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Year 3 - Clinical Science and Professionalism > Lymphoma > Flashcards

Lymphoma Flashcards

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1
Q

Define lymphoma

A

Cancer of lymph nodes

- effects the main cells in B cell maturation

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2
Q

what cells are effected in lymphoma

A
  • 90% B cell

- 10% T and NK cell

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3
Q

What is the clinical presentation of lymphoma

A
  • Indolent/low grade

- Aggressive/high grade

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4
Q

What are the two types of lymphoma

A

Hodgkin and non-Hodgkin lymphoma

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5
Q

what lymphoma is more common

A

Non-hodgkin lyphoma

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6
Q

What are the common types of non Hodgkin lymphoma

A
  • Diffuse large B cell lymphoma – most common (High grade)
  • Burkitt lymphoma (High grade)
  • Follicular lymphoma (Low grade)
  • Marginal zone lymphoma (Low grade)
  • Lymphocytic lymphoma (Low grade)
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7
Q

What are the classical types of Hodgkin and other types of Hodgkin lymphoma

A

Classical types

  • Nodular sclerosing - most common
  • Mixed cellularity
  • Lymphocyte rich
  • Lymphocyte depletes - only one with a poor prognosis

Other types
- Nodular lymphocyte predominant

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8
Q

What can cause lymphomas

A

Can be caused/Associated with/ by viral infections

  • EBV- Hodgkin and diffcule large B cells
  • HIV
  • HTLV
  • Hep C
    • HHV8

Bacterial infections

  • H.pylori – treatment can involve H.pylori removal
  • Chlamydia psittaci

Inflammatory conditions

  • Coeliac disease
  • Sjogren’s syndrome

Industrial/medical exposure

  • Ionising radiation
  • Benezene
  • Immunosuppression
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9
Q

What are the 5 different types of classification of lymphoma

A
  • Mature B cell expansion
  • Hodgkin lymphoma
  • Histiocytic and dendritic cell neoplasma
  • Mature T and NK neoplasma
  • Posttransplant lymphoproliferative disorders
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10
Q

What investigations are used in lymphoma

A
  • Blood tests
  • Biopsy
  • Imaging
  • Disease specific tests
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11
Q

What are the symptoms of lymphoma

A
  • Fever – greater than 38 degrees
  • Night sweats
  • Greater than 10% weight loss
  • Can present with no symptoms
  • Fatigue
  • Pain/swelling from lymphadenopathy
  • Pruritus – itching, sometimes you can get skin rashes
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12
Q

What is the characteristic cell that is present in Hodgkin’s lymphoma

A
  • Cells with mirror imaging age nuclei are found – these are called Reed-Sternberg cells
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13
Q

What are the signs of lymphoma

A
  • Hepatomegaly
  • Lymphadenopathy – neck, axillae, abdomen, groin
  • Skin
  • Other targeted organ specific
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14
Q

What blood tests are used for lymphoma

A
  • FBC and film
  • Immunophenotyping – looking at the CD markers that tell you whether a blood type is one or another
  • LDH, uric acid
  • Serum electrophoresis
  • B2 microglobulin
  • Serology; Hepatitis B and C, HIV
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15
Q

Where do you do a biopsy in lymphoma

A
  • Lymph node

- Bone marrow

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16
Q

describe how to get a lymph node biopsy

A
  • Core/excision preferred

- Not a fine needle as don’t get a sense of core architecture, do in core and even more in excision

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17
Q

describe when you would get a bone marrow transplant

A
  • Not needed when PET scan imaging suggests bone marrow uptake
  • Only in PET negative when it might change treatment or management
  • Does change management if you have bone marrow involvement
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18
Q

What imaging do you use for lymphoma

A
  • CT neck, chest, abdominal, pelvis
  • CT PET preferred
  • MRI if CNS involvement
  • Abdominal USS optional
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19
Q

Define the Ann Arbor classification

A

Stage 1 – one node above diaphragm

Stage II – more than one node above diaphragm

Stage III – more than one node above the diaphragm and one node below

Stage IV – multiple nodes above and below and the diaphragm and bone marrow involvement

A= no associated symptoms

B = unexplained fever, night sweats and weight loss greater than 10% in the last 6 months

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20
Q

Name the B symptoms in lymphoma

A
  • weight loss >10% in the last 6 months
  • unexplained fever >38 degrees
  • night sweats
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21
Q

what are the cytogenic for follicular lymphoma

A

follicular lymphoma t(14:18)

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22
Q

what are the markers for follicular lymphoma

A

CD10 particularly, CD79a, bcl2, bcl6, cd10, MYC, KI67, IRF4, Cyclin D1, CD5, CD23

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23
Q

name a marker on the B cell

A
  • B cell CD20 positive
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24
Q

What are the marker for Hodgkin lymphoma

A

CD15, CD30

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25
Q

how does the lymphocyte look in follicular lymphoma

A
  • Cleaved nucleus

- clumped chromatin

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26
Q

what does a biopsy look like in follicular lymphoma

A
  • Darker smaller centrocytes – predominate – follicular lymphoma
  • Larger paler centroblasts – follicular lymphoma
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27
Q

What does the bone marrow biopsy look like in follicular lymphoma

A
  • Paratrabecular infiltration of small lymphocytes characteristic
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28
Q

what should you evaluate before you decide to treat follicular lymphoma

A
  • Prognosis stage, stage, FLIPI 1/2 grade
  • Symptoms
  • Patient priority, longer survival, long remission, better quality of life
29
Q

What should the treatment for follicular lymphoma be in

  • asymptomatic
  • mild symptoms
  • High tumour burden
A

Asymptomatic
- Watch and weight

Mild symptoms

  • Non chemotherapy
  • Treatment
  • Rituximab
  • Radioimmunotherapy

High tumour burden

  • Chemoimmunotherapy
  • R-CHOP
  • R- CVP
  • Consider rituximab maintenance
  • R- Bendamustine
30
Q

What are the risk factors for follicular lymphoma

A
  • Age over 60 years
  • Elevated LDH (high tumour burdern) or B2- microglobulin
  • Advanced according to Ann Arbor classification
  • Bone marrow involvement
  • Haemoglobin less than 12g/dl
  • Diffuse or disseminated extra lymphatic organ involvement
  • 6-15 blasts/high power field
31
Q

What is the pathophysiology for follicular lymphoma

A
  • Secondary genetic alterations are needed for transporation to follicular lymphoma
  • T (14:18) and transportation into the germinal centre transform the disorder into follicular lymphoma
32
Q

what is the median age of diagnosis of follicular lymphoma

A
  • Male : female = equal

- Median age of diagnosis: 65years

33
Q

what type of lymphoma is follicular lymphoma

A
  • Type of lymphoma: indolent, low grade, hard to cure
34
Q

what stage of presentation does follicular lymphoma usually present

A
  • Presence of B symptoms: uncommon

- Stage at presentation: most stage III or IV

35
Q

what is the prognosis of follicular lymphoma

A
  • Prognosis: 5 year overall survival low risk– 90%, high risk – 50%
36
Q

describe diffuse large B cell lymphoma

A
  • Highly aggressive but highly curable
37
Q

What does the blood film look like in diffuse large B cell lymphoma

A
  • Normal segmented neutrophil

- In advanced cases there might be lymphoma cells in the blood

38
Q

What does the biopsy look like in diffuse large B cell lymphoma

A
  • Effacement with centroblasts lack of other cells/ inflammatory infiltrate
  • Diffuse large B cell as there is just centroblasts with no centrocytes and no other cells in that biopsy
39
Q

What is the treatment of diffuse large B cell lymphoma

A
  • R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone) x 6
  • Given every 14-21 days, for 6 cycles
  • 1st relapse – platinum based chemotherapy and consolidation with autologous transplantation – take cells, give high dose chemotherapy, put cells back
  • 2nd relapse – allogenic transplantation/clinical trial
  • Special considerations – CNS prophylaxis in high risk disease
40
Q

What does R-CHOP stand for

A 
Rituximab, 
cyclophosphamide, 
doxorubicin,
vincristine
prednisolone
41
Q

What are the two main types of diffuse large B cell lymphoma and what has better prognosis

A
  • Germinal centre type – better prognosis (BCL2 pathway)

- Activated B cell type – worse prognosis (NF- Kappa B pathway)

42
Q

what is the median age of diffuse large B cell lymphoma

A
  • Median age is 64
43
Q

What is the stage at presentation of diffuse large B cell lymphoma

A
  • Presence of B symptoms – common

- Stage at presentation I-II

44
Q

What is the prognosis of diffuse large B cell lymphoma

A
  • Prognosis – low risk >90%, high risk – 50% for 5 years
45
Q

List the statistics for diffuse large B cell lymphoma

A
  • Incidence 7/1000,000 – 30-40% of non hodkgin lymphoma
  • More males
  • Type of lymphoma – aggressive/high grade and potentially curable
46
Q

What does the blood film look like in Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Normal
47
Q

What does the biopsy look like in Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Bilobed – owls eyes appearance = reed Sternberg cell (not exclusive but it is this type of cell in the presence of inflammatory infiltration and eosinophils that makes the diagnosis of classical Hodgkin lymphoma)
  • Lacunar cells
  • Inflammatory infiltration/fibrosis
  • Eosinophil
48
Q

What is the treatment pathway for Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Get ABVD treatment no mater what stage – get 2 cycles
  • ALL stage 2 x ABVD chemotherapy
  • ABVD – doxorubicin, bleomycin, vinblastine, dacarbazine
  • Then you get a PET scan
  • PET scan positive – escalate chemotherapy, involved node radiotherapy
  • PET scan negative – continue chemo, involved node radiotherapy
  • Special considerations – breast screening in females less than 40 at time of chest axillary radiation
49
Q

What does ABVD stand for

A

doxorubicin
bleomycin
vinblastine
dacarbazine

50
Q

what is the pathophysiology for Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Germinal centre cell, normally a transforming event and you get a reed Sternberg cell, loss of apoptosis, and cytokine infiltration leading to an inflammatory micro environment, this feeds back on the reed Sternberg cell
51
Q

What is the median age of Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Mediationa ge of diagnosis – bimodal so two peaks one in the mid twenties and one in the mid 70s
52
Q

what is the stage of presentation of Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Presence of B symptoms 40%

- Stage at presentation – most stage I/II

53
Q

What is prognosis of Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Aggressive but curable in 80% of patients

- Prognosis – 80-90% cured

54
Q

What are the statistics of Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • 2-4/100,000
  • 10% of all lymphoma
  • Slight male predominance
55
Q

how do you assess the response to treatment in Classical Hodgkin lymphoma (nodular sclerosing type)

A
  • Assessment at 6-8 weeks at the completion of treatment – clinical assessment, PET-CT scan

Follow up

  • 3 monthly for the first 1-2 years
  • Then 6 monthly
  • Yearly from 5 years
56
Q

list some new treatments being used for lymphoma

A

Anti CD20 mab

  • Rituximab
  • Ofatunmab

Kinase inhibitors
- Ibrutinib

HDAC inhibitros
- Romidepsin

Alkylaotrs
- Bendamustine

BCL2 inhibitors
- Venetoclax

Checkpoint inhibitors

  • Nivolumab
  • Pembrolizumab
57
Q

List differences between Hodgkin and Non-hodking

A
  • Non-Hodgkin lymphoma is more common than Hodgkin lymphoma.
  • The majority of non-Hodgkin patients are over the age of 55 when first diagnosed, whereas the median age for diagnosis of Hodgkin lymphoma is 39.
  • Non-Hodgkin lymphoma may arise in lymph nodes anywhere in the body, whereas Hodgkin lymphoma typically begins in the upper body, such as the neck, chest or armpits.
  • Hodgkin lymphoma is often diagnosed at an early stage and is therefore considered one of the most treatable cancers.
  • Non-Hodgkin lymphoma is typically not diagnosed until it has reached a more advanced stage.
58
Q

What is the most common type of Hodgkin’s lymphoma

A
  • Nodular sclerosing
59
Q

What is the type of Hodgkin lymphoma with the poorest prognosis

A
  • Lymphocyte depleted
60
Q

What are the symptoms and signs for a Hodgkin lymphoma

A

Symptoms

  • Enlarged non-tender, rubbery superficial lymph nodes – cervical also axillary or inguinal
  • E.g. fever, weight loss, night sweats, pruritus’ and lethargy
  • Mediastinal lymph node involvement can cause mass effect e.g. bronchial or SVC obstruction or direct extension e.g. causing pleural effusions

Signs

  • Lymphadenopathy
  • also cachexia, anaemia, splenomegaly or hepatomegaly
61
Q

What tests do you carry out for a Hodgkin lymphoma

A
  • Lymph node excision biopsy if possible
  • Image guided needle biopsy, laparotomy or mediastinoscopy
  • FBC, blood film, ESR, LFT, LDH, urate and calcium
  • Raised ESR or lowered HB indicate a worse prognosis
  • Imaging – CXR, CT/PET of thorax, abdominal and pelvis
62
Q

What chemotherapy do you use for Hodgkins lymphoma

A
  • ABVD = Adriamycin (doxorubicin), Bleomycin, Vinblastine, Dacarbazine = cures 80% of patients
63
Q

What are the complications of treatment for Hodgkin lymphoma

A
  • Radiotherapy may increase risk of secondary malignancies – solid tumours in lung and breast
  • Ischaemic heart disease, hypothyroidism and lung fibrosis due to the radiation field
  • Chemotherapy side effects include = myelosuppression, nausea, alopecia, infection
  • AL, non-Hodgkin’s lymphoma and infertility may be due to chemo and radiotherapy
64
Q

What are the signs and symptoms for a non-hodgkin lymphoma

A
  • Superficial lymphadenopathy
  • Extra nodal disease – Gut is most common
  • Gastric MALT is caused by H.pylori and may regress with its eradication
  • Fevers, night sweats, weight loss
  • Pancytopenia from marrow involvement – anaemia, infection, bleeding (decreased platelets)
65
Q

What tests do you do for non-Hodgkin lymphoma

A
  • Blood = FBC, U&E, LFT, increased LDH means that there is a worse prognosis
  • Marrow and node biopsy for classification
  • Staging – Ann Arbor system – CT+/- PET of chest, abdomen and pelvis
66
Q

What are the types of grades of non-hodgkin lymphoma that you can get and which ones have better prognosis

A
  • Low grade = if symptomless none may be needed = better prognosis
  • High grade = R-CHOP - Rituximab, Cyclophosphamide, Hydroxydaunorubicin, vincristine (Oncovin®) and Prednisolone.
67
Q

What are the complications of non-hodgkin lymphoma

A
  • Bone marrow infiltration causing neutropenia, anaemia, thrombocytopenia
  • Superior vena cava obstruction
  • Metastasis
  • Spinal cord compression
  • Complications related to treatment e.g. side effects of chemotherapy
68
Q

What is the difference in treatment for Hodgkin V non Hodgkin Lymphoma

A

Hodgkin
- ABVD = doxorubicin, bleomycin, vinblastine, dacarbazine

Non- Hodgkin
- RCHOP = rituximab, cyclophophosphamide, doxorubicin, vincristine, prednisolone

Year 3 - Clinical Science and Professionalism (32 decks)

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