nasal type NK/T-cell lymphoma (ENKTCL) or non-nasal type
NK/T-cell lymphoma of the upper aerodigestive system (UADT ENKTCL), the CTV is often
large due to extended macroscopic disease and/or continuous multisite spread. Addition-
ally, the effectiveness of systemic therapy in ENKTCL is low compared to other lymphoma
entities [9]. Here, the CTV comprises all involved primary sites and adjacent anatomic
sites where infiltration is likely. Contrary to other lymphoma types, in cases of lymph
node involvement, all regional lymph nodes are included, resulting in treatment fields that
appear unusual in the context of lymphoma radiation, but reminiscent of solid head and
neck tumours. Consulting the detailed ILROG guidelines by Qi et al. [9] is advised.
Even though this article does not cover the subject of dose prescription, it is important
to note that all treatment field sizes as well as prescribed doses should consider uncertain-
ties of disease localization, risk factors and possible toxicity resulting from surrounding
organs at risk (OARs) on a case-by-case basis [21,31]. While the ILROG guidelines aim
for the homogenization of treatment, they cannot fully replace the need for individual
decisions based on clinical experience. An example is the in- or exclusion of lymph nodes of
uncertain status (e.g., enlarged, but PET-negative) which is always subject to individual risk
Lymphatics 2023, 1 266

assessment. Strict compliance with limitations of normal tissue is advised wherever possi-
ble, especially if long-term survival is likely (see Dabaja et al. [8] for further information on
dose limitations).
Table 2 gives a summary of the key aspects of target definition for ISRT presented in
the corresponding ILROG guidelines. Detailed information as well as exemplary depiction
of volumes and field setups are given in respective publications as well and should be
consulted for further detail.

Table 2. Summary of ILROG guidelines.

Key Aspects for ISRT Volume Definition in the ILROG Guidelines

Guideline Key Aspects
GTV Definition
• Primary treatment (e.g., LPHL): GTV is visualized in simulation.
• Combined-modality treatment: GTV is affected due to upfront chemotherapy. The
pre-chemo and post-chemotherapy/residual GTV extension should be defined in the
simulation study.
CTV Definition
• The CTV comprises the pre-chemo GTV, but excludes OAR tissue with consideration
of fusion accuracy, anatomical changes, and potential subclinical disease.
• More generous margins and inclusion of directly adjacent lymph nodes (even if
Treatment volumes for uninvolved) is advisable in cases of sole RT.
Hodgkin’s lymphoma [5] • Nodes more than 5 cm apart can be treated in separate fields.
and nodal non-Hodgkin’s • For irradiation of residual mass after chemotherapy in advanced disease, the CTV
lymphoma [4] consists of the residual GTV (post-chemotherapy) with a margin of 10 mm (larger
margins in areas of increased motion, see ITV).
ITV Definition
• ITV is defined on 4D simulation for chest and upper abdomen treatment with margins
of 1.5–2 cm craniocaudal extension.
PTV Definition
• PTV definitions vary across institutions based on estimated setup errors. Typical
margins around the CTV (or ITV) are 5–10 mm, but should be as small as clinically
appropriate, based on individual treatment circumstances.
ISRT can include the whole involved organ (especially in definitive RT) or just an affected
part (as part of combined-modality treatment).
CTV definitions are detailed below by organ.
PTV definitions can vary based on setup (but margins are commonly 4–10 mm).
CTV-to-PTV margins should be as small as clinically appropriate.
Primary central nervous system
• GTV definition is based on MRI and slit lamp examination.
• CTV consists of the whole brain including C1-2 and the optical nerve bulbs.
• If eyes are involved prior to systemic therapy, the entire globe should be included.
Extranodal non-Hodgkin’s
• The role of a tumour site boost remains uncertain.
lymphoma [3]
• In cases of local treatment, margins < 4 cm seem to be associated with increased risk of
failure [32].
Primary intraocular lymphoma
• CTV includes the whole globe and optic nerve to the chiasm.
• If suspicions of contralateral involvement arise, both globes should be treated.
Dura mater lymphoma
• CTV includes presurgical MRI volume with a margin along the dura.
• In cases of multiple lesions, WBI with boost to the involved sites is advised.
Lymphatics 2023, 1 267

Table 2. Cont.

Key Aspects for ISRT Volume Definition in the ILROG Guidelines

Guideline Key Aspects
Orbital (ocular adnexal) lymphoma
• CTV includes the whole bony orbit with inclusion of areas of suspected bone
infiltration or extraorbital infiltration. Spare lenses if possible.
• In cases only affecting conjunctiva or eyelid, RT (consider electrons) should cover the
conjunctival reflection to the fornices but may spare the bony orbit.
• For residual disease after systemic treatment for aggressive lymphoma, a local boost
should be defined.
Lymphoma of the head and neck (excluding nasal type NK/T-cell lymphoma)
• CTV is based on initial GTV and mostly includes the entire involved subsite.
• For lymphoma of the nasal cavity and paranasal sinuses, branched structures, based
on PET and MRI as well endoscopic examination, are partially or completely included
(based on certainty of infiltration).
• For indolent pharyngeal NHL, the role of inclusion of the whole Waldeyer’s ring
remains unclear (and is not generally recommended).
• For salivary gland involvement, the whole gland is included.
Thyroid lymphoma
• CTV is the whole thyroid, including the initial GTV extension.
Breast lymphoma
• CTV includes the whole breast without inclusion of uninvolved lymph nodes.
• Partial breast irradiation might be considered in selected cases.
Extranodal non-Hodgkin’s Lymphoma of the lung
lymphoma [3] • CTV and ITV include pre-intervention GTV sites with a margin based on suspected
adjacent infiltration areas.
Gastric lymphoma
• CTV includes the complete gastric outline. ITV is advisable (10–20 mm margin).
• Perigastric lymph nodes are usually included in the CTV. Further inclusion of
portal/hepatic or para-aortic lymph nodes can be discussed.
Duodenum/small bowl lymphoma
• CTV for indolent NHL includes the whole duodenum.
• For aggressive NHL, consider initial GTV extension with respect to anatomical
changes and intraabdominal shift.
• In select cases, consider a boost definition based on post-chemo GTV.
Lymphoma involving bladder and/or Gynaecological Organs
• CTV includes the whole organ.
• Decision for full or empty bladder should be made individually.
Testicular lymphoma
• Preferred treatment is an anterior electron field.
• A bolus might be advisable.
Lymphoma of the bone
• CTV includes sites of pre-chemo GTV with extension around uncertain areas of
infiltration, based on PET/CT and MRI.
Lymphatics 2023, 1 268

Table 2. Cont.

Guideline Key Aspects

Key Aspects for ISRT Volume Definition in the ILROG Guidelines
GTV Definition
• Based on imaging (MRI, CT, and PET/CT), endoscopy, and clinical examination.
CTV Definition
• CTV encompasses the initial GTV + 5 mm margin + areas with high risk of
involvement with respect to anatomical borders (i.e., bones).
• Anatomical volumes are treated as a whole, even if only partially involved (with
Nasal type NK/T-cell exclusion of the orbit where only involved structures are included).
lymphoma [9] • Include the whole Waldeyer’s ring, if involved.
• Include uncertain or first-echelon nodes based on clinical judgment.
• Include bilateral cervical nodes if cervical lymph nodes are involved.
Additional aspects for non-nasal UADT ENKTCL:
• With primary disease in the upper aerodigestive tract, CTV includes the entire
structure with a 2 cm margin and adjacent areas with suspected infiltration.
• Prophylactic lymph node irradiation can be considered, even if not involved.
• If lymph nodes are involved, bilateral cervical node stations are included.

4. Status Quo and Future Directions of ISRT

Overall, the developments in lymphoma treatment can be seen as a prime example
of a scientific-driven process in the field of radiation oncology, continuously pushing the
limits of the ALARA principle, the mantra of our profession, aiming for all application of
ionizing irradiation to be “as low as reasonably achievable”.
With image-guided and intensity-modulated therapy widely accessible today, radia-
tion oncologists may challenge themselves to harness the potential of increasing treatment
precision. The recent analyses regarding quality control of INRT application in large clinical
trials (the German HD17-trial and the EORTC H10-Trial) show a high and increasing quality
of compliance with the given treatment field definitions [33–35]. Nevertheless, incorrect def-
initions of treatment fields remain the primary source of protocol violations. In a real-world
setting, the margin for clinically relevant errors grows smaller considering decreasing RT
volumes. Interobserver variability in the interpretation of complex guidelines like the ones
at hand are concerning and need to be taken seriously [36,37], to ensure a high standard in
lymphoma RT.
With a growing arsenal of systemic agents and several trials aiming (mostly unsuc-
cessfully) for the omission of RT from treatment regimens, the radiation oncologist’s role
remains challenging [38]. The effectiveness of RT in securing exceptional local control rates,
resulting in better outcome or even translating to cure, is not debatable. At this point,
treatment volumes can barely become any smaller and the benchmark for RT remains the
tolerance of normal tissue. The switch from IFRT to INRT/ISRT has already proven effective
in the reduction in treatment toxicity [39–41]. Additionally, rapidly evolving techniques for
safer application and better sparing of OARs need to be explored and adapted in day-to-
day practice: enhanced image fusion (e.g., with artificial intelligence (AI)-based deformed
registration of PET/CT data) as well as optimized treatment positioning and beam setup
(e.g., with 4D imaging, deep inspiration breath hold [42–45], and use of the optimal beam
setup [38,46,47]) are just some branches that have already seen considerable improvements
in individualization. It remains to be seen how the development of adaptive treatment
with the possibility of high-frequency adjustments of volumes and the implementation of
AI in the planning process might also benefit this development.
Despite the need for long-term follow-up, there is a lack of data regarding the long-
term toxicity of current concepts. More data on the late sequelae of this new generation
of precise individual treatment will lead to further optimization of the planning process.
Optimization of IMRT planning happens on an individual basis, at the moment driven by
Lymphatics 2023, 1 269

physics-centred parameters (DVH-based), but there is also progress to be expected from the
ever-evolving insights into normal tissue complication probability modelling, rendering a
more biologically driven approach possible [38].
With immunotherapy entering first-line treatment regimens [48], new synergies with
RT may be established, comparable to solid tumours. Even in entities with decreasing use
of RT (like primary central nervous lymphoma [49]), this treatment modality may witness
a renaissance with more precise, less toxic, and well-combined concepts. In the future,
personalized RT strategies may be possible.

5. Conclusions
RT plays a key role for lymphoma therapy, making long-term survival possible for low-
and high-grade entities as part of single- or combined-modality treatment. The reduction
in treatment field size from involved field to involved site is the basis for current and future
developments to achieve maximum effectiveness with minimal toxicity. The guidelines of
the ILROG, as summarized in this paper, give detailed information for modern state-of-the-
art lymphoma treatment.