MH2 Flashcards
What is NHL?
Non Hodgkin’s Lymphoma
What causes NHL?
Viruses
Environmental Exposure
Chronic Antigen Exposure
What is the difference between Lymphoma and Leukaemia?
Lymphoma is a tissue disease
Leukaemia is disease of the blood
How frequent is NHL?
NHL is the sixth most frequent malignancy in the UK
What is staging?
Cancer staging is the process of determining the extent to which a cancer has developed by spreading.
Describe stage I lymphoma
Lymphoma:
In one group of lymph nodes or in just one organ or area of the body outside the lymphatic system (extranodal lymphoma)
Describe stage II lymphoma
Lymphoma:
In 2 or more groups of lymph nodes on the same side of your diaphragm, or
In 1 or more groups of lymph nodes and also in one nearby organ or area of body, all on the same side of the diaphragm
Describe stage III lymphoma
Lymphoma:
In lymph nodes on both sides of the diaphragm, or
In lymph nodes on both sides of the diaphragm and a nearby organ or area of body is affected
Describe stage IV lymphoma
Lymphoma:
Throughout one or more organs that are not part of the lymphatic system, or
In an organ that is not part of the lymphatic system, and it has also spread to organs or lymph nodes far away from the organ, or
In your liver, bone marrow, cerebrospinal fluid (CSF) or lung (unless it has spread to your lung from nearby lymph nodes)
What staging investigations can be performed?
Clinical examination FBC Liver function CXR CT, or PETCT scan Bone marrow examination
What prognostic markers can be used in evaluating NHL prognosis?
ESR LDH Anaemia Comorbidity (performance status) Age Stage
Give examples of low grade lymphomas
Follicular NHL Small lymphocytic lymphoma/Chronic lymphocytic leukaemia Hairy cell leukaemia Marginal Zone lymphoma Lymphoplasmacytic Lymphoma – All behave similarly...
Which low grade NHL is most common?
Follicular NHL
Which two low grade NHL make up the majority of NHL’s?
Follicular NHL
DLBCL
Describe the presenting features of low grade lymphomas
Painless lymphadenopathy Abdominal mass B Symptoms – Weight loss – Night sweats
How is follicular lymphoma characterised?
Follicular lymphoma is characterised by a translocation between chromosome 14 and 18 results in the overexpression of the bcl-2 gene.
As the bcl-2 protein is normally involved in preventing apoptosis, cells with an overexpression of this protein are basically immortal.
What are the treatment options for low grade lymphomas?
Aim for long term control
Rare cures in early stage disease (Stage I)
Otherwise incurable even with high dose therapy
• ? May be curable with allogeneic transplant
May transform to aggressive disease
– poor prognosis
Develop resistance to drugs over time
– Successive remissions shorter
• Eventual progression of refractory disease
What are the treatment options for Follicular Lymphoma?
‘Watch and Wait’ – no treatment
Chemotherapy plus antibody (anti-CD20)
– Chemo
• Alkylating agents – chlorambucil (gentle)
• Combination chemotherapy – CHOP CVP etc
• Fludarabine combinations
• Bendamustine………..others….
Anti-CD20 maintenance therapy
Autografts/allografts
?small (targeted) molecules – eg BCL2 inhibitor, BTKi…others…..
How is Rituximab used in Follicular Lymphoma?
Induction treatment with chemotherapy
– Initial treatment and relapse
Maintenance
– for 2 years after initial treatment or relapse Rituximab monotherapy
– can also be used for patients with relapsed/refractory Stage III/IV disease where other treatment options have been exhausted.
Apart from Rituximab, what other antibodies can be used to treat Follicular Lymphoma?
Anti-CD20 as a means of targeting radiation
– 131 I-Tositumomab labelled anti-CD20 – Bexxar
– 90Y-labeled ibritumomab tiuxetan – Zevalin
Later generation anti-CD20
– Better cellular and complement mediated killing
– Trials awaited……
What are the presenting features of high grade lymphomas?
Painless peripheral lymphadenopathy Abdominal mass B symptoms – Weight loss – Night sweats
What are the prognostic features of high grade lymphomas?
IPI score (International Prognostic Index) – Age – Stage – LDH – Performance score (how fit patient is) – Extranodal sites Other issues – CNS involvement – poor prognosis
How is treatment for DLBCL approached?
AIM FOR CURE
Cyclical Combination Chemotherapy with Rituximab – 6-8 courses of RCHOP
Dual modality treatment for early stage disease RCHOPx3 + Radiotherapy
Radiotherapy to sites of initial bulk disease
Salvage therapy and autograft if relapse
– Autograft at relapse can be curative still.
What are some key issues involved in HGL?
Getting treatment in on time is important
CNS disease
– CNS directed chemotherapy
CNS prophylaxis for patients at high risk of CNS relapse.
– High IPI
– Extranodal disease – eg Breast
– Disease close to CNS
Give examples of High Grade NHL
Burkitts Lymphoma
Mantle Cell NHL
Describe the features of Burkitts Lymphoma
– Very, very aggressive
– Tumour lysis (rapid cell death) a problem
– Needs intensive chemotherapy with CNS prophylaxis
– Majority cured if survive the first 6 months
Describe the features of Mantle Cell Lymphoma
– Variable grade – indolent to blastic
– Difficult to treat
– Poor prognosis - 3-4 yrs
What are the presenting features of Hodgkin’s Disease?
Painless lymphadenopathy – Often cervical/mediastinal – Contiguous Spread Systemic symptoms/B Symptoms – Weight loss/fevers/Night sweats
How is HD classified?
Nodular lymphocyte predominant HD – very indolent! Classical HD - Lymphocyte rich - Nodular sclerosis - Mixed cellularity - Lymphocyte depleted
What investigations can be performed for HD?
Histology CT PET scan BM ESR/LDH/FBC/Biochemistry Baseline cardiac and lung function Follow up CT/PET to assess response after 2 cycles of treatment
How is HD treated?
Stage IA & IIA – divided into low and high risk - bulk/age/esr etc
– Abbreviated chemotherapy + IF-RT
• Involved Field – limits radiation to where it is needed
– Higher risk early stage may be treated as later stage
disaese
Stage IB – IVB
– Cyclical combination chemotherapy
• ABVD – current standard of care
• Others
– MOPP/COPP
– ChlVPP/PABLOE and other hybrid regimens
– Stanford V
• BEACOPP/eBEACOPP – more aggressive treatment
What is the prognosis for HD?
Most are cured (70%)
Better if – good risk. – Young age – Low bulk – IA – Good histology? RATHL trial after 3 yrs – 95%OS, 82%PFS...... PET scans after two cycles predictive of long-term response
What issues relate to long term survival of HD?
Therapy related toxicity a big issue!
Secondary malignancy – cumulative risk > 10%
– NHL/MDS or AML/solid tumours.
– Breast cancer risk high in young women treated with Radiotherapy prior to age 30
Early cardiovascular disease
Infertility
Lung problems
Psychosocial issues.
