Lymphoma

Lymphoma

DEFINITION Lymphoma is a group of cancers that affect the cells of the immune system, and primarily represents cells involved in the lymphatic system of the body (lymphocytes)

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ALL

CLL

Lymphomas

MM

naïv e B-lymphocytes

Lymphoid progenitor

AML Hematopoietic stem cell

Myeloid progenitor

Plasma cells T-lymphocytes

Myeloproliferative disorders Neutrophils Eosinophils Basophils Monocytes Platelets Red cells

Types of Lymphoma Hodgkin’s lymphoma (HL) is a neoplastic disorder of the lymphoid system characterized by the presence of binucleated giant cells, known as Reed Sternberg (RS) cells. Non-Hodgkin’s lymphoma (NHL) refers to any type of lymphoma that does not have the distinctive Reed-Sternberg cell.

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Types of Non-Hodgkin Lymphoma • There are about 35 recognized subtypes of non-Hodgkin lymphoma • Each subtype can require different treatment • Types are described by how quickly the cancer is growing: indolent (slow) or aggressive (fast)

Epidemiolog y www.MansFans.com

Epidemiolog 5th most frequently diagnosed ▪ cancer in both sexes males > females ▪ Incidence NHL increasing ▪ Hodgkin lymphoma stable ▪

Relative frequencies of different lymphomas Non-Hodgkin Lymphomas

Diffuse large B-cell Hodgkin lymphoma

Follicular NHL

Other NHL

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 There is an age related bimodal incidence for Hodgkin disease . The first peak occur in the third decade of life , with a second rise in incidence occurring in the seventh decade.

0-1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

incidence/100,000/annum

Age distribution of new Hodgkin lymphoma cases 6

5

4

3

2

1

0

Age (years)

Although non-Hodgkin lymphoma can occur in young people, the chance of developing this disease goes up with age. Most people with nonHodgkin lymphoma are older than 60.

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0-1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Incidence/100,000/annum

Age distribution of new NHL cases 100

80

60

40

20

0

Age (years)

Etiology www.MansFans.com

Etiology 

Several different theories have been proposed for the etiology of lymphoma.

 The argument for an infectious etiology of lymphoma data back to the early description of the disorder

Epstein Bar Virus (EBV)

is a leading candidate as the causative agent for Hodgkin disease. EBV is the causative agent in African Burkitt lymphoma, and EBV associated lymphomas are documented in patients with immunodeficiency disorders.

HIV virus

People who have HIV infection are at much greater risk of some types of non-Hodgkin lymphoma.

H. pylori

are bacteria that can cause stomach ulcers. They also increase a person's risk of lymphoma in the stomach lining (MALT Lymphoma).

 HCV

Some studies have found an increased risk of lymphoma in people with hepatitis C virus.

 Immundeficiency or suppression  Ionizing radiation  Connective tissue diseases

Pathology www.MansFans.com

Histopathology  Hodgkin disease is unique among lymphomas for its histologic diversity. Involved lymph nodes contain varying degrees of normal reactive and inflammatory cells, fibrosis and scattering of the characteristics malignant cells of Hodgkin disease, the Reed Sternberg cells.

Reed-Sternberg cell

Lymph node section from a patient with Hodgkin’s disease showing a classic Reed .Sternberg cell

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Hodgkin lymphoma Histologic subtypes – nodular sclerosis (most common subtype) – mixed cellularity – lymphocyte-rich – Lymphocyte- depleted

Non-Hodgkin lymphoma Histologic subtypes – Small cell type – Intermediate cell type – Large cell type

Clinical Presentatio n

Clinical manifestations Variable severity asymptomatic to extremely ill

time course: evolution over weeks, months, or years

Local manifestations

lymphadenopathy, Splenomegaly: most common any tissue potentially can be infiltrated

Systemic manifestations

fever, night sweats, weight loss, anorexia, pruritis

Other complications of lymphoma bone marrow failure (infiltration) CNS infiltration immune hemolysis or thrombocytopenia compression of structures (eg spinal cord, ureters) • pleural/pericardial effusions, ascites • • • •

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Clinical manifestations of HL • Lymphadenopathy • contiguous spread • extranodal sites relatively uncommon except in advanced disease • “B” symptoms • Survival is variable → Months to Years

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Classical Hodgkin Lymphoma

Clinical Presentation of NonHodgkin’s Lymphoma

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Small cell lymphomas  Slowly progressive clinical course, during which spontaneous regression may be observed.  Moderate sensitivity to chemotherapy.  Final disease eradication and cure is rarely achievable by currently available regimens.  Survival without treatment → Years

Large cell Lymphomas  More rapid clinical course.  Moderate to good response CTx.  Considerable

proportion

of

patients

experience long term disease-free and overall survival after treatment.  Survival without treatment → Months

Staging of Lymphoma

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Stage I

Stage II

Involvement of a single lymph node region or lymphoid structure (spleen, thymus, waldeyer ring). Or involvement of a single extralymphatic site (IE) Involvement of two or more lymph node regions on the same side of the diaphragm (hilar node when involved on the both sides, constitute stage II disease). Localized contiguous involvement of only one extranodal organ or site and lymph node regions on the same side of the diaphragm (IIE)

Stage III

 Involvement of lymph node regions on both sides of the diaphragm (III), Which may also a compained by involvements of the spleen (IIS) or localized contiguous involvement of only one extra nodal organ site (IIIE) or both (III SE)

III 1

With or without involvement of splenic, hilar, celiac, or portal nodes.

III 2

With involvement of paraoertic, iliac, and mesenteric nodes

Stage IV Diffuse or disseminated involvement of one or more extranodal organs or tissues, with or without associated lymph node involvement.

Staging of lymphoma Stage I

Stage II

Stage III

Stage IV

A: absence of B symptoms B: fever, night sweats, weight loss

Designations applicable to any disease stage

A

No symptoms

B

Fever (temp.>38 c[100.4 F], drenching night sweats, unexplained loss of >10% of body weight within the precending 6 months.

X

Bulky disease (a widening of the mediastinum by more than one third of the presence of a nodal mass with a maximal dimension greater than 10 cm.

E

Involvement of a single extranodal site that is contiguous or proximal to the known nodal site Clinical stage

CS PS

Pathologic stage (as determined by laparotomy)

Recommend ed staging

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 Adequate surgical biopsy reviewed by an experienced hemopatholoigist.  Detailed history with attention to the presence or absence of systemic symptoms. Careful physical examination, emphasizing node chains, size of liver and spleen, and Waldeyer ring inspection

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

Routine laboratory tests: complete blood count, erythrocyte sedimentation rate, and liver function tests.

Chest radiograph (posteroanterior and lateral) with measurement of mass/thoracic ratio Chest, abdominal, and pelvic computed tomography scans.



Radioisotopic evaluation with gallium 67 or position emission tomography.

Core needle biopsy of bone marrow from the posterior iliac crest in patients with stages IIB to IV disease. Needle or surgical biopsy of any suspicious extranodal (hepatic, osseous, pulmonary, cutanous) lesions.

 Cytologic examination of any

effusion.

Staging laparotomy in rare circumstances in early stage Hodgkin disease where the use of limited radiation therapy alone depends on pathologic staging.

Treatment of Lymphoma

Treatment of Lymphoma : Chemotherapy • Use of drugs to kill cancer cells • Primary treatment for lymphomas • Drugs used depend on the type and stage of cancer

Hodgkin Lymphoma

Long term complications of treatment

• infertility – – –

MOPP > ABVD; males > females sperm banking should be discussed premature menopause

• secondary malignancy

– skin, AML, lung, MDS, NHL, thyroid, breast...

• cardiac disease

Treatment Overview LG - NHL  Localized low-grade disease is most often cured by radiotherapy.  Most patients present with advanced stages, for which only palliative ttt is considered.  Single agent chemotherapy (  Combination chemotherapy (COP- CHOP)  With minimal therapy, patients are expected to survive a median of 7.5 to 9 years.

Treatment Overview HG - NHL  The treatment of localized high-grade disease is controversial. Most authorities would use shortcourse combination chemotherapy.  CHOP represents the treatment of 1st choice (cyclophosphamide, doxorubicin, vincristine. prednisone)  This is followed by radiotherapy.

Salvage Therapy www.MansFans.com

 For the purpose of this section, salvage therapy refers to treatment administrated to patients with HL or NHL who fail to achieve an initial complete remission or relapse after achieving an initial complete remission. Although seemingly straightforward, the diagnosis of treatment failure is not always easy.

Progressive disease or relapse

• Rebiopsy • Restaging (same as initial work up, including bone marrow biopsy) • Consider cytogenetics prior to transplant



Hodgkin’s Lymphoma If primary therapy was chemotherapy alone or combination chemotherapy/RT

IF INITIAL STAGE WAS IA-IIA: NO PRIOR RT and failure in initial sites only

propriate treatment in this setting s not been identified, individualized eatment is recommended. reatment nsider RT

AII other

 chemotherapy  (ICE,DHAP,ESHAP)  AHSCT ± Locoregional RT

Non-Hodgkin’s Lymphoma  More than 50% of NHL patients will relapse after initial therapy. Low-grade NHL will typically respond to single agent, CTx or radiotherapy, but intermediate-grade and high-grade NHL that relapses or fails to remit carries a poor prognosis but may respond to high-dose chemotherapy and marrow or peripheral blood stem cell rescue.

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