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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. 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

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  1. Clinical Management of Lymphoma 新光醫院 血液腫瘤科 溫 武 慶

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

  3. 90.9.28 90.11.28 91.03.13

  4. 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)

  5. Differences in HL and NHL • HL • NHL RS or L & H cells Lymphoma cells diffuse nodular

  6. Differences in HL and NHL

  7. Lymphoma Work-up • Diagnosis and Classification • Stage • Other prognostic factors • Age • LDH • Beta-2 microglobulin • IPI (international prognostic index)

  8. Staging Work-up • CBC, platelet • LDH, biochemistry • CXR, chest/abdomen/pelvic CT • PET scan • Bone marrow examination

  9. 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

  10. 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)

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

  12. Lymph Node Region

  13. Gastric Lymphoma Stage

  14. SL/CLL Stage

  15. 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

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

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

  18. NHL Treatment- DLBCLIPI • 5ys: score 0-1 73%; 2 51%; 3 43%; 4-5 26%

  19. NHL Treatment-FL

  20. NHL Treatment-FL(follicular lymphoma)

  21. NHL Treatment-FL Median survival 8-10y

  22. NHL Treatment-Margional Zone Lymphoma

  23. NHL Treatment-Margional Zone Lymphoma Median survival 10y

  24. NHL Treatment-MCL(Mantle Cell Lymphoma)

  25. NHL Treatment-MCL Median survival 3-5y

  26. NHL Treatment-SL/CLL(small lymphocytic lymphoma)

  27. NHL Treatment-SL/CLL Median survival: 10 y

  28. NHL Treatment-Burkitt Lymphoma

  29. NHL Treatment-PTL

  30. NHL Treatment-PTL

  31. NHL Treatment-PTL 5 year survival 25%

  32. HL TreatmetPrognostic factors

  33. 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)

  34. Classic HL Treatmet-C/T

  35. 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

  36. NLPHL Treatmet-C/T • 10 year survival 80%

  37. HL Treatmet-R/T

  38. PET in lymphoma

  39. 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

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