Presentation on theme: "Lymphoma Brevity in writing is the best insurance for its perusal."— Presentation transcript:
1Lymphoma Brevity in writing is the best insurance for its perusal. Dr.Usha Dorairajan MS ,FRCSEdProfessor of SurgeryKilpauk Medical CollegeBrevity in writing is the best insurance for its perusal.Rudolf Virchow
7Incidence of lymphoma in India GLOBOCAN 2008INDIAMaleFemaleBoth sexes610618570793430.1518.8948.9Population (thousands)Number of new cancer cases (thousands)Incidence6982033333505936476737123718Mortality4765324123356425690358716243 Cancer Lip, oral cavity Nasopharynx Stomach Colorectum Hodgkin lymphoma Non-Hodgkin lymphomaGLOBOCAN 2008 (IARC) Section of Cancer Information
8Symptoms Painless lymphadenopathy cervical axilla or groin 2. Weight loss3. Fever4. drenching sweating at night5. Pruritis6. Loss of appetite7. A feeling of weakness8. Breathlessness along with edema of the face and neck
9Risk factors Age Sex Infectious agents Chemicals Genetics Immunodeficiency states autoimmuneCancer treatment
10Infections Human T-lymphotrophic virus type1 adult T lymphoma Epstein-Barr (EBV) Burkitt’s Hodgkin’sHelicobacter pylori MALT lymphomas of the stomach;Human immunodeficiency virus (HIV),HHV-8 (Human Herpes virus) Primary effusion lymphomaHepatitis C virus B-NHLDeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, Eighth Edition
16Biopsy of easily accessible largest node. Lymph node biopsyBiopsy of easily accessible largest node.A complete node is best. And more than one nodeAxilla and groin are avoided.To be delivered immediately without fixation to path lab.Cell suspensions of fresh tissue for flow cytometry immunotyping, cell kinetics analysis and molecular analysis.Touch imprint cytology is for comparing bone marrow and nodal cytology.A portion is snap frozen for molecular genetics and forimmunohistochemistry.A portion is fixed and processed for morphological study.
17Evaluation Diagnosis of NHL lymphoma depends on finding abnormal numbers of lymphocytes that are destroyingnormal architecture of lymphoid tissueor invading non lymphoid tissue or both.
19Hodgkin’s lymphoma contain one of the characteristic Reed SternbergcellHodgkin’s lymphoma contain one of the characteristicReed Sternberg cells and mononuclear malignant cells Hodgkin cell) HRS cellsIn a background of non neoplastic cells.HRS cells form only .1% - 1.5% of cellular population
24Immunohistochemistry The cells are examined to determine what antigens are expressed on the surface of the cells by using antibodies that bind to those antigens.Helps determine the type of lymphoma with far greater accuracy than just examining the biopsy under the microscope.A chart of which antigens are typically positive or negative is on CD chart.( Cluster Differentiation )
25Flow Cytometry Flow cytometry Individual cells are separated and examined. Flow cytometryidentifies types of lymphoma from FNAC specimens
26FNAC To diagnose relapse Flow cytometry possible with FNAC Inaccessible nodes like abdominal and retroperitoneal nodes can be targeted under CT guidance for FNAC
27Why Immuno phenotyping To differentiate a lymphoma from poorly differentiated carcinomaTo differentiate a lymphoma from a reactive lesion (monoclonal)Classification of lymphoma
28Treatment of lymphoma Treatment Staging work Up Treatment
29Staging Work Up X-ray chest, CT chest and CT abdomen Bone marrow biopsy.PET scanMRICSF analysis
31Cotswold modifications XMassive mediastinal disease has been defined by the Cotswold meeting as a thoracic ratio of maximum transverse mass diameter greater than or equal to 33% of the internal transverse thoracic diameter measured at the T5/6 intervertebral disc level on chest radiography .or 10 cmThe number of anatomic regions involved should be indicated by a subscript (eg, II3)Stage III1Stage III2Stage III may be subdivided into: III1, with or without splenic, hilar, celiac, or portal nodes;III2, with para-aortic, iliac, mesenteric nodesCS \ PSCRStaging should be identified as clinical stage (CS) or pathologic stage (PS)A new category of response to therapy, unconfirmed/uncertain complete remission (CR) can be introduced because of the persistent radiologic abnormalities of uncertain significance
32The treatment and prognosis depends on stagepatient performance statusthe characteristic of lymphoma.
33International Prognostic Index for Hodgkin’s lymphoma 1- Serum albumin < 4 gm/dl2- Hemoglobin level below 10.5 gm/dl3- Male gender4- Stage IV disease5- Age ≥ 45 years6- WBC of ≥ 15,000/mm²7- Lymphocyte count ≤ 600/mm² or ≤ 8% of WBC
34International Prognostic Index for Non Hodgkin’s lymphoma Age> 60 yearsPerformance status>2LDH> than normalAnn Arbour stage III or IV> 2 Extranodal sites
37Hodgkin’s lymphoma usually arises in lymph nodes and spreads to contiguous groups. Extranodal presentation are rare.Treatment is bystage of diseaseandprognostic factors
38Treatment of lymphoma Treatment modality radiotherapy chemotherapy combination therapyhigh dose chemotherapy with bone marrow transplantmonoclonal antibody RITUXIMAB
39Treatment of Hodgkin’s lymphoma With appropriate treatment about 85% of patients with Hodgkin disease are cured
40Treatment of Hodgkin Lymphoma Radiation therapy alone in special circumstancesChemoradiotherapyABVD for two to four cycles plus involved field radiotherapy(20 Gy or 30 Gy).Chemotherapy aloneABVD for four to six to eight cycles. (ABVD: doxorubicin plus bleomycin plus vinblastine plus dacarbazineBEACOPP (increased dose). (bleomycin plus etoposide plus doxorubicin plus cyclophosphamide plus vincristine plus procarbazine plus prednisone
41Radiation therapy CURRENT TREND Involved field radiotherapy Neck Extended fieldmantle fieldparaaortic fieldpelvic fieldCURRENT TRENDInvolved field radiotherapyNeckMediastinumAxillaParaaorticinguinal
42Complications of treatment Second malignancyCardiac dysfunctionLung fibrosissterilityIn Hodgkin’s disease current trend isless aggressive treatment to minimisecomplications
43Cochrane Reviews For early-stage patients chemoradiotherapy Chemotherapy, radiotherapy and combined modality for Hodgkin's disease, with emphasis on second cancer riskFor early-stage patients chemoradiotherapyresulted in longer survival and longer HD-free survival than either RT or CT aloneSecond malignancy (SM) risk was lower with CRT than with RTFor advanced stagesno difference in survival between CRT and CT alone was established
44Treatment of non-Hodgkin lymphoma (NHL) depends on the histologic type and stage.
45Treatment of Non Hodgkin’s lymphoma Watchful waitingChemotherapy with radiation therapy.Rituximab, an anti-CD20 monoclonal antibody, either alone or in combination with chemotherapy .R-CHOP (four to eight cycles).R-CHOP (three to eight cycles) plus IF-XRT.Autologous BMT or peripheral stem cell transplantation or allogeneic BMT for patients at high risk of relapse is under clinical evaluation
46Cochrane Summaryimproved survival of follicular and in mantle cell lymphoma when treated with R-chemo compared to chemotherapy alone.no benefit for high-dose chemotherapy with stem cell transplantation as a first line treatment in patients with aggressive NHL.IFN as maintenance therapy for FL improves progression-free survival. A net benefit for overall survival is less evident
47HIV associated lymphoma HIV-associated, non-Hodgkin’s lymphoma occurs in 5-10% of individuals with HIV infectionvirtually all of B-cell origin. Most are intermediate- or high-grade lymphomasComplete response occurs in 33-62% of patients. Relapse occurs in 25% of complete responders within 6 months.Median survival is 4-8 months, with about half dying of lymphoma and half of opportunistic infection.
48Lymphoma is the most common small bowel malignancy in the pediatric age 50-93% of patients have intestinal lymphomas located in the ileocecal region.a history of nonspecific chronic abdominal pain commoncan present acutely as appendicitis or intussusception
49Oliver Wendell Holmes Jr Man’s mind once stretched by a new idea never regains it’s original dimensionsOliver Wendell Holmes Jr
50SummaryManagement of lymphoma needs a multidisciplinary approach with a need to keep abreast of evidence based medicine.Lymphoma is associated with immuno compromised statesSurgeon ‘s rolein diagnosis of lymphoma.In treatment of lymphoma in extranodal sites (GItract emergencies).