indolent non hodgkins lymphoma

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  1. 1. Indolent non Hodgkin lymphomas Dr. Rajib Bhattacharjee Junior Resident IPGMER, Kolkata
  2. 2. WHO classification 2008
  3. 3. Most common types of NHL encountered in clinical practice types of NHL Incidence DLBCL 33% Follicular Lymphoma 22% Marginal Zone Lymphoma 10% PTCL 10% SLL/CLL 7% Mantle cell lymphoma 7%
  4. 4. Types of NHL based on aggressiveness Low grade Intermediate grade high grade Follicular lymphoma Marginal zone lymphoma SLL/CLL DLBCL PTCL Burkitts lymphoma Lymphoblastic lymphoma
  5. 5. New ticket day in the OPD Our patient enters. A man in his 60s Median age at presentation 55-65 years Males are affected more than females
  6. 6. I started to listen to his clinical history.. He complained of a painless swelling in his neck.. 2/3rd of NHL patients present with asymptomatic lymph node swelling (nodal disease) Common in FL,MCL & SLL Sites- Neck 70% Groin 60% Axilla 50%
  7. 7. Any extranodal disease I asked him, Do you have any problem during swallowing or do you get full with little food? 1/3rd of NHL patients may present with extranodal disease. Common in DLBCL & MZL Site- GIT - 25-35% Waldayers ring 18-23%
  8. 8. B Symptoms I asked 3 questions:- 1. Did you suffer from fever in the last few months? 2. Have you lost a lot of weight lately? 3. Do you change your shirt often due to night sweats? Then I asked did you find any cause to these or were they unexplained?
  9. 9. Exam time.. Lymph node examination Head and neck waldeyers ring Chest Sternal/2nd ICS percussion Pleural effusion Abdomen- Organomegally, Lump, Ascites Testes Skin - Nodules
  10. 10. Investigations .. Lab investigations CBC, KFT, LFT, Electrolytes Ca2+ LDH, Uric acid HBsAg, IgM HBc HIV I & II
  11. 11. Imaging Chest X-Ray CT Thorax, abdomen & pelvis PET CT Tc-99m Bone Scan MUGA/ Echocardiography Endoscopy Upper GI
  12. 12. Bone marrow biopsy A must for all NHL patients (SLL, mantle cell lymphoma 70% FL 50% , DLBCL 15%) CSF Cytology Only in suspected leptomeningeal involvement
  13. 13. Histopathological examination The cervical lymph node must go for biopsy. A medium sized accessible lymph node is preferred for excision. Cervical lymph node if palpable, is preffered
  14. 14. Which stage is the disease..???
  15. 15. X = Bulky disease Clinically diameter > 10cm CXR PA- Mediastinal mass ratio(MMR) = Max width of mass__ > 0.33 Max intrathoracic dia = Max width of mass >0.35 Intrathoracic dia @ T5 - T6
  16. 16. Possible histologies for our discussion Follicular Lymphoma Marginal zone Lymphoma SLL/CLL
  17. 17. Follicular Lymphoma 5Y OS 70.7% 50.9% 35.5%
  18. 18. How do I treat this patient if he has localised FL Stage I & II? Gr 1-2, non bulky, asymptomatic IFRT (30Gy) Gr 3, bulky, B symptoms IFRT(30Gy) RCHOP (4 cycles) Boost (upto 40 Gy) IFRT to the bulky site (30Gy)
  19. 19. How do I treat this patient if he has advanced FL Stage III & IV? Asymptomatic Observation or Rituximab Symptomatic, B symptoms, cytopenias, compromised end organ function RCVP/RCHOP (6 cycles) Gr 3 RCHOP (6 cycles)
  20. 20. Important studies study Conclusion BNLI Study 2003 Observation is a good initial approach in asymptomatic stage III & IV FL GLSG Trial 2005 & Marcus et al Rituximab with both CVP & CHOP produce enhanced OS SWOG Trial Anthracyclins fail to improve OS in indolent lymphoma
  21. 21. Bendamustine in 1st line indolent/mantle cell R-B R R-CHOP 69.5mo PFS 31.2mo toxicity
  22. 22. Maintenance Rituximab Follicular lymphoma RCHOP/RCVP/RFCM mRituximab R Obv 75% PFS 58% 72% CR 52%
  23. 23. Progressive disease Elderly, asymptomatic Obv 2nd line chemotherapy Bendamustine FCM Radioimmunotherapy Zavaline, Baxxar mTOR inhibitors NVP-BEZ235 Proteasome inhibitors Stem cell transplant
  24. 24. Marginal zone lymphoma Three entities Nodal Extranodal - MALToma Splenic Stomach Small intestine Occular Skin Parotid Thyroid
  25. 25. How to treat Extranodal disease Symptomatic local tumor RT Generalized disease Asymptomatic Obv Symptomatic - CT (Chlorambucil) Nodal disease R-CHOP Splenic disease Splenectomy or Splenic RT
  26. 26. Gastric MALToma C/F- abdominal fullness, loss of appetite, waight loss, B symptoms, pain, bleeding Diagnosis- Endoscopic biopsy H. pylori association in 92% (# Isaacson et al) Antibiotics and PPI (even in H.pylori ve cases) CRR-75% 5Y FFS-50% OS>90% Endoscopy after 3 months Lymphoma persist- *deep invasion *t(11:18) Antibiotic failure T/t RT(24-30Gy) Not suitable for RT Rituximab monotherapy
  27. 27. SLL Localized disease IFRT (30Gy) Advanced disease Chemoimmunotherapy Age>70, co-morbidities Age