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LYMPHOMA.pptx

  1. 1. LYMPHOMA DR.D.HEBER JOBSON I YR RESIDENT-SURGICAL ONCOLOGY GOVERNMENT ROYAPETTAH HOSPITAL Prof. S. SUBBIAH et al.
  2. 2. • Heterogenous group of biologically and clinically distinct neoplasms that originate from cells in the lymphoid organs 1.NON HODGKIN LYMPHOMA 2.HODGKIN LYMPHOMA Prof. S. SUBBIAH et al.
  3. 3. B CELL DEVELOPMENT Prof. S. SUBBIAH et al.
  4. 4. T CELL DEVELOPMENT Prof. S. SUBBIAH et al.
  5. 5. CD MARKERS B-CELL LYMPHOMA T-CELL LYMPHOMA STAIN FOR CD20 AND CD3 CD20+ B CELL LYMPHOMA CD5,CD10,CD11a, CD20,CD45,CD79a, Bcl-2,Bcl-6 CD3+ T CELL LYMPHOMA CD2,CD3,CD4,CD5,CD7, CD8,CD30,CD45,CD56 Prof. S. SUBBIAH et al.
  6. 6. HODGKIN LYMPHOMA • Hodgkin lymphoma is an uncommon lymphoproliferative malignancy of B lymphocytes Prof. S. SUBBIAH et al.
  7. 7. REED-STERNBERG CELL Prof. S. SUBBIAH et al.
  8. 8. REED STERNBERG CELL • Large cells with abundant cytoplasm and bilobed nuclei • IHC : PAX 5 , CD 15 and CD 20 positive • Constitute less than 1% of tumor cellularity, rest made of inflammatory cells Prof. S. SUBBIAH et al.
  9. 9. WHO CLASSIFICATION • Classic Hodgkin lymphoma – Accounts for approximately 95% of cases – Characterized by presence of Reed-Sternberg cells in an inflammatory background – Divided into 4 subtypes: » Nodular sclerosis (most common, 75%-80%) » Mixed cellularity » Lymphocyte-depleted » Lymphocyte-rich • Nodular lymphocyte predominant Hodgkin lymphoma – Accounts for approximately 5% of cases – Characterized by presence of lymphocyte-predominant cells known as popcorn cells – Reed-Sternberg cells are absent Prof. S. SUBBIAH et al.
  10. 10. ANN ARBOR STAGING STAGE DESCRIPTION I Involvement of a single lymph node region (I) or single extranodal site (IE) II Involvement of two or more lymph node regions or lymphatic structures on the same side of the diaphragm alone (II) or with involvement of limited, contiguous, extralymphatic organ or tissue (IIE) III Involvement of lymph node regions on both sides of the diaphragm (III), which may include the spleen (IIIS), or limited, contiguous, extralymphatic organ or tissue (IIIE), or both (IIIES) IV Diffuse or disseminated foci of involvement of one or more extralymphatic organs or tissues, with or without associated lymphatic involvement SUBCLASSIFICATON: Category A: no systemic symptoms Category B: fevers higher than 38 °C, night sweats, or weight loss greater than 10% of body weight within 6 months of diagnosis Prof. S. SUBBIAH et al.
  11. 11. • EARLY STAGE-I,II FAVOURABLE/UNFAVOURABLE • ADVANCED STAGE-III,IV Prof. S. SUBBIAH et al.
  12. 12. UNFAVOURABLE PROGNOSTIC FACTORS NCCN EORTC,GHSG •Mediastinal lymphadenopathy with ratio of maximum mass width to maximum thoracic diameter of more than 0.33 •Bulky lymphadenopathy >10 cm •>3 nodal sites involved •B symptoms (fever, night sweats, and weight loss) •ESR>50 mm/hr Presence of extranodal contiguous disease >2 involved nodal sites Age>50yrs Prof. S. SUBBIAH et al.
  13. 13. INTERNATIONAL PROGNOSTIC INDEX-HL MALE SEX AGE>45 STAGE IV SR. ALBUMIN<4 HB<10.5 WBC>15000 LYMPHOCYTE COUNT<600/MICROL OR <8% OF WBC 5 yr survival - 88% for no risk factor - 62% for 4 or more risk factors Prof. S. SUBBIAH et al.
  14. 14. RISK FACTORS • Immunosuppression-acquired/EBV • Increasing age (waning immunity) • Previous history • Family history Prof. S. SUBBIAH et al.
  15. 15. CLINICAL PRESENTATION • Lymphadenopathy-Painless/ Alcohol-pain • B symptoms • Hepatomegaly and splenomegaly • Cough, dyspnea with bulky mediastinal involvement. • Aggressive/Indolent Prof. S. SUBBIAH et al.
  16. 16. WORKUP • Excisional or incisional biopsy is preferred. • Image-guided core needle biopsies in patients without peripheral adenopathy. • FNA-not adequate for precise lymphoma subclassification. • Tissue biopsy with histologic, immunophenotypic, and genetic studies interpretation. Prof. S. SUBBIAH et al.
  17. 17. LYMPH NODE BIOPSY • A lymph node>1.5 × 1.5 cm, not associated with a documented infection, persists longer than 4 weeks. • Patients with findings suggesting malignancy (e.g., systemic complaints or B symptoms, such as fever, night sweats, weight loss). • Definitive diagnosis and histological categorization. Prof. S. SUBBIAH et al.
  18. 18. LYMPH NODE BIOPSY • Peripheral Blood Smear-To rule out leukemia • Core needle biopsy of lymph node is an alternative in patients without accessible lymph nodes, but not generally recommended Prof. S. SUBBIAH et al.
  19. 19. BONE MARROW BIOPSY Indicated in Patients with B Symptoms Stage III-IV Recurrent Disease • Not routine -PET scan demonstrates bone marrow involvement, but indicated if cytopenia is present and PET is negative. Prof. S. SUBBIAH et al.
  20. 20. DIAGNOSTIC IMAGING PET-CT scan • Standard test for initial staging and assessing response to therapy • High FDG uptake should raise suspicion for aggressive-histology lymphoma • Diagnostic biopsy should be targeted to the site of greatest FDG avidity . Prof. S. SUBBIAH et al.
  21. 21. PET-CT • FDG-PET scanning is highly sensitive for detecting both nodal and extranodal sites. • The intensity of FDG avidity, or Standardized Uptake Value, correlates with histologic aggressiveness. Prof. S. SUBBIAH et al.
  22. 22. • Detects actively metabolizing tumor in residual masses following or during chemotherapy. • Persistent abnormal uptake predicts early relapse and/or reduced survival. • More accurate than the detection of a residual mass on CT scans, which can often be a false positive. Prof. S. SUBBIAH et al.
  23. 23. PET-CT RESPONSE SCORE SCORE UPTAKE 1 NO UPTAKE 2 <MEDIASTINUM 3 >MEDIASTINUM<LIVER 4 MODERATELY MORE THAN LIVER 5 MARKEDLY MORE THAN LIVER OR NEW SITE Prof. S. SUBBIAH et al.
  24. 24. Prof. S. SUBBIAH et al.
  25. 25. STAGE-IA/IIA(Non Bulky)/Favourable* ABVD X 2Cycles Restage with INTERIM PET-CT DEAUVILLE 1-2 DEAUVILLE 3 DEAUVILLE 4 ABVD X 2 CYCLES or ISRT 20GY ABD X 4 CYCLES or ISRT 20GY or ABVD X 1 CYCLE ABVD - 2 Cycle Restage with INTERIM PET/CT DEAUVILLE 1-3 DEAUVILLE 4/5 BIOPSY – NEG-ISRT 30GY- POS-Refractory disease ISRT 30GY *-Favourable Factors-ESR<50/<3 Nodal Sites/No Extra Nodal Disease
  26. 26. Unfavourable-B/Bulky->10CM ABVD X 2Cycles Restage with INTERIM PET-CT DEAUVILLE 1-3 DEAUVILLE 4/5 AVD X 4 CYCLES ESCALATED BEACOPP
  27. 27. STAGE III/IV ABVD X 2Cycles Restage with INTERIM PET-CT DEAUVILLE 1-3 DEAUVILLE 4/5 AVD X 4 CYCLES ABVD-2 Cycles+ESCALATED BEACOPP
  28. 28. REFRACTORY DISEASE SECOND LINE AGENTS (ICE/DHAP/GVD) Restage with INTERIM PET-CT DEAUVILLE 1-3 DEAUVILLE 4/5 AUTOLOGOUS STEM CELL TRANSPLANT BRENTUXIMAB VEDONTIN BRENTUXIMAB VEDONTIN
  29. 29. Prof. S. SUBBIAH et al.
  30. 30. WHO CLASSIFICATION Prof. S. SUBBIAH et al.
  31. 31. INTERNATIONAL PROGNOSTIC INDEX AGE OLDER THAN 60 YRS LDH>UPPER LIMIT NORMAL ECOG PERFORMANCE STATUS ≥2 ANN ARBOR STAGE III OR IV NUMBER OF EXTRANODAL DISEASE SITES GREATER THAN ONE Prof. S. SUBBIAH et al.
  32. 32. TREATMENT • Cyclophosphamide-750 mg/m2 IV on DAY-1 • Doxorubicin-50mg/m2 IV on DAY-1 • Vincristine-1.4 mg/m2 IV on DAY-1 • Prednisone-100mg/ PO on DAYS 1-5 • Rituximab-375mg/m2 on DAY-1 CYCLE EVERY 21 DAYS Prof. S. SUBBIAH et al.
  33. 33. NON HODGKIN LYMPHOMA STAGE I,II LIMITED STAGE DLBCL (↑ LDH/ ECOG PS 2-4) PARTIAL RESPONSE MORE EXTENSIVE DISEASE RESULTS OF PET POSITIVE NEGATIVE R-CHOP X3 Cycles F/B RISK ADAPTED MANAGEMENT BASED ON PET R-CHOP X4 Cycles TREAT FOR REFRACTORY DLBCL 3 Addl CYCLES OF R-CHOP (TOTAL 6 CYCLES) VS ISRT 30GY WITH 6-10 GY BOOST TO FDG AVID AREA (NO Addl R-CHOP) 3 Addl CYCLES OF R-CHOP (TOTAL6 CYCLES) VS ISRT 30GY (NO Addl R- CHOP) PET? 1 Addl CYCLE OF R-CHOP(TOTAL 4) VS ISRT 30 GY (NO ADDL R-CHOP) BX FDG AVID SITE (RES DISEASE?)
  34. 34. NON HODGKIN LYMPHOMA STAGE I,II bulky PARTIAL RESPONSE MORE EXTENSIVE DISEASE RESULTS OF PET POSITIVE NEGATIVE R-CHOP X 6 Cycles TREAT FOR REFRACTORY DLBCL 3 Addl CYCLES OF R-CHOP (TOT 6 CYCLES) VS ISRT 30GY WITH 6-10 GY BOOST TO FDG AVID AREA (NO Addl R-CHOP) ISRT 30 – 40 GY PET? ISRT 30 GY BX FDG AVID SITE (RES DISEASE?)
  35. 35. NON HODGKIN LYMPHOMA ADVANCED STAGE ADVANCED STAGE PARTIAL RESPONSE RESULTS OF PET POSITIVE NEGATIVE R-CHOP X6 Cycles TREAT FOR REFRACTORY DLBCL BX FDG AVID SITE (RES DISEASE?) PET OBSERVATION II LINE THERAPY F/B AUTOLOGOUS STEM CELL TRANSPLANT
  36. 36. THANK YOU Prof. S. SUBBIAH et al.

Notas del editor

  • PAX 5-Transcription factor BSAP-B CELL LINEAGE SPECIFIC ACTIVATOR PROTEIN
  • MULTILOBATED OR EXTREMELY FOLDED NUCLEUS-L&H
  • NUMBER,LOCATION,LYMPHATIC ORGAN
  • Aggressive lymphomas-acute or subacute presentation with increasing size of the mass and B symptoms.
    Indolent lymphomas-chronic course, with asymptomatic lymphadenopathy and/or slowly progressive cytopenias.
  • CBC,LDH
  • Less commonly in practice
    Staging and Prognostic purposes depending on the disease histology.
    Overall involvement in Hodgkin is less than 5%
  • BLEOMYCIN 10MG/M2
    ETOPOSIDE 200MG/M2
    DOXORUBICIN 35MG/M2
    CYCLOPHOSPHAMIDE 1250MG/M2
    VINCRISTINE 1.4MG/M2
    PROCARBAZINE 100 MG/M2 PO
    PREDNISONE 40 MG/M2 PO
  • HDT/ASCT-BV
    HDT/RT-BV
  • Serum protein electrophoresis-pres of monoclonal paraproteins
    b2 microglobulin and LDH
  • DEXAMETHASONE/CISPLATIN/CYTARABINE+/-RITUXIMAB
    DEXAMETHASONE/CYTARABINE/OXALIPLATIN+/-RITUXIMAB

    TUMOR LYSIS SYNDROME
    In the first 12 to 72 hrs of treatment
    VIRAL REACTIVATION

    RCHOP FOR 6 CYCLES
    NO ROLE OF INTERIM PET
    R-POLA CHP VS RCHOP

    II LINE THERAPY
    ICE/DHAP
    CAR T CELL THERAPY
    AXICABTAGENE CILOLEUCEL

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