Lymphoma

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Lymphoma

• S. Vincent Rajkumar, MD

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Lymphoma
Hodgkins Disease
Non-Hodgkins Lymphoma
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Benign Reactive Lymph Node
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Lymph Node Follicle
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Non-Hodgkins Lymphoma

• 4 of cancers
• gt50,000 new cases each year
• No known etiology in majority
• Some a predisposing factor may be present
• Immunosuppression
• H. pylori

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Non Hodgkins Lymphoma

• Malignant proliferation of Lymphoid cells
• Heterogeneous
• Can be T cell or B cell
• We depend on the pathologist!!

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Non-Hodgkins Lymphoma Presentation

• Lymphadenopathy
• B Symptoms

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Non Hodgkins Lymphoma
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Non Hodgkins Lymphoma
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Non Hodgkins Lymphoma
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Non Hodgkins Lymphoma
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Non Hodgkins Lymphoma
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Non-Hodgkins Lymphoma Diagnosis

• Tissue/ LN biopsy
• Staging

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Non-Hodgkins Lymphoma

• Histological diagnosis is key

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Non Hodgkins Lymphoma Diagnosis

• Tissue Biopsy

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Non-Hodgkins Lymphoma Staging

• Stage I Disease confined to a single lymph node
  region or lymphoid structure
• Stage II Involvement of two or more lymphoid
  regions or structures but with disease confined
  to one side of the diaphragm

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Non-Hodgkins Lymphoma Staging

• Stage III Disease on both sides of the diaphragm
  
• Stage IV Involvement of non-lymphoid organs such
  as liver, lung or bone marrow

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Non-Hodgkins Lymphoma Staging

• Stage A No B symptoms
• Stage B
• Fever
• Drenching night sweats
• Significant weight loss (gt10 of body weight in
  the preceding 6 months)

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Non-Hodgkins Lymphoma Staging

• History of B symptoms
• Performance status
• Physical examination of nodes
• CBC, Liver function tests
• CT scans of chest, abdomen and pelvis
• Bilateral bone marrow biopsy
• Other tests creatinine, LDH

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Non-Hodgkins Lymphoma

• Indolent eg., Follicular lymphoma
• Aggressive eg., Diffuse large cell
• Others
• MALT
• High grade
• Mantle cell

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Follicular lymphoma

• Low grade
• Not curable
• Indolent course

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Follicular Lymphoma
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Follicular Lymphoma
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Follicular Lymphoma
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Diffuse Large Cell Lymphoma

• Curable
• Aggressive

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Diffuse Large Cell Lymphoma
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Large Cell Lymphoma
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Large Cell Lymphoma

• International Prognostic Index
• Age gt60
• High LDH
• Poor Performance status
• Stage III or IV
• Extranodal disease

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Large Cell Lymphoma

• International Prognostic Index
• 0-1 factor 75 5 yr survival
• 4 or 5 factors 25 5 yr survival

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NHL Treatment

• Depends on histology
• Low grade lymphomas can be observed
• Median survival is 5-8 years
• Diffuse large cell lymphoma Usually treated with
  chemotherapy

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Diffuse Large Cell Lymphoma Chemotherapy

• CHOP
• Cyclophosphamide
• Hydroxy-daunorubicin (Adriamycin, Doxorubicin)
• Oncovin (Vincristine)
• Prednisone
• R-CHOP

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Non-Hodgkins Lymphoma Salvage Therapy

• Autologous stem cell transplantation

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Hodgkins Disease

• B cell malignancy
• Reed Sternberg Cells
• 7500 new cases each year
• Bimodal peak incidence
• 25 years and 80 years

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Hodgkins Disease Presentation

• Contigous involvement
• B Symptoms
• Pruritus
• Alcohol induced pain in nodes
• SVC syndrome

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Hodgkins Disease Pathology

• RS L
• Lymphocyte predominant
• Nodular Sclerosing (40-70)
• Mixed cellularity (20-40)
• Lymphocyte depleted

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Hodgkins Disease
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Hodgkins Disease
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Hodgkins Disease
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Hodgkins Disease
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Hodgkins Disease
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Hodgkins Disease Diagnosis

• Tissue Biopsy

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Hodgkins Disease Staging

• Stage I Disease confined to a single lymph node
  region or lymphoid structure
• Stage II Involvement of two or more lymphoid
  regions or structures but with disease confined
  to one side of the diaphragm

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Hodgkins Disease Staging

• Stage III Disease on both sides of the diaphragm
  
• Stage IV Involvement of non-lymphoid organs such
  as liver, lung or bone marrow

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Hodgkins Disease Staging

• Stage A No B symptoms
• Stage B
• Fever
• Drenching night sweats
• Significant weight loss (gt10 of body weight in
  the preceding 6 months)

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Hodgkins Disease Staging

• Other staging terminology
• E (extranodal)
• Bulky

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Hodgkins Disease Staging Evaluation

• History of B symptoms
• Physical examination of nodes
• CBC, Liver function tests
• CT scans of chest, abdomen and pelvis
• Bilateral bone marrow biopsy
• Other tests creatinine, sed rate

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Hodgkins Disease Treatment

• Early Stage XRT or combined modality therapy
• gt85-90 cure rates
• Advanced Stage Chemotherapy
• 55-65 cure rates

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Hodgkins Disease Chemotherapy

• Adriamycin
• Bleomycin
• Vinblastine
• Dacarbazine

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Hodgkins Disease Salvage Therapy

• Autologous stem cell transplantation

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Hodgkins Disease Treatment

• Hypothyroidism
• 20 risk of solid tumors 20 years post radiation
• Increased leukemia risk with chemotherapy

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Diagnosis of CLL

• Lymphocytosis
• Clonal
• Dim surface Ig and light chains
• B cell surface Antigens(CD19, CD 20, CD 23)
• CD5 surface Antigen expression

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Survival by Rai Stage
Diehl, et.al., Cnncer. 1999862684-2691(overall
survival)
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CLL-Types

• Unmutated
• Naïve B-cell (Mantle)
• CD38 positive

• Mutated
• Memory B-cell (Follicular)
• CD38 minus

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Survival based on Ig Variable gene mutation
status.
Damle RN. Wasil T.Blood. 94(6)1840-1847, 1999
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When do you initiate therapy?
No treatment(169 deaths)
Overallsurvival ()
Chlorambucil(175 deaths)
P0.23
Years
CP935485- 1
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CLL Chemotherapy

• Fludarabine
• Alkylators Cyclophosphamide, Chlorambucil
• Rituximab