Lymphomas

What is lymphoma?

proliferation of malignant lymphocytes within the lymph system

-solid tumors

What are the primary presenting symptoms of patients with lymphomas?

-Superficial adenopathy (otherwise asymptomatic)

-B-symptoms: fever, night sweats, & weight loss

What characteristics describe the lymph nodes in patients with lymphomas? (3)

-PAINLESS

-rubbery

-matted (sometimes)

What is the only diagnostic test for lymphomas?

-where should you try to get a sample?

-what area should you avoid?

excisional biopsy (take whole thing out)

-try to get sample from above the diaphragm, if possible

-avoid groin nodes, as they're the least diagnostic

What cells are pathognomonic for Hodgkin lymphoma?

-explain what they look like.

Reed Sternberg cells

-Bi-nucleate B cells

What are the 4 subtypes of Hodgkin lymphoma?

-which is most common?

1. Nodular sclerosis

-most common

2. Lymphocyte predominant

3. Mixed cellularity

4. Lymphocyte depleted

True or False: The prognosis of Hodgkin lymphoma is more dependent on the stage than the subtype.

True

What are the clinical manifestations of Hodgkin lymphoma? (4)

-enlarged, painless lymph nodes

-lymphadenopathy causing obstruction or pressure

-Mediastinal mass

-B symptoms (fever, night sweats, weight loss)

What is the work up for Hodgkin lymphoma?

-Physical exam for lymphadenopathy & organomegaly

-CBC

-Chest X-ray (looking for hilar fullness)

-CT scan w/contrast from neck-pelvis (more sensitive than CXR)

-PET scan (most sensitive)

*remember only biopsy makes dx

What test is mandatory for the follow up measuring response to treatment in Hodgkin lymphoma?

PET scan

What % is considered notable weight loss in Hodgkin lymphoma?

weight loss of >10%

What is the treatment for limited & advanced stage Hodgkin lymphoma?

ABVD is the standard of care!!!

-Adriamycin

-Bleomycin

-Vinblastine

-Dacarbazine

Limited: chemo & radiation

-ABVD x 4 if CR achieved or...

-ABVD x 2 + radiation

Advanced: all ABVD; no radiation

-ABVD for 6-8 cycles

What are some long term complications from treatment of Hodgkin lymphoma?

-fertility issues

-cardiac toxicity

-secondary malignancies (acute leukemia, NHL, breast cancer, etc.)

-Immune dysfunction

-avascular necrosis

-dental caries

-hypothryoidism

Which lymphoma is most common, HL or NHL?

Non-Hodgkin lymphoma (NHL)

What are the 2 main subtypes of Non-Hodgkin lymphoma?

-which is the most common form for Non-Hodgkin lymphoma?

1. Diffuse Large B-Cell Lymphoma (DLBCL)

-most common

2. Follicular lymphoma (FL)

What are some environmental risk factors for developing Non-Hodgkin lymphoma? (2)

exposure to...

-Agent orange

-Herbicides

What are the clinical manifestations of Non-Hodgkin lymphoma? (6)

-painless lymphadenopathy at multiple nodes

-abdominal masses/fullness

-ascites (fluid in peritoneal cavity)

-leg edema

-B symptoms (fever, night sweats, weight loss)

-superior vena cava syndrome

What is the workup for Non-Hodgkin lymphoma? (4)

-CBC

-CT of chest-pelvis

-PET scan

-Bone marrow biopsy (if needed)

excisional biopsy is only dx

What is Richter's transformation?

transformation from FL or CLL/SLE to aggressive lymphoma usually DLBCL

What are the clinical presentations of Diffuse Large B-Cell Lymphoma (DLBCL)? (3)

-where are the masses typically found? (2)

-rapidly enlarging nodes (usually on neck or abdomen)

-B symptoms

-Elevated LDH

True or False: Most Diffuse Large B-Cell Lymphoma (DLBCL) patients present in the limited stages.

False

-most present in advanced stages

According to the International Prognostic Index, what risk factors indicate low prognosis for Diffuse Large B-Cell Lymphoma (DLBCL) patients? (4)

-age > 60

-LDH > upper limit of normal

-ECOG performance status > or = 2

- > 1 extranodal sites

What is the treatment of limited and advanced stage Diffuse Large B-Cell Lymphoma (DLBCL)?

Limited: options dependent of prognosis factors

-radiation only

-chemo + radiation

-full chemo

Advanced: 6 cycles of R-CHOP

-Rituximab

-Cyclophosphamide

-Hydroxydaunorbuicin

-Oncovorin

-Prednisone

What tests should to be to assess a patient's response to treatment in Diffuse Large B-Cell Lymphoma (DLBCL)? (4)

-when should they be done?

-assess all palpable sites each cycle

-PET/CT after 2-3 cycles of chemo

-Repeat PET/CT at end of tx (6-8 weeks after chemo; 12 weeks after radiation)

-Repeat bone marrow biopsy if initially +

Majority of Diffuse Large B-Cell Lymphoma (DLBCL) patients relapse within ____ years.

-is relapse usually symptomatic or asymptomatic?

2

-relapse usually symptomatic & not found my routine imaging

What is the follow-up schedule for patients after Diffuse Large B-Cell Lymphoma (DLBCL) treatment?

-f/u every 3 months for the 1st 2 years

-then every 6 months

Explain the difference in rate of onset between Diffuse Large B-Cell Lymphoma (DLBCL) & Follicular Lymphoma (FL)?

DLBCL: rapid

FL: slow

What is the clinical presentation of Follicular Lymphoma (FL)?

-in which stage to patients typically present?

usually only symptomatic from enlarged nodes

-occasionally present with abdominal masses

typically present in advanced stage

According to the FLIPI index, what risk factors indicate low prognosis for Follicular Lymphoma (FL)? (4)

-age > 60

-Hemoglobin < 12

-involved nodal sites > 4

-LDH > upper limit of normal

What is the treatment for limited stage Follicular Lymphoma (FL)?

observation only

-slow growing

True or False: There is no cure for Follicular Lymphoma (FL).

True

-DLBCL can be cured, FL can't