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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.

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clinical management of lymphoma

Clinical Management of Lymphoma

新光醫院 血液腫瘤科

溫 武 慶

malignant lymphoma
Malignant Lymphoma
  • Neoplastic lymphoid cells
  • Arrested at different stages of normal differentiation
  • Tumor formation in the lymph nodes (usually) or extranodal areas
slide6

90.9.28

90.11.28

91.03.13

classification of lymphoma
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
Differences in HL and NHL
  • HL
  • NHL

RS or L & H cells

Lymphoma cells

diffuse

nodular

lymphoma work up
Lymphoma Work-up
  • Diagnosis and Classification
  • Stage
  • Other prognostic factors
    • Age
    • LDH
    • Beta-2 microglobulin
    • IPI (international prognostic index)
staging work up
Staging Work-up
  • CBC, platelet
  • LDH, biochemistry
  • CXR, chest/abdomen/pelvic CT
  • PET scan
  • Bone marrow examination
lymphoma stage
Lymphoma Stage
  • 1974 Ann Arbor, 1988 Cotswolds
  • I 1 single LN region or lymphoid structure
  • II > 2 LN regions on the same side of diaphragm (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 stage1
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)
slide16

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

principles of nhl treatment
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 ipi
NHL Treatment- DLBCLIPI
  • 5ys: score 0-1 73%; 2 51%; 3 43%; 4-5 26%
nhl treatment fl1
NHL Treatment-FL

Median survival 8-10y

nhl treatment mcl
NHL Treatment-MCL

Median survival 3-5y

nhl treatment sl cll
NHL Treatment-SL/CLL

Median survival: 10 y

nhl treatment ptl2
NHL Treatment-PTL

5 year survival 25%

hl treatment classic hl
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)
nlphl treatmet
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
NLPHL Treatmet-C/T
  • 10 year survival 80%
international harmonization project 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