clinical lymphoma Flashcards
how many tumour cels in classical hodgkin lymphoma
Very few tumour cells and lots of reactive cells
presentation of lymphoma
painless progressive lymphadenopathy
* palpable node
* extrinsic compression - Ureter, Bile duct, large blood vessel, bowel, trachea, oesophagus, mediastinum
malignant lymphocytes infiltate or impair organ system - skin rash, ocular&CNS, liver failure
Recurrent infections – because clonal cells cant fight the infection
Constitutional symptoms – fever/sweats
Coincidental e.g. FBC, Imaging
where is the lymphoma here
mesenteric and axillary
axillary and cervical
splenomegaly
ix for dx and staging of lymphoma
histological dx - biopsy
anatomical stage:
* CT, or PET scans – look for LN
* BM biopsy
* +/-Lumbar puncture CNS should not have lymphocytes – but if concern that there is meningeal involvement – need to look In CSF
Blood tests
LDH - intracellular enzyme - any dying cells
Albumen,
kidney/BM function - will affect ability to treat
HIV & Hep B serology If carrier of hep B – if wipe away B cells may get fatal reactivation of Hep B
+/- HTLV1
Extensive stage, CNS involved, impaired high LDH and impaired function all = poor Px
what ar the lymphoid malignancies
epidemiology of HL
1% all cancer
>male
bimodal - 20-29yrs young women NS (nodular sclerosis subtype) subtype
Second smaller peak affecting elderly >60 years old
sx of HL
enlargement of nodes - can -> obstructive sx
B sx - fever, night sweats, wht loss (10% in 6mo)
Pruritis and rarely alcohol induced pain – at the time of drinking alcohol
classification and px of HL
Classical HL
* Nodular sclerosing (thick band fibrous tissue around nodules) 80% Good prognosis (causes the peak incidence in young women)
* Mixed cellularity 17% Good prognosis
* Lymphocyte rich (rare) Good prognosis
* Lymphocyte depleted (rare) Poor Prognosis
Nodular Lymphocyte predominant HL 5% (disorder of the elderly multiple recurrences)
how does HL spread
contiguously
means spread through lymphatics - so presents with more limited/early stage disease compared to NHL
staging for HL
after dx wih biopsy - do FDG-PET/CT and consider biopsying another site eg liver
Stage
* I; one group of nodes
* II; >1 group of nodes same side of the diaphragm
* III; nodes nodes above and below the diaphragm (note - spleen counts as a node and not stage 4)
* IV; extra nodal spread – liver/bone marrow mainly
Suffix A if none of below, B if any of below
* Fever
* Unexplained Weight loss >10% in 6 months
* Night sweats
want to see improvement in stage after 2 chemo
nodular sclerosing HL
Young women(>men) 20-29 years
Neck nodes and mediastinal mass(may be massive and compress SVC or trachea – cause obstructive sx)
May have B symptoms
Needs a Tissue diagnosis
chemo for HL
ABVD
* Adriamycin
* Bleomycin
* Vinblastine
* DTIC
given at 4-weekly intervals, 2-6cycles (depending on stage and response)
* PET CT at 2 cycles - assess response
* PET CT end of treatment - see if need radio
* +- radio
curative
preserves fertility
can cause pul fibrosis and cardiomyopathy long term
if relapse - high dose chemo + autologous PB stem cell transplant
radiotherapy for HL
Very good at sterilizing area where HL is - doesn’t work as sole modality of Rx
Reduce chance of relapse by adding radio to chemo - but dealing with young pts and a disease that may have been Rx with chemo – so radio increases chance of developing a secondary Ca
px of HL
older = worse
lymphocyte depleted histology = poor px
cure rate from 50-90%
overall:
* 80% are loing term survivors,
* 10% die from relapse,
* 10% die from treatment complications
* therefore curing cHL doesnt = long term survival
summarise NHL
def - neoplastic proliferation of lymphoid cells
incidence increasing
clinical course depends on subtype:
* fastest proliferating malignancy (Burkitt Lymphoma)
* indolent diseases (eg Follicular NHL with a possible 25 year survival)
* Antibiotic responsive disease such as Gastric MALT
ix for NHL
Stage the disease (as in Hodgkin Lymphoma)
* CT scan
* PET scan (indicated in aggressive lymphomas)
* BM biopsy
* Lumbar puncture (if risk of CNS involvement ) – not routine – only if indicated
prognostic markers & Important tests
* LDH
* Performance status
* HIV serology (if appropriate HTLV1 serology)
* Hepatitis B serology (risk of reactivation if B cell depleting therapy given)
approach to rx of lymphoma
Plan Therapy (histology & Performance status) – based on nature, subtype and state of pt ie more aggressive if young.
* Urgent chemotherapy ?
* Monitor only {watch & wait} ?
* Antibiotic eradication (H.Pylori gastric MALT lymphoma) ?
subtypes of NHL
different types of NHL and their clinical course
PX of NHL
how do you treat the very aggressive NHL
like acute leukaemia
what is the Prognosis and treatment of diffuse large B cell NHL determined by
IPI (International Prognostic Index)
* Age
* Stage (Ann Arbor)
* LDH – marker how rapidly cell turn over
* Extra-nodal disease sites
* ECOG performance status
treatment of diffuse large b cell lymphoma
6-8 cycles of R-CHOP (Rituximab-CHOP)
combination chemo including a number of drugs - usually inc anthracycline (eg doxorubicin)
Combination drug regimens e.g. CHOP
* Cyclophosphamide
* Adriamycin
* Vincristine
* Prednisolone
R is Immunotherapy using the anti CD20 monoclonal antibody Rituximab
aim is curative
Relapse: Autologous Stem Cell transplant salvage 25% of patients
summarise follicular lymphoma
indolent
t(14,18) -> over expression of bcl-2 - anti-apoptosis protein
FLIPI score
incurable - survival 12-15yrs
may need 2-3 different chemo schedules - each remission shorter until succumb
