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

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Presentation on theme: "Clinical Management of Lymphoma 新光醫院 血液腫瘤科 溫 武 慶."— Presentation transcript:

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

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7 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)

8 Differences in HL and NHL HL NHL RS or L & H cells Lymphoma cells nodular diffuse

9 Differences in HL and NHL HLNHL Cell RS (Reed-Sternberg) L & H (lymphocytic and histiocytic) cells B- and T- cells GradeLowLow intermediate high SpreadLymphatic (contiguously) Hematogenous Lymphatic

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

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

14 Lymphoma Stage 1974 Ann Arbor, 1988 Cotswolds I1 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. II 2 ) IIILN regions or lymphoid structures on both sides of the diaphragm –III1splenic hilar, celiac, or portal LNs –III2PALN, iliac, mesenteric LNs IV> 2 extranodal sites

15 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)

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

17 Lymph Node Region

18 Gastric Lymphoma Stage

19 SL/CLL Stage

20 Principles of NHL Treatment Low risk –Stage I, IIC/T + R/T –Stage III, IVobservation, C/T Intermediate~ high grade –Stage I, IIC/T + R/T –Stage III, IVC/T

21 NHL Treatment- DLBCL (diffuse large B-cell lymphoma)

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23 NHL Treatment- DLBCL IPI 5ys: score %; 2 51%; 3 43%; %

24 NHL Treatment-FL

25 NHL Treatment-FL (follicular lymphoma)

26 NHL Treatment-FL Median survival 8-10y

27 NHL Treatment- Margional Zone Lymphoma

28 Median survival 10y

29 NHL Treatment-MCL (Mantle Cell Lymphoma)

30 NHL Treatment-MCL Median survival 3-5y

31 NHL Treatment-SL/CLL (small lymphocytic lymphoma)

32 NHL Treatment-SL/CLL Median survival: 10 y

33 NHL Treatment-Burkitt Lymphoma

34 NHL Treatment-PTL

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36 5 year survival 25%

37 HL Treatmet Prognostic factors

38 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)

39 Classic HL Treatmet-C/T

40 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

41 NLPHL Treatmet-C/T 10 year survival 80%

42 HL Treatmet-R/T

43 PET in lymphoma

44 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 ;571-8


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