Clinical Oncology - Leukemias and Lymphomas

What are the major lymph nodes involved in lymphomas?

1. Waldeyer Ring: nasopharynx, oropharynx, cervical, preauricular, occipital

2. Supra and infraclavicular

3. Axillary

4. Thorax: hilar and mediastinal

5. Abdominal: para-aortic

6. Pelvic cavity: iliac and Peyer patches

7. Inguinal and femoral

Where do B and T cells develop and mature?

B and T cells develop in bone marrow and mature in lymphatic organs

What age group is Hodgkin lymphoma more common in?

20 to 34 years old, and < 17 years old

What gender is Hodgkin lymphoma more common in?

Males

What race is Hodgkin lymphoma more common in?

White and black people have a higher incidence

Is Hodgkin or non-Hodgkin lymphoma more common?

Non-Hodgkin (80% of all lymphomas)

What is the etiology of Hodgkin lymphoma?

Largely unknown

Family history, Epstein-Barr (Reed-Sternberg), HIV

What is the clinical presentation of Hodgkin lymphoma?

Most common is painless lymphadenopathy and is often asymptomatic

What is common in extensive disease of lymphoma?

B-symptoms:

Unexpected weight loss of > 10% of body weight in 6 months

Night sweats

Fevers

What is the clinical presentation of advanced lymphoma?

Enlarged spleen, tender abdomen, pleural effusion, achy bones

What is the hallmark of Hodgkin lymphoma?

Reed-Sternberg, which is a large lymphoid cell with multiple nuclei

What are the most common pathologies of Hodgkin lymphoma?

Classical HL (95%) and nodular lymphocyte (5%)

What are the most common subtypes of classical HL?

Nodular scleorsing (80%) and mixed cellularity (15%)

Describe the natural history of Hodgkin lymphoma

Most often arises above diaphragm

Continuous and predictable spread (cervical > supraclavicular > mediastinal)

What staging system is used for lymphoma?

Ann Arbor System

A - no B symptoms

B - B symptoms

E - extranodal disease

S - spleen involvment

What is a prognostic indicator for lymphoma?

Bulky disease, mass > 10 cm

What is the treatment for Hodgkin lymphoma?

Chemotherapy (primary; for stage I and II) and adjuvant RT (stage III and IV) to treat subclinical or residual disease

What chemotherapy drugs are used in Hodgkin lymphoma?

4 cycles of ABVD (Adriamycin), can use MOPD instead due to risk of heart damage from Adriamycin

What are mantle fields used to treat?

Cervical, submandibular, axillary, supraclavicular, mediastinal and hilar lymph nodes

Describe the mantle field technique and simulation

Large field size with AP/PA

Supine, hands above head and akimbo position, chin extended

May use body molds to decrease movement

What are the field borders for mantle field?

Superior: below mandible and mastoid tips

Inferior: T9 to T10

Lateral: flash above axillary nodes

What is the inverted Y?

Pelvis and para-aortic

What is an involved field radiation?

Only encompass areas of known disease

What is an extended field?

Areas of known disease and contiguous uninvolved lymph nodes

What if chemotherapy and RT fail?

Autologous bone marrow or blood stem cell transplant

What is the abdominal/para-aortic field used to treatment in lymphoma?

Spleen, para-aortic and retroperitoneal nodes

Describe the treatment technique for the abdominal/para-aortic field

AP/PA field

What needs to be shielded with the abdominal/para-aortic field?

Spine and kidneys

Describe the field borders for the abdominal/para-aortic field

Superior: mid T10-T11

Inferior: L4-L5

Lateral: 9 to 10 cm wide

Describe the treatment technique for the pelvic field for lymphoma

AP/PA field with shielding of bone marrow, bowel and bladder - could be shielding for fertility

Describe the field borders for the pelvic field for lymphoma

Superior: L5

Inferior: 2 cm below ischial tuberosity

Lateral: 2 cm from pelvic inlet

What dose is used for RT for Hodgkin lymphoma?

35 to 44 Gy for RT alone

20 Gy for chemo + RT

What age group is Non-Hodgkin lymphoma more common in?

65 to 74 years old, median age at 67 years old

What gender is Non-Hodgkin lymphoma more common in?

Males

What is the etiology of Non-Hodgkin lymphoma?

Largely unknown

Immunosuppression, viruses (Epstein-Barr, HIV/AIDS, Hep. C, HTVL-1), radiation, chemotherapy

What is the most common site for extranodal disease in Non-Hodgkin lymphoma?

GI system (stomach)

What is the natural history of Non-Hodgkin lymphoma?

Lymphatic spread is not contiguous or predictable

What are the two groups of Non-Hodgkin lymphoma?

B-cell (diffuse large B-cell) (85%)

T-cell and cutaneous T-cell (15%)

*Non-Hodgkin lymphoma can be indolent or aggressive, and indolent can change to aggressive within 2 years after treatment. Not all cells make transition - diagnosed with both indolent and aggressive.

What is the treatment for indolent and early stage (I and II) Non-Hodgkin lymphoma?

Radiation alone

What is the treatment for aggressive Non-Hodgkin lymphoma?

Chemotherapy + RT

What dose is used for Non-Hodgkin lymphoma?

35 to 44 Gy to involved site and related drainage

What is the clinical presentation of leukemia?

Fatigue

Bruise easily

Bleed easily

Consistent infections that are hard to clear

*RBC, WBC, and platelets are low

What is the most common leukemia in children?

Acute lymphocytic leukemia (ALL)

What is the most common leukemia in adults?

Chronic lymphocytic leukemia (CLL)

What is the etiology of acute lymphocytic leukemia (ALL)?

Radiation, benzene, HTVL-1

What treatment is available for acute lymphocytic leukemia?

Chemotherapy

TBI

Targeted therapy for Philadelphia chromosome

Describe acute myeloid leukemia (AML)

Age: 68 years old

Etiology: radiation, benzene, smoking

Treatment: chemotherapy

*Worse prognosis than ALL as patients are older and may not tolerate chemotherapy toxicities

What is the clinical presentation for chronic lymphocytic leukemia (CLL)?

Asymptomatic until spread to LNs, spleen, liver

What is the etiology for chronic lymphocytic leukemia?

Agent orange, age, family history

What is the treatment for chronic lymphocytic leukemia?

Chemotherapy, TBI, rituxamab

What is the average age of diagnosis for chronic myeloid leukemia (CML)?

64 tears old

What is involved in detection of chronic myeloid leukemia (CML)?

Usually found incidentally

Need genetic testing for Philadelphia chromosome and BCR-ABL gene (mutation of myeloid cell) for diagnosis

What is the treatment for chronic myeloid leukemia?

Chemotherapy and targeted therapy (tyrosine-kinase inhibitor taken for rest of patient's life)