Indolent non hodgkins lymphoma
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Transcript of Indolent non hodgkins lymphoma
Indolent non Hodgkin lymphomas
Dr. Rajib BhattacharjeeJunior Resident
IPGMER, Kolkata
WHO classification 2008
Most common types of NHL encountered in clinical practice
types of NHL Incidence DLBCL 33%
Follicular Lymphoma 22%
Marginal Zone Lymphoma 10%
PTCL 10%
SLL/CLL 7%
Mantle cell lymphoma 7%
Types of NHL based on aggressiveness
Low grade Intermediate grade high grade
Follicular lymphoma
Marginal zone lymphoma
SLL/CLL
DLBCL
PTCL
Burkitt’s lymphoma
Lymphoblastic lymphoma
New ticket day… in the OPD…
Our patient enters…. A man in his 60s
•Median age at presentation – 55-65 years
•Males are affected more than females
I started to listen to his clinical history..
He complained of a painless swelling in his neck..
2/3rd of NHL patients present with asymptomatic lymph node swelling (nodal disease)Common in FL,MCL & SLLSites- Neck 70%Groin 60%Axilla 50%
Any extranodal disease…
• I asked him,” Do you have any problem during swallowing or do you get full with little food?”
1/3rd of NHL patients may present with extranodal disease.Common in DLBCL & MZLSite-GIT - 25-35%Waldayers ring – 18-23%
B Symptoms
I asked 3 questions:-1. Did you suffer from fever in the last few
months?2. Have you lost a lot of weight lately?3. Do you change your shirt often due to night
sweats?Then I asked… did you find any cause to these or
were they unexplained?
Exam time..
• Lymph node examination• Head and neck – waldeyer’s ring• Chest – Sternal/2nd ICS percussion Pleural effusion• Abdomen- Organomegally, Lump, Ascites Testes• Skin - Nodules
Investigations ..
Lab investigations• CBC, KFT, LFT, Electrolytes• Ca2+
• LDH, Uric acid• HBsAg, IgM HBc• HIV I & II
Imaging• Chest X-Ray• CT Thorax, abdomen & pelvis• PET CT• Tc-99m Bone Scan• MUGA/ Echocardiography
Endoscopy • Upper GI
• Bone marrow biopsy A must for all NHL patients (SLL, mantle cell lymphoma – 70% FL – 50% , DLBCL – 15%)
• CSF Cytology Only in suspected leptomeningeal
involvement
Histopathological examination
The cervical lymph node must go for biopsy….
A medium sized accessible lymph node is preferred for excision.Cervical lymph node if palpable, is preffered
Which stage is the disease..???
X = Bulky disease• Clinically diameter > 10cm• CXR PA- Mediastinal mass ratio(MMR) = Max width of mass__ > 0.33
Max intrathoracic dia = Max width of mass >0.35 Intrathoracic dia @ T5 - T6
Possible histologies for our discussion
Follicular Lymphoma
5Y OS
70.7%
50.9%
35.5%
How do I treat this patient if he has localised FL – Stage I & II?
Gr 1-2, non bulky, asymptomatic
IFRT (30Gy)
Gr 3, bulky, B symptoms
IFRT(30Gy) RCHOP (4 cycles)
Boost (upto 40 Gy) IFRT to the bulky site (30Gy)
How do I treat this patient if he has advanced FL – Stage III & IV?
Asymptomatic
Observation or Rituximab
Symptomatic, B symptoms, cytopenias, compromised end organ function
RCVP/RCHOP (6 cycles)
Gr 3 RCHOP (6 cycles)
Important studies study Conclusion
BNLI Study 2003 Observation is a good initial approach in asymptomatic stage III & IV FL
GLSG Trial 2005 & Marcus et al Rituximab with both CVP & CHOP produce enhanced OS
SWOG Trial Anthracyclins fail to improve OS in indolent lymphoma
Bendamustine in 1st line
indolent/mantle cell
R-B R R-CHOP 69.5mo PFS 31.2mo
toxicity
Maintenance Rituximab
Follicular lymphoma RCHOP/RCVP/RFCM
mRituximab R Obv
75% PFS 58%
72% CR 52%
Progressive disease
• Elderly, asymptomatic – Obv• 2nd line chemotherapy – Bendamustine FCM• Radioimmunotherapy – Zavaline, Baxxar• mTOR inhibitors – NVP-BEZ235• Proteasome inhibitors• Stem cell transplant
Marginal zone lymphoma
Three entities• Nodal • Extranodal - MALToma• Splenic
StomachSmall intestineOccularSkinParotidThyroid
How to treat…Extranodal disease• Symptomatic local tumor – RT• Generalized disease Asymptomatic – Obv Symptomatic - CT (Chlorambucil)
Nodal disease – R-CHOP
Splenic disease – Splenectomy or Splenic RT
Gastric MALToma• C/F- abdominal fullness, loss of appetite,
waight loss, B symptoms, pain, bleeding• Diagnosis- Endoscopic biopsy• H. pylori association in 92% (# Isaacson et al)• Antibiotics and PPI (even in H.pylori –ve cases) CRR-75% 5Y FFS-50% OS>90%• Endoscopy after 3 months• Lymphoma persist- *deep invasion *t(11:18)• Antibiotic failure T/t – RT(24-30Gy)• Not suitable for RT – Rituximab monotherapy
SLL
• Localized disease – IFRT (30Gy)
• Advanced disease – Chemoimmunotherapy
Age>70, co-morbidities Age<70, medically fit Relapse
•Obinutuzumab + Chlorambucil•Rituximab + Chlorambucil•Bendamustine + Rituximab
•FCR (Fludarabine + Cyclofosfamide + Rituximib)
•Ibrutinib
IFRT
Fallow up
• Physical exam & labwork - 3-6 months for 1st 5 years then annually.
• CT scan every 6 months for 2 years then annually.
THANK YOU