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Introduction to Lymphoma PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Introduction to Lymphoma” by Rafi Ahmed, MD.

This medical PowerPoint presentation is about lymphoma, a type of cancer that affects the lymphatic system, which is part of the bodys immune system. The lymphatic system includes lymph nodes, spleen, thymus gland, and bone marrow, which work together to help fight infections and diseases.

Lymphoma occurs when lymphocytes, a type of white blood cell that helps to fight infections, grow and multiply uncontrollably. These abnormal lymphocytes can form tumors in the lymph nodes, spleen, or other parts of the body.

There are two main types of lymphoma: Hodgkin lymphoma and non-Hodgkin lymphoma. Hodgkin lymphoma is characterized by the presence of Reed-Sternberg cells, which are large, abnormal cells found in the lymph nodes. Non-Hodgkin lymphoma refers to a group of lymphomas that do not have Reed-Sternberg cells.

Tags : Lymphoma, cancer, lymphatic system, immune system, Hodgkin lymphoma, non-Hodgkin lymphoma, Hematology, Hematology PowerPoint presentation

Published on : May 29, 2023 | Views : 2106 | Downloads : 6

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Slide 1-

Introduction to Lymphoma Rafi Ahmed, MD Hematology-Oncology UCLA-Olive View / Cedars-Sinai / Kaiser Los Angeles
Slide 2-

Lymph Node Architecture
Slide 3-

Normal lymph node architecture is distorted or effaced by the proliferating malignant lymphoid cells Lymphoma
Slide 4-

Nodal Architecture Effacement can be diffused, follicular, or both
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Classification Non-Hodgkin's Lymphoma B-cell neoplasm: Diffuse large B-cell lymphoma Follicular lymphoma Marginal zone lymphoma B-cell CLL/SLL Mantle Cell Lymphoma Burkitt Lymphoma Lymphoplasmacytic lymphoma Precursor B-cell ALL, Bcell lymphocytic leukemia, hairy cell, T-cell, NK cell neoplasms: Anaplastic large cell lymphoma Precursor T-cell ALL Primary T-cell lymphoma Mycosis fungoides/Sezary syndrome Angioimmunoblastic lymphoma Hodgkin's Lymphoma Nodular lymphocyte-predominant Hodgkin lymphoma Nodular lymphocyte-depleted Nodular sclerosis Mixed cellularity
Slide 6-

Follicular lymphoma (22%) Diffuse largeB-cell (31%) Armitage JO and Weisenberger DD. J Clin Oncol. 1998;16:2780. Mantle cell (6%) Peripheral T-cell (6%) Other subtypes with a frequency 2% (9%) Composite lymphomas (13%) Small lymphocytic lymphoma (6%) Marginal zone B-cell lymphoma MALT type (5%) Marginal zone B-cell lymphoma nodal type (1%) Lymphoplasmacytic lymphoma (1%) Non Hodgkin Lymphoma Prevalence
Slide 7-

NHL Epidemiology The National Cancer Institute estimates that 69,740 news cases of Non-Hodgkin's Lymphoma will be diagnosed in 2013. Estimate of 19,020 deaths Increases exponentially with age Greater in men than women, whites than blacks
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Etiology Known associations Continual immunosuppressive agents Autologous stem cell or solid organ transplantation Inherited immune defects Rheumatoid arthritis HIV/AIDS: 100 times increased risk prior to HAART Infectious agents In most cases, etiology is unknown
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NHLEtiology-Related Immune Dysregulation AIDS Organ transplant recipients Congenital immunodeficiency syndromes Agammaglobulinemia Ataxia-telangiectasia Wiskott-Aldrich syndrome Autoimmune disorders Sjogren’s syndrome Rheumatoid arthritis Systemic lupus erythematosus Hashimoto’s thyroiditis
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Infectious etiology HIV associated with high-grade B-cell lymphomas Hepatitis C associated with indolent B-cell lymphomas EBV-associated with (African) Burkitt lymphoma
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Presenting symptoms and signs Adenopathy 65% Mediastinal in 20% B symptoms 20% Fevers, night sweats, weight loss Splenomegaly 20% Marrow involvement 33%
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Staging and Prognosis Studies Tissue diagnosis Incisional or excisional LN biopsy: flow, fish, cytogenetics FNA is inadequate for initial diagnosis: Need to see architecture CT neck, chest, abdomen, pelvis Echo if planning anthracycline PET scan Useful for DLBCL, mantle cell, follicular, Hodgkin’s lymphoma Demonstrates disease in less than half of marginal zone NHL and peripheral T-cell NHL Useful in assessing after treatment Bone marrow evaluation Labs CBC, CMP, LDH, Uric Acid, HIV, Hepatitis Panel,
Slide 13-

Diagnostic Lumbar Puncture
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Ann Arbor Staging Cotswolds Modification of Ann Arbor Staging System I: single LN group II: multiple LN groups on same side of diaphragm III: multiple LN groups on both sides of diaphragm IV: multiple extranodal sites or LNs and extranodal disease X: bulk >10 cm E: extranodal extension or single isolated site of extranodal disease B symptoms: weight loss >10%, fever, drenching night sweats
Slide 15-

Ann Arbor Staging
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Prognostic Index
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NHLs Categories Indolent Lymphomas: Long clinical course, watch and wait, usually not curable Aggressive NHLs: Grow quickly, respond well to aggressive chemotherapy, potentially curable
Slide 18-

Indolent NHL Follicular grade I and II Marginal zone NHL Lymphoplasmacytic lymphomas Mycosis Fungoides (cutaneous T cell) Small lymphocytic lymphoma/ CLL
Slide 19-

Follicular Lymphoma FL is derived from germinal center B cells Grades I and II are indolent disease while the rare grade IIIb is more aggressive and generally managed like DLBCL Express CD19, CD20, CD22, surface immunoglobulin, and 60% express CD10 A hallmark of the disease is t(14;18) which contributes to the overexpression of the antiapoptotic protein BCL2
Slide 20-

Follicular Lymphoma Median age at presentation is 60 years Men and women are equally affected Patients usually present asymptomatic lymphadenopathy Treatment not indicated if asymptomatic Rituxan, cyclophosphamide, vincristine, prednisone RCVP Rituxan Bendamustin B-R 10% transform to DLBCL FLIPI Age>60, Stage III or IV, Hb<12, >4 Nodal areas, High LDH
Slide 21-

Follicular Grade I and II
Slide 22-

Marginal Zone Lymphoma; MALT Usually from chronic antigen stimulation MALT (gastric, intestinal): H pylori (CR 70-80% with abx for localized) Splenic- HCV Bronchial mucosa, salivary glands Look for infectious causes and treat Early treatment of local disease: XRT, lobectomy, splenectomy, Chemo for extensive disease
Slide 23-

CLL/SLL Indolent clonal proliferation of MATURE but poor functioning B cell lymphocytes Usually diagnosed asymptomatic with elevated WBC and predominance of lymphocytes Flow cytometry: CD5, CD23, clonal population Presence of smudge cells: fragile and break
Slide 24-

Rai - Binet Staging for CLL/SLL
Slide 25-

CLL/SLL Frequent antibodies directed against red cells/platelets AIHA-> tx with immunosuppression Hypogammaglobulinemia Frequent infections-> IVIG 10% can transform to DLBCL Treat when symptomatic B symptoms, LAD, cytopenias FCR, chlorambucil, Ibrutinib
Slide 26-

Lymphoplasmacytic Lymphoma (Waldenstrom) Clonal expansion of lymphocytes with plasma cell properties Produce Monoclonal IgM-> thickens blood Cytopenias Hyperviscosity Headache, dizziness, vision disturbances Treat when symptomatic Immunosuppression, Rituximab
Slide 27-

Mycosis Fungoides CD4+ T cell leukemia Characterized by major skin involvement Sezary Syndrome: With leukemic phase Evaluate for T cell receptor gene rearrangements Cells hay folded nucleus morphology Topical agents: steroids, carmustin, retinoids Phototherapy, chemotherapy, immunotherapy
Slide 28-

Diffuse Large B-cell Lymphoma
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Diffuse Large B-cell Lymphoma Most common subtype of lymphoma in the world 30% of all lymphomas Can be seen after histologic transformation of most other types of B-cell lymphoma, especially in patients with follicular lymphoma The transformation occurring in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma is called Richter transformation In general, these patients have a poor prognosis
Slide 30-

Diffuse Large B-cell Lymphoma DLBCL can be divided into clinically relevant groups using gene-expression profiling Germinal-center type Activated B-cell type Both of these have a median age at presentation in the 60s, male predominance, can occur at any site in the body Mediastinal large BCL <10% DLBCL Occurs primarily in young women and always presents with a mediastinal mass “Double Hit” High expression of oncogenes c-myc and bcl2
Slide 31-

Diffuse Large B-cell Lymphoma
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Treatment First line: R-CHOP High Risk: R-EPOCH Salvage: R-DHAP,RICE,RESHAP followed by autologous stem cell transplantation
Slide 33-

Rituximab Monoclonal Antibody Chimeric antibody against CD 20 Binding of antibody to neoplastic cells leads to complement mediated lysis, cellular toxicity, direct apoptosis Well tolerated
Slide 34-

Burkitt Lymphoma Most aggressive of NHLs African Burkitt’s associated with EBV “Starry Sky” Extranodal, CNS disease common Oncogene C-Myc expression due to t(8,14) High dose chemotherapy, CNS therapy Tumor lysis is common
Slide 35-

Mantle Cell Lymphoma Worse features of indolent and aggressive Disseminated disease Aggressive with median survival <3 years Hallmark is overexpression of BCL-1 gene produce cyclin D1 (cell cycle protein) due to translocation of t(11;14) Respond to chemo, but duration of response is short (RCHOP, R HyperCVAD) Transplant/ Biologic Agents
Slide 36-

T cell Lymphoblastic Lymphoma Rare in adults, usually <35 years Treated with highly complex regimens Same regimens as acute lymphocytic leukemia's Includes 2-3 years of therapy Induction Consolidation Maintenance +/- Bone Marrow Transplant
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Hodgkin's Lymphoma Hodgkin’s lymphoma accounts for 14% of lymphomas The National Cancer Institute estimates that 9,290 news cases of Hodgkin's Lymphoma will be diagnosed in 2013. Estimate of 1,180 deaths Bimodal incidence peak at 15-34, 55-70yrs High among white men
Slide 38-

Classification Distinctive finding is the Reed-Sternberg cell, a multinucleate giant cell characterized by abundant cytoplasm and large nucleoli WHO classification
Slide 39-

Classical Hodgkin’s LymphomaNodular-sclerosis More than 60% of patients present with this subtype More common in women, adolescents, young adults R-S cell is the lacunar variant– giant cells with a multilobulated nucleus CD30+, CD15+/-, CD45- Good prognosis
Slide 40-

Classical Hodgkin’s LymphomaMixed-cellularity 20-40% of cases More common in males R-S cells are of the classical variety CD30+, CD15+/-, CD45- 60-70% with EBV genomic DNA detected
Slide 41-

Classical Hodgkin’s LymphomaLymphocyte-depletion Occurs more often in older men, in persons infected with HIV, in nonindustrialized countries Patients typically present with abdominal adenopathy (less peripheral adenopathy), HSM, and involved bone marrow R-S cells, CD30+, CD15+/-, CD45- are plentiful Worse prognosis
Slide 42-

Classical Hodgkin’s LymphomaLymphocyte-rich Patients are typically males older than 40 years at diagnosis Presenting mass frequently in mediastinum Late relapses are less common but more often fatal
Slide 43-

Nodular Lymphocyte-Predominant Median age of 34 years Popcorn cells are atypical lymphocytic cells that express B-cell antigens such as CD20 but rarely CD15 or CD30 and are negative for serum Ig and CD45 Often localized disease at presentation Disease course is slowly progressive with a favorable outcome although 35% progress to DLBCL
Slide 44-

Clinical features Asymptomatic lymphadenopathy Painless mass in 70% Lymph nodes usually non-tender, rubbery consistency Location 60-80% cervical nodes 10-20% axillary 6-12% inguinal
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Clinical features B symptoms Fever – Pel Ebstein characteristic (recurs at variable intervals and lasts 1-2 weeks) before waning Drenching night sweats Weight loss > 10% in preceding 6 months
Slide 46-

Clinical features Pruritus may precede diagnosis by months to years. Severe pruritus poor prognostic sign Intra-abdominal disease Retroperitoneal LAD with paravertebral pain Hepatosplenomegaly Rarely ascites Cholestatic liver disease Alcohol-induced pain – Pain few minutes after alcohol ingestion at sites of bony or lymph node involvement (usually nodular sclerosis) Skin lesions Urticaria Erythema Nodosum
Slide 47-

Diagnosis H&P Tissue biopsy Bone marrow biopsy if: B symptoms, bulky disease, anemia/leukopenia/ thrombocytopenia CBC with diff, BMP, ESR, liver panel, LDH CT C/A/P, PET scan
Slide 48-

Staging and prognosis Prognosis falls into three groups Favorable: stage IA and IIA Intermediate risk: stage III and IV disease and any stage disease with B symptoms Less favorable: bulky disease Cotswald staging system emphasizes unfavorable prognostic impact of tumor bulk (>10 cm or mediastinal mass >1/3rd diameter of chest)
Slide 49-

International Prognostic Scoring System Risk factors Albumin <4 g/dL -- Age >45 years Hemoglobin <10.5 g/dL -- Stage IV disease Male sex -- WBC >15k Lymphocyte count <600/mm3 or <8% WBC 5-year survival
Slide 50-

Chemotherapy ABVD Adriamycin/Doxorubicin (Cardiomyopathy) Bleomycin (Pulmonary fibrosis) Vinblastine (Neurotoxicity, SIADH) Dacarbazine BEACOPP Bleomycin (Pulmonary fibrosis) Etoposide (Acute leukemias) Adriamycin/Doxorubicin (Cardiomyopathy) Cyclophosphamide (Hemorrhagic cystitis, infertility) Oncovin/Vincristine (Neurotoxicity, SIADH) Procarbazine (Disulfiram-like reaction with alcohol) Prednisone
Slide 51-

Principles of chemotherapy Stage IA-IIA non-bulky disease ABVD x 2 + involved field radiation ABVD x 4 Stage I-II bulky disease ABVD x 4-6 followed by involved field irradiation Stanford V chemotherapy x 3 followed by involved field irradiation Stage IB-IIB non-bulky, Stage III-IV ABVD x 6-8 Restaging after 4-6 cycles CR 2 additional cycles Bulky disease consolidative RT Stanford V x 3 +/- consolidative irradiation BEACOPP dose escalated x 8 cycles +/- irradiation www.nccn.com
Slide 52-

64 year old man with 3 year history of stage II grade I follicular lymphoma is evaluated for cervical and axillary lymph nodes that have been gradually enlarging since diagnosis. He is unable to wear a tie, can’t fasten his shirt, has trouble shaving and is concerned the appearance of cervical lymph nodes. Physical exam with normal vital signs. Bilateral cervical, axillary lymphadenopathy. No inguinal lymphadenopathy. CT CAP with progressive axillary, mediastinal, and cervical LAD. NEXT STEP IN MANAGEMENT? Cyclophosphamide, vincristine, prednisone, rituxan (RCVP) High dose chemotherapy with stem cell transplant FNA of cervical LN Observation
Slide 53-

61 year old man has 3 week history of growing masses in the bilateral cervical, inguinal region. He reports intermittent night sweats, and weight loss. Physical exam with VSS, a 2-3 cm of bilateral cervical, axillary, and inguinal lymphadenopathy noted Test Result show LDH 695, CBC and CMP wnl. CT/PET with cervical, axillary, inguinal, retroperitoneal masses noted. Bone marrow biopsy is negative. Lumbar Puncture was negative LN biopsy results are consistent with Diffuse Large B Cell Lymphoma What’s the most appropriate treatment? RCHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) for 3 cycles then involved field radiation Involved field radiation Observation Rituximab RCHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) for 6 cycles with CNS prophylaxis with IT methotrexate
Slide 54-

Questions?