1. Staging evaluation for NHL Ann Arbor Staging system is applicable to both Hodgkin’s disease and NHL

2. Ann Arbor Staging System StageDefinition IInvolvement of a single LN region or lymphoid structure (eg. Spleen, thymus, Waldeyer’s ring) IIInvolvement of ≥2 LN regions on the same side of the diaphragm (the mediastinum is a single site; hilar LN should be considered as “lateralized” and, when involved on both sides, constitute stage II disease) IIIInvolvement of LN regions or lymphoid structures on both sides of the diaphragm III1Subdiaphragmatic involvement limited to spleen, splenic hilar nodes, celiac nodes, or portal nodes III2Subdiaphragmatic involvement includes paraaortic, iliac, or mesenteric nodes plus structures in III1 IVInvolvement of extranodal site(s) beyond that designated as “E” >1 extranodal deposit at any location Any involvement of liver or bone marrow Source: p. 691

3. Ann Arbor Staging System StageDefinition ANo symptoms B- Unexplained weight loss of >10% of the body weight during the 6 months before staging investigation - Unexplained, persistent, or recurrent fever with temperatures >38°C during previous month - Recurrent drenching night sweats during the previous month ELocalized, solitary involvement of extralymphatic tissue, excluding liver and bone marrow Source: p. 691 Staging for our patient: Stage III1B

4. To manely the patient is possibly Stage III1B Premise : Stage III1 – Bilateral cervical lymphadenopathy – Mass in R axilla – (another region) – Spleen involved Premise : Stage B – Although history does not satisfy strictly the description, the patient cannot fall under A because still he is symptomatic.

5. Ancillary procedures for Primary staging CBC ESR LDH ß2- microglobulin Serum protein electrophoresis Chemistry studies reflecting major organ function CT scans (chest, abdomen, pelvis) Bone marrow biopsy Source: p. 692

6. To manely All these (in black) are used in evaluation of Hodgkin’s disease and is also applicable to NHL The blue ones are added for evaluation of NHL – (sorry sa background… para hindi mo malimot erasin un slide hehe)

7. International Prognostic Index (IPI) for NHL A powerful predictor of outcome in all subtypes of NHL Scoring: based on presence or absence of – 5 adverse prognostic factors – may have none or all 5 of these Source: p. 692

8. To manely The following slides will help eval for presence of prognostic factors. Based on the case, the patient did not have prognostic factors according to Karnofsky and ECOG Serum LDH should be requested Just discuss briefly the next two tables For the IPI table, the patient only has the age w/c is 70 as the prognostic factor Consider LDH if elevated, for the last slide. Tnx!

9. ECOG PERFORMANCE STATUS* http://ecog.dfci.harvard.edu/general/perf_stat.html

10. KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA http://www.hospicepatients.org/karnofsky.html

11. International Prognostic Index (IPI) for NHL Five clinical Risk Factors Age ≥ 60 years Serum lactate DH levels elevated Performance status ≥ 2 (ECOG) or ≤ 70 (Karnofsky) Ann Arbor stage III or IV > 1 site of extranodal involvement Patients are assigned a number for each risk factor they have Patients are grouped differently based upon the type of lymphoma For diffuse large B cell lymphoma 0, 1 factor 2 factors 3 factors 4, 5 factors Low risk Low-intermediate risk High-intermediate risk High risk 35% of cases; 5-yr survival 73% 27% 51% 22% 43% 16% 26% For diffuse large B cell lymphoma treated with R-CHOP 0 factor 1, 2 factors 3, 4, 5 factors Very good Good Poor 10% of cases; 5-yr survival 94% 45% 79% 45% 55% Source: p. 692

12. IPI for Patient (Pre treatment) Age ≥ 60 years Serum LDH levels elevated 0-1 factor Low risk 35% of cases; 5-yr survival 73% 2 factors Low-intermediate risk 27% of cases; 5-yr survival 51%