Lecture 1.1: The Lymphomas

Question 1

What is the most common and second most common clinical presentation of Hodgkin Lymphoma?

Answer 1

• Most common = PAINLESS peripheral LAD; often in the cervical or supraclavicular nodes
• 2nd = mediastinal mass seen on CXR

Question 2

What are “B symptoms” associated with advanced stage HL; what is another unusual but rather common symptoms?

Answer 2

• “B symptoms” = temp >38 C; weight loss >10% BW; or drenching night sweats
• Generalized pruritus is another common findings

Question 3

Diagnosis of HL and NHL should be made how and what is the preferred method?

Answer 3

Biopsy; preferred method being excisional biopsy

Question 4

Which 2 imaging modalities are important for the initial staging of HL?

Answer 4

CT and PET imaging

Question 5

Using the Ann Arbor staging system for lymphomas what is stage I?

Answer 5

Involvement of a single LN region (I) or single extranodal organ site (IE)

Question 6

Using the Ann Arbor staging system for lymphomas what is stage II?

Answer 6

• Involvement of 2 or more LN regions or lymphatic structures on the same side of the diaphragm (II)

or

• With involvement of limited, contiguous extranodal tissue (IIE)

Question 7

Using the Ann Arbor staging system for lymphomas what is stage III?

Answer 7

• Involvement of LN regions or lymphoid structures on BOTH sides of the diaphragm (III)
• May involve the spleen (IIIS) or limited, contiguous extranodal tissu (IIIE)

Question 8

Using the Ann Arbor staging system for lymphomas what is stage IV?

Answer 8

Diffuse or disseminated involvement of one or more extranodal organs or tissues, with or without lymphatic involvement

Question 9

Using the Ann Arbor staging system for lymphomas what do the disease modifiers A, B, E, and X indicate?

Answer 9

• A = Absence of B symptoms
• B = Presence of B symptoms
• E = Extranodal site or organ
• X = Bulky disease (more than 10cm)

Question 10

Why should a baseline cardiac function study (such as echocardiography) and PFT’s be done before treating HL?

Answer 10

Tx of HL involves the use of chemotherapy with an anthracycline and bleomycin

Question 11

What is the most commonly used 4-drug regimen used for HL?

Answer 11

ABVD = doxorubicin + bleomycin + vinblastin + dacarbazine

Question 12

How are pt’s with early stage HL treated and what is used especially if bulky mediastinal disease is present?

Answer 12

Abbreviated course (2-3 months) of chemo followed by radiation to the involved region (especially with bulky mediastinal disease)

Question 13

How are patients with advanced stage HL treated?

Answer 13

Longer course (6 months) of chemo ALONE

Question 14

What are some of the common adverse risk factors which must be accounted for when considering treatment options for HL?

Answer 14

• ↑ erythrocyte sedimentation rate (ESR)
• Male gender
• Age >40 y/o
• Stage IV
• Bulky mediastinal disease

Question 15

What is the recommended follow-up schedule for HL pt’s during the first five year after completing tx?

Answer 15

• Every 3-6 months for the first 3 years
• Every 6 months in the 4th and 5th year
• Annually thereafter

Question 16

What should HL survivors be screened for and managed at their follow-up appointments?

Answer 16

• Annual visits with a CBC to screen for BM dysfunction
• Thyroid function testing in those who received radiation to the neck
• Annual influenza vaccine in pt’s who received bleomycin or chest irradiation

Question 17

Women who received radiation prior to age 35 for tx of HL should undergo breast cancer screening w/ annual mammography starting when?

Answer 17

Beginning 8-10 years post-treatment or at age 40, whichever comes first

Question 18

How do indolent NHL’s typically present?

Answer 18

Slowly growing LAD, enlarged spleen or liver, or with CBC abnromalities such as anemia, thrombocytopenia or leukopenia

Question 19

Which findings sx’s and labs are more common of aggressive NHL’s?

Answer 19

• B symptoms
• ↑ LDH
• ↑ uric acid

Question 20

Patients diagnosed with NHL should also be tested for what infections?

Answer 20

HIV and hepatitis B and C

Question 21

Which imaging studies should be performed in pt with NHL and to what regions?

Answer 21

CT scans of the chest, abdomen, and pelvis; in some cases integrated PET/CT scans are useful

Question 22

When would lumbar puncture with cytologic evaluation of the CSF be important in the management of NHL?

Answer 22

In highly aggressive NHL (i.e., Burkitt lymphoma) and in some types of aggressive NHL (i.e., testicular diffuse large B-cell lymphoma)

Question 23

What are treatment options for indolent NHL’s?

Answer 23

• May often be observed without tx
• Nearly always respond to chemotherapy when tx is indicated

Question 24

For B-cell lymphoid NHL’s what is used for tx?

Answer 24

Cytotoxic chemotherapy used concurrently with the anti-CD20 monoclonal antibody, RITUXIMAB

Question 25

Following tx for NHL, how often should pt’s be seen for follow-up during the first 5 years and what studies should be done?

Answer 25

• Should be seen every 3-6 months during the first 3-5 years after tx and annually thereafter
• Imaging of the chest, abdomen, and pelvis w/ CT scans is often performed

Question 26

Patients who receive radiation to the neck for HL and NHL are at risk for what future complications?

Answer 26

HYPOthyroidism