Clinical Management of Lymphoma 新新新新 新新新新新 新 新 新
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
• 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
• HL
• NHL
RS or L & H cells
Lymphoma cellsnodular diffuse
Differences in HL and NHL
HL NHL
Cell RS (Reed-Sternberg)
L & H (lymphocytic and histiocytic) cells
B- and T- cells
Grade Low Low intermediate high
Spread Lymphatic (contiguously)
Hematogenous
Lymphatic
Lymphoma Work-up
• Diagnosis and Classification
• Stage
• Other prognostic factors– Age– LDH– Beta-2 microglobulin– IPI (international prognostic index)
Staging Work-up
• CBC, platelet
• LDH, biochemistry
• CXR, chest/abdomen/pelvic CT
• PET scan
• Bone marrow examination
Lymphoma Stage
• 1974 Ann Arbor, 1988 Cotswolds • I 1 single LN region or lymphoid structure• II > 2 LN regions on the same side of di
aphragm (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 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)
A = without symptoms, B = with symptoms including unexplained weight loss 10% in 6 months), unexplained fever, and
drenching night sweats
Lymph Node Region
Gastric Lymphoma Stage
SL/CLL Stage
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(diffuse large B-cell lymphoma)
NHL Treatment- DLBCL(diffuse large B-cell lymphoma)
NHL Treatment- DLBCLIPI
• 5ys: score 0-1 73%; 2 51%; 3 43%; 4-5 26%
NHL Treatment-FL
NHL Treatment-FL(follicular lymphoma)
NHL Treatment-FL
Median survival 8-10y
NHL Treatment-Margional Zone Lymphoma
NHL Treatment-Margional Zone Lymphoma
Median survival 10y
NHL Treatment-MCL(Mantle Cell Lymphoma)
NHL Treatment-MCL
Median survival 3-5y
NHL Treatment-SL/CLL(small lymphocytic lymphoma)
NHL Treatment-SL/CLL
Median survival: 10 y
NHL Treatment-Burkitt Lymphoma
NHL Treatment-PTL
NHL Treatment-PTL
NHL Treatment-PTL
5 year survival 25%
HL TreatmetPrognostic factors
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)
Classic HL Treatmet-C/T
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
• 10 year survival 80%
HL Treatmet-R/T
PET 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