Clinical Management of Lymphoma

新光醫院 血液腫瘤科溫 武 慶

Malignant Lymphoma

• Neoplastic lymphoid cells

• Arrested at different stages of normal differentiation

• Tumor formation in the lymph nodes (usually) or extranodal areas

90.9.28 90.11.28 91.03.13

Classification of Lymphoma

• Hodgkin lymphoma (HL) – Classic (CHL)

• LR (lymphocyte-rich)• LD (lymphocyte-depleted)• MC (mixed cellularity) 17%• NS (nodular sclerosis) 80%

– NLPHL (nodular lymphocyte predominant) 3-8%

• Non-Hodgkin lymphoma (NHL)– B-cell, T-cell– High, intermediate, low grade

(REAL/WHO classification)

Differences in HL and NHL

• HL

• NHL

RS or L & H cells

Lymphoma cellsnodular diffuse

Differences in HL and NHL

HL NHL

Cell RS (Reed-Sternberg)

L & H (lymphocytic and histiocytic) cells

B- and T- cells

Grade Low Low intermediate high

Spread Lymphatic (contiguously)

Hematogenous

Lymphatic

Lymphoma Work-up

• Diagnosis and Classification

• Stage

• Other prognostic factors– Age– LDH– Beta-2 microglobulin– IPI (international prognostic index)

Staging Work-up

• CBC, platelet

• LDH, biochemistry

• CXR, chest/abdomen/pelvic CT

• PET scan

• Bone marrow examination

Lymphoma Stage

• 1974 Ann Arbor, 1988 Cotswolds • I 1 single LN region or lymphoid structure• II > 2 LN regions on the same side of di

aphragm (No. of LNs indicated by a subscript e.g. II2)

• III LN regions or lymphoid structures on both sides of the diaphragm

– III1 splenic hilar, celiac, or portal LNs– III2 PALN, iliac, mesenteric LNs

• IV > 2 extranodal sites

Lymphoma Stage

• A: no symptoms

• B: fever, night sweating, BW loss (any one)

• X: bulky disease– Mediastinal mass > 1/3 of maximum transverse

chest diameter– LN > 10cm

• E: single extranodal site (contiguous or proximal to a known LN stie)

A = without symptoms, B = with symptoms including unexplained weight loss 10% in 6 months), unexplained fever, and

drenching night sweats

Lymph Node Region

Gastric Lymphoma Stage

SL/CLL Stage

Principles of NHL Treatment

• Low risk – Stage I, II C/T + R/T– Stage III, IV observation, C/T

• Intermediate~ high grade– Stage I, II C/T + R/T– Stage III, IV C/T

NHL Treatment- DLBCL(diffuse large B-cell lymphoma)

NHL Treatment- DLBCL(diffuse large B-cell lymphoma)

NHL Treatment- DLBCLIPI

• 5ys: score 0-1 73%; 2 51%; 3 43%; 4-5 26%

NHL Treatment-FL

NHL Treatment-FL(follicular lymphoma)

NHL Treatment-FL

Median survival 8-10y

NHL Treatment-Margional Zone Lymphoma

NHL Treatment-Margional Zone Lymphoma

Median survival 10y

NHL Treatment-MCL(Mantle Cell Lymphoma)

NHL Treatment-MCL

Median survival 3-5y

NHL Treatment-SL/CLL(small lymphocytic lymphoma)

NHL Treatment-SL/CLL

Median survival: 10 y

NHL Treatment-Burkitt Lymphoma

NHL Treatment-PTL

NHL Treatment-PTL

NHL Treatment-PTL

5 year survival 25%

HL TreatmetPrognostic factors

HL treatment- Classic HL

• Stage IA, IIA, nonbulky, cure rate: >90%– C/T (ABVD) + IFRT (category 1)– C/T only (ABVD x 6) (category 2B)

• Stage I, II, bulky, cure rate >80%• Stage III, IV, cure rate 60-70%

– ABVD x 4 -> restage -> 2-4 cycles -> observe or IFRT

– Stanford V x 3 -> restage + R/T– Escalated BEACOPP (if IPS > 4)

Classic HL Treatmet-C/T

NLPHL Treatmet

• I-IIA: IFRT or regional R/T

• I-IIB: C/T + IFRT

• III-IVA – C/T + R/T – local R/T– observation (category 2B)

• III-IVB: C/T + R/T

NLPHL Treatmet-C/T

• 10 year survival 80%

HL Treatmet-R/T

PET in lymphoma

International Harmonization Project in Lymphoma

• PET scanning before treatment is recommended only for those lymphomas that are routinely avid for labeled glucose (eg, DLBCL, Hodgkin lymphoma)]. There is not sufficient evidence in support of the use of PET scanning for lymphomas other than DLBCL and Hodgkin Lymphoma.

• Use of PET for treatment monitoring during a course of therapy should only be done as part of a clinical trial or as part of a prospective registry.

• PET scanning after completion of therapy should be performed at least three weeks and preferably at six to eight weeks after chemotherapy or chemo-immunotherapy and 8 to 12 weeks after radiation or chemoradiotherapy.

• Mediastinal blood pool activity is recommended as the reference background activity to define PET positivity for a residual mass ≥2 cm in greatest transverse diameter, regardless of location.

• A smaller residual mass or a normal sized lymph node (ie, ≤1 x 1 cm in diameter) should be considered positive if its activity is above that of the surrounding background.

• There is no role for the use of PET to follow patients in remission. • JCO 2007 25;571-8