2.  Management varies with type of lymphoma and pt factors (co-morbidities, age, performance status, pt preferences)  Goal of tx can be curative, to prolong life, or palliative  Multidisciplinary team (haematologists, medical oncologists, radiation oncologists, anatomical pathologists, surgeons, allied health profs, plus ongoing GP care)

3.  Chemotherapy – systemic control  Radiation therapy – local control  Immunotherapy - targeted monoclonals (like that CD20 guy)  Allogeneic haematopoeitic stem cell transplantation  Autologous haematopoietic stem cell transplantation

4.  Tx depends on stage (Ann Arbor)  Indolent  low-grade, aggressive  Intermediate-grade, aggressive  High-grade  Special forms

5.  Indolent  Usually disseminated by time of diagnosis and therefore not curable  Not bulky, not symptomatic  no initial tx necessary  Some tx options available, no consensus  Rituximab (the anti-CD20 guy) can be used (low toxicity, avoid chemotherapy)  Or, common chemotherapy regimens (R-CHOP, R- CVP)  Low grade – aggressive  allogeneic haematopoeitic stem cell transplantation

6.  Intermediate grade, aggressive (diffuse large B- cell lymphoma)  Tx with curative intent  Short course chemo (x3) R-CHOP + localised radiation  or, 6-8 cycles R-CHOP w/o radiation (especially more advanced)  Very high risk lymphoma  autologous haematopoeitic stem cell transplantation  High grade (Burkitt’s, lymphoblastic)  Intense, cyclic chemo + intrathecal chemo as CNS prophylaxis

7.  MALT lymphoma of stomach – kill pylori with combo antibiotics; or, whole stomach radiation  Mantle cell – doesn’t respond to standard chemo; intensive chemo + autologous haematopoeitic stem cell transplantation  Primary CNS lymphoma – repeated cycles of high-dose methotrexate w/ rituximab

8.  R – Rituximab (Mabthera)  that monoclonal that binds to CD20  C - Cyclophosphamide  Nitrogen mustard alkylating agent – adds alkyl group to DNA causing irreversible cross-links  H - Hydroxydaunorubicin (Doxorubicin, Adriamycin)  intercalating agent - damages DNA by inserting itself between DNA bases  O - Oncovin (Vincristine)  prevents cell proliferation by binding to tubulin  P - Prednisone (or prednisolone)  corticosteroid

9.  Nausea/vomiting (antiemetics),  Allopecia  Neutropenia  Tumour-lysis syndrome  caused by the break-down products of dying cancer cells and include hyperkalaemia, hyperphosphataemia, hyperuricaemia and hyperuricosuria, hypocalcaemia, and consequent acute uric acid nephropathy and acute renal failure  Allopurinol - prophylactic to prevent hyperuricaemia

10.  Indolent - med surv 10-15yrs  Intermediate  uses IPI (International Prognostic Index)  Factors – age >60, high serum LDH, stage III/IV dis, poor performance status, more than 1 extranodal site  0-1 factor  5y surv 73%  2 factors  5y surv 51%  3 factors  5y surv 43%  4-5 factors  5y surv 26%  Relapse after initial chemo  autologous haematopoeitic stem cell transplantation  50% long term lymphoma-free survival

12.  All should be treated with curative intent  Stage IA w/ high cervical lymph node and low ESR – radiation  Stage I/II – short course chemo ABVD + involved-field radiation  Stage III/IV – full course ABVD  Stage II w/ lge mediastinal mass – full course ABVD + mediastinal radiotherapy

13.  A - Adriamycin (the H in R-CHOP)  B - Bleomycin  antibiotic that also induces DNA strands to break  V - Vincristine (the O in R-CHOP)  D - Dacarbazine  Alkylating agent – adds alkyl groups to DNA

14.  Acute  Alopecia, nausea/vomiting (antiemetics can be given), myelosuppression, allergic reactions to bleomycin (test dose often given first), neuropathy (temp or perm)  Delayed  Infertility, pulm tox (again bleomycin), cardiac tox (adriamycin), secondary malignancies

15.  Influenced by 7 features – stage, age, gender, haemoglobin, albumin, WBC, lymphocyte count  0-2 features  75% cure  3+ features  55%  Stage IA/IIA  10y surv >90%  Stage III/IV  10y surv 50-60%  Poor outcomes – older folk, bulky disease, lymphocyte depletion, mixed-cellularity on histo  Relapse after intial chemo  autologous haematopoeitic stem cell transplatation  35- 50% cure

17. Paul Conway Rob Illingworth