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Lymphoma- All you Need to know in ONE hour

Lymphoma- All you Need to know in ONE hour. Cathleen Cook Pediatric Hematology/ Oncology March 12, 2014. Ranking of pediatric m alignancies for children aged 0-14 years. Leukemia. Brain tumors. Lymphoma. http://www.meb.uni-bonn.de/cancer.gov/CDR0000062872.html.

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Lymphoma- All you Need to know in ONE hour

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  1. Lymphoma- All you Need to know in ONE hour Cathleen Cook Pediatric Hematology/ Oncology March 12, 2014

  2. Ranking of pediatric malignancies for children aged 0-14 years Leukemia Brain tumors Lymphoma http://www.meb.uni-bonn.de/cancer.gov/CDR0000062872.html

  3. Ranking of pediatric malignancies for children aged 15-19 years Lymphoma Carcinomas and Melanoma Brain tumors http://www.meb.uni-bonn.de/cancer.gov/CDR0000062872.html

  4. Objectives Hodgkin Lymphoma Late Effects Non-Hodgkin Lymphoma Nicole Juan Pablo

  5. Epidemiology of Hodgkin Lymphoma • 5% of cancers ≤14 years of age • 15% of cancers ≥14 years of age • Bimodal age distribution

  6. Associations with Hodgkin Lymphoma CMV EBV HHV6

  7. What is Hodgkin Lymphoma? • Cancer of the lymphoreticular system

  8. Hodgkin Lymphoma Explained http://www.youtube.com/watch?v=saYsSIsBObw&list=PLlacjr_GktwC9JDvcxvgGKQ4jMq2JAE0L

  9. Reed-Sternberg (RS) Cells = Hallmark of classical Hodgkin Lymphoma

  10. Other Subtypes of Hodgkin Lymphoma

  11. To where can Hodgkin Lymphoma metastasize? Brain Spleen Liver Bone Marrow Bone

  12. Symptoms of Hodgkin Lymphoma • Painless, nontender, firm, rubbery lymph node • Cough • Weight loss • Fever • Night sweats • Pruritus (itching) • Anorexia (appetite loss) • Tiredness/ Lethargy • Pain WORSENING with Alcohol B symptoms

  13. Nicole’s Symptoms http://www.youtube.com/watch?v=vsSrdEYjcpc 1:30 sec. --- 5:00

  14. So how do we diagnose Nicole? Physical Exam

  15. So how do we diagnose Nicole? Sites of Disease Source: Metzger M. Hodgkin Lymphoma Lecture. 2009

  16. So how do we diagnose Nicole? CBC with differential LDH Labs CMP Uric Acid Ferritin ESR EBV titers CRP CMV titers

  17. Diagnostic Work Up: Chest X-ray

  18. Diagnostic Work Up: CT CAP

  19. Diagnostic Work Up: PET Scan

  20. Diagnostic Work Up: Bilateral Bone Marrow Biopsy/Aspirate http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Hodgkin-Lymphoma.aspx#Cancer_Summary

  21. Diagnostic Work Up: Excisional Lymph Node Biopsy http://www.flickr.com/photos/santoshpath/5453069538/ http://tessascancerjourney2.blogspot.com/2010/11/lymph-node-biopsy.html

  22. Summary of Nicole’s diagnostic work up for Hodgkin Lymphoma? • Physical Exam • CBC • CMP • LDH • Uric Acid • ESR • CRP • Ferritin • EBV titers • CMV titers • Chest Xray- PA/L • CT scan (CAP) • PET scan • Bone marrow aspirate/biopsy • Excisional LN biopsy

  23. So how do we stage Hodgkin Lymphoma? A=no “B symptoms B=fever (>38C), unexplained weight loss (>10%), drenching night sweats E=extranodal extension S= splenic involvement Source: Metzger M. Hodgkin Lymphoma Lecture. 2009

  24. So how do we treat Hodgkin Lymphoma? Chemotherapy • Prednisone (P) • Vinblastine (V) • Bleomycin (B) • Doxorubicin (A) • Vincristine (O) • Procarbizine (P) • Etoposide (E) • Cyclophosphamide (C) COPDAC COPP OEPA OPPA ABVD VAMP

  25. So how do we treat Hodgkin Lymphoma? Radiation Source: Metzger M. Hodgkin Lymphoma Lecture. 2009

  26. Objectives Hodgkin Lymphoma Late Effects Non-Hodgkin Lymphoma Nicole Juan Pablo

  27. Epidemiology of Non-Hodgkin Lymphoma (NHL) • 60% of all lymphomas in children and adolescents • 8-10% of cancers between 5-19 yo • >70% have advance disease at diagnosis Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19th edition. 2011. pg 8002.

  28. Associations with Non-Hodgkin Lymphoma Wiskott-Aldrich Syndrome SCID De NOVO EBV HIV Bloom syndrome Ataxia-telangiectasia Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19th edition. 2011. pg 8002.

  29. What is Non-Hodgkin Lymphoma? • Cancer of the lymphocytes

  30. Non-Hodgkin Lymphoma Explained https://www.youtube.com/watch?v=x3c9dy3MPZo

  31. Subtypes of Non-Hodgkin Lymphoma 0-14 years 38% Burkittlymphoma (BL) 29% Lymphoblastic lymphoma (LL) 20% Diffuse large B-cell lymphoma (DLBCL) 10% Anaplastic large cell lymphoma (ALCL) Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19th edition. 2011. pg 8003.

  32. Subtypes of Non-Hodgkin Lymphoma 15-19 years 37% Diffuse large B-cell lymphoma (DLBCL) 21% Burkittlymphoma (BL) 19% Lymphoblastic lymphoma (LL) 17% Anaplastic large cell lymphoma (ALCL) Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19th edition. 2011. pg 8003.

  33. Clinical Presentationof Non-Hodgkin Lymphoma Chest masses MASSES Jaw swelling Abdominal masses Paraspinal masses Orbital swelling

  34. Clinical Presentationof Non-Hodgkin Lymphoma

  35. Juan Pablo’s Symptoms http://www.youtube.com/watch?v=Zx9SjYTr7CU Initial 1:00min

  36. Non-Hodgkin Lymphoma- Tumor Lysis Syndrome Tumor masses (similar to leukocytosis with leukemia) http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569

  37. Tumor Lysis Syndrome Uric Acid Phosphate Potassium NO CHANGE Calcium Sodium http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569

  38. Tumor Lysis Syndrome Uric Acid Phosphate Potassium RISK OF Acute Kidney Injury -stones -renal failure http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569 http://www.nytimes.com/health/guides/disease/acute-gouty-arthritis/print.html

  39. Tumor Lysis Syndrome RISK OF Calcium Chvostek sign Trousseau's sign http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569 http://www.pinterest.com/pin/90986854945562677/ http://www.aaemrsa.org/communication/modernresident/2012/images/hands-lg.jpg

  40. Emergency Presentations of Non-Hodgkin Lymphoma

  41. So how do we diagnose Juan Pablo? Physical Exam

  42. So how do we diagnose Juan Pablo? CBC with differential LDH Labs CMP Uric Acid Ferritin ESR EBV titers CRP CMV titers

  43. Diagnostic Work Up: Chest X-ray

  44. Diagnostic Work Up: CT CAP http://tmcr.usuhs.edu/tmcr/chapter8/differential3.htm http://www.radiologyschools.com/Radiology-Courses/gu/kidneys/lymphoma.html

  45. Diagnostic Work Up: PET Scan http://www.hindawi.com/journals/crim/2012/239719/fig2/ https://www.mi-lifenet.com/ImagingCenter/zportal/portals/phys/clinical/petct_case_studies/lymphoma/lymphoma_case3

  46. Diagnostic Work Up: Bilateral Bone Marrow Biopsy/Aspirate http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Hodgkin-Lymphoma.aspx#Cancer_Summary

  47. Diagnostic Work Up: Least Invasive Biopsy http://www.umphysicians.org/cancercare/cancer-information/cancer-library/CDR269299.html#_1

  48. Diagnostic Work Up: Lumbar Puncture http://www.webmd.com/cancer/tc/brain-cancer-primary-central-nervous-system-lymphoma-treatment-patient-information-nci-pdq-general

  49. Summary of diagnostic work up for Non-Hodgkin Lymphoma? • Physical Exam • CBC • CMP • LDH • Uric Acid • ESR • CRP • Ferritin • EBV titers • CMV titers • Chest Xray- PA/L • CT scan (CAP) • PET scan • Lumbar puncture • Bone marrow aspirate/biopsy • Least invasive Biopsy

  50. So how do we treat Non-Hodgkin Lymphoma? Chemotherapy • Cyclophosphamide (C) • Vincristine (O) • Prednisone (P) • Doxorubicin (A) With intra-thecal Chemotherapy COPAD • Methotrexate (M) • Hydrocortisone (H) • Cytarabine (A) + Radiation

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