This document discusses hematopoietic malignancies including leukemias and malignant lymphomas. It covers the classification, epidemiology, etiology, clinical manifestations, diagnosis, staging, and treatment of non-Hodgkin's lymphoma. The types of NHL are divided into indolent, aggressive, and very aggressive. Treatment depends on the type, stage, and patient characteristics. Options include chemotherapy, immunotherapy, radiotherapy, clinical trials, observation, and stem cell transplant. The document provides details on therapeutic approaches for different stages and types of NHL.

1. FARMAKOTERAPI KANKER
LIMFOMA NON HODGKINS

2. chronic myeloid
leukaemia
(CML)
Haematopoietic Malignancies
Polycythemia
vera
(PV)
Idiopathic
myelofibrosis
(MF)
Essential
thrombocythemia
(ET)
Acute myeloid
leukaemia
(AML)
Chronic myeloid
leukaemia
(CML)
Acute lymphatic
leukaemia
(ALL)
Chronic lymphatic
leukaemia
(CLL)
hairy cell
leukaemia
(HCL)
Hodgkin’s
lymphoma
Burkitt's lymphoma
cutaneous T-cell
lymphoma (CTCL)
Non-hodgkin’s
lymphoma
(NHL)
Myeloproliferative
diseases Leukaemias
Malignant
lymphomas

3. Haematopoietic Malignancies
 Family of chronic
neoplastic
diseases
 Due to a clonal
disorder arising
at the level of the
pluripotent stem
cell
 Characterised by
abnormal
proliferation of 1
or more blood cell
lines
 Neoplastic
disease of a
haematopoietic
precursor cell
 Characterised by
replacement of
normal bone
marrow
 Often infiltration
into other organs
 Malignant clones
suppress normal
cell formation
 Neoplastic
disease of
lymphatic tissue
 Originates in
lymph node or
spleen
 Hodgkin’s (15%)
 non-Hodgkin’s
(85%)
Myeloproliferative
diseases
Malignant
lymphomas
Leukaemias
I. DEFINISI

4.  LNH menempati urutan kelima saat ini
d Amerika,
di Indonesia sendiri LNH bersama LH
dan leukemia menempati urutan
keenam tersering.
 Insiden usia puncak LH : usia 20-30
tahun dan usia diatas 50 tahun
 Insiden LNH mencapai puncak pada
usia 80-84 tahun
II. EPIDEMIOLOGI

5. 1. Etiologi sebagian besar LNH tidak diketahui.
Namun terdapat beberapa faktor resiko
terjadinya LNH, antara lain:
a. Imunodefisiensi
kelainan herediter langka, seperti : severe
combined immunodeficiency, hypogamma-
globulinemia, seringkali dihubungkan pula
dengan Epstein-Barr virus (EBV)
III. ETIOLOGI

6. 2. Agen Infeksius : Epstein-Barr virus
(EBV)
3. Paparan Lingkungan dan Pekerjaan :
paparan herbisida dan pelarut organik.
4. Diet dan Paparan Lainnya
 Resiko LNH meningkat pada orang
yang mengkonsumsi makanan tinggi
lemak hewani, merokok, dan yang
terkena paparan unlraviolet.

7. IV. MANIFESTASI KLINIK
Limfoma memilki gejala relatif yang khas,
berupa :
 Demam tinggi 38oC tanpa sebab jelas (pada LH
disebut panas Pel-Ebstein)
 Keringat malam hari,
 Penurunan berat badan 10% dalam waktu 6
bulan
 Tampak limfedenopati bagian leher, aksila,
inguinal, dan kelenjar limfe mandibula.
Limfedenopati sering kali asimetri,
konsistensi padat dan kenyal, tidak nyeri.

8. Perbandingan Penggolongan stadium Lymphoma Non
Hodgkins menurut European Guideline VS American
Guideline VS Indonesian Guideline
European Guideline 2019 VS American Guideline 2019
VS Indonesian Guideline 2019
V. PENENTUAN STADIUM

9. Revised European-American Lymphoma
(REAL) Classification: B-Cell Neoplasms
Hiddemann. Blood. 1996;88:4085.
Indolent Aggressive Very Aggressive
CLL/SLL
Lymphoplasmacytic/
IMC/WM
HCL
Splenic marginal
zone lymphoma
MZL
- Extranodal (MALT)
- Nodal
Follicle center
lymphoma, follicular,
grade I-II
PLL
Plasmacytoma/
Multiple myeloma
MCL
Follicle centre
lymphoma, follicular,
grade III
DLCL
Primary mediastinal
large B-cell lymphoma
High-grade B-cell
lymphoma/Burkitt’s-
like
Precursor
B-lymphoblastic
lymphoma/
Leukemia
Burkitt’s
lymphoma/
B-cell acute
leukemia
Plasma cell
leukemia

10. REVISED STAGING SYSTEM FOR
PRIMARY NODAL LYMPHOMAS
Cheson BD, et al. JCO 2014;32(27):3059-68
Tonsils, Waldeyer’s ring, and spleen are considered nodaltissue.
Whether stage II bulky disease is treated as limited or advanced disease may be determined
by histology and a number of prognostic factors.
Stage Involvement Extranodal status (E)
Limited
Stage I One node or group of adjacentnodes
Single extranodal lesion withoutnodal
involvement
Stage II
Two or more nodal groups on thesame
side of the diaphragm
Stage I or II by nodal extent with limited,
contiguous extranodal involvement
Stage II bulky II as above with bulky disease N/A

11. REVISED STAGING SYSTEM FOR
PRIMARY NODAL LYMPHOMAS
Cheson BD, et al. JCO2014
Stage Involvement Extranodal status (E)
Advanced
Stage III
Nodes on both sides of the diaphragm
Nodes above the diaphragm with spleen
involvement
N/A
Stage IV
Additional non-contiguous extranodal
involvement
N/A

12. Ann Arbor Classification & Costwold
Modification

13. non-Hodgkin Lymphoma
Ann Arbor Staging
A = no symptoms
B = fever (unexplained)
night sweats
weight loss >10%

14. Staging of NHL

15. Staging of NHL

16. VI. DIAGNOSIS
 History/ Physical examination
 CT scan thorax
 CT scan abdomen
 PET scan: aggressive lymphomas
 Bone marrow biopsy

17. CT scans in lymphoma

18. PET scan in lymphoma

19. General Principles :
 It is (still ) not possible to select a specific treatment for
each type of NHL
 Therefore NHL are divided into major subgroups:
 Indolent types (follicular lymphoma)
 Aggressive types (diffuse large B cell lymphoma)
 Very aggressive types (Burkitt)
VII. PENATALAKSANAAN

20. Treatment of non-Hodgkin
lymphoma
considerations as to choice of therapy
 Type of lymphoma (REAL classification)
 Ann Arbor stage (I to IV)
 localizations
 Risk profile/prognostic score of the patient
 Which treatment is possible?

21. Treatment of non-Hodgkin
lymphoma
Indolent (stage II-IV)*
 “Wait and see”
 (mild) chemotherapy
 (low dose) radiotherapy
Aggressive (stage II-IV)
**
• CHOP chemotherapy
1x / 3 weeks,8x
* Stage I(II): high dose radiotherpy ** Stage I: 3x CHOP + radiotherapy

22. Therapy of aggressive
NHL
 polychemotherapy
 golden standard : CHOP
Drug Dose Route Day
Cyclophosphamide 750 mg/m2 i.v. 1
Doxorubicin
(hydroxydaunorubicine)
50 mg/ m2 i.v. 1
Vincristine (oncovin) 1.4 mg/ m2 * i.v. 1
Predniso(lo)ne 100 mg p.o. 1-5
* max. dose per cycle: 2 mg

23. Survival of NHL patients (till 2004)
Years since diagnosis
indolent
aggressive
very aggressive
100%
50%
10 20

24. The results of the treatment of
patients with NHL have been
improved impressively by the
use of antibodies directed
against the lymphoma cells

25. Rituximab (mabthera®) : a mouse/ human
chimeric anti- CD20 monoclonal antibody
Murine variable regions
bind specifically to CD20 on
normal/ malignant B-cells
Human K constant regions
Human IgG1 Fc domain
• interacts with human effector
mechanisms (ADCC, CDC)
• low immunogenicity

26. Anti-CD20 (Rituximab= Mabthera®)
mechanism of action
Adapted from Male D, et al., Advanced Immunology 1996: 1.1–1.16
Malignant B-cell
Complement
CD20
CD20
Direct
induction of
apoptosis
Killer
Leukocyte

27. New developments in the treatment of
lymphoma
 New monoclonal antibodies (HumaxCD20, CD22)
 Radio-immunotherapy
 New agents (bortezomib, lenalidomide, bendamustine,
apoptosis-inducers, small molecules)
 New combinations
 Allogeneic SCT (RIST)

28. non-Hodgkin’s lymphoma
Why treatment with antibodies?
• With present chemotherapy no or insufficient
cure
• Treatment of minimal residual disease after
chemotherapy might improve prognosis
• Antibodies are more specific than cytostatic
drugs
• Antibodies are less toxic
• Antibodies have a different mechanism of action

29. DLCL in the elderly :
Rituximab improves overall survival
Years
1.
0
0.
8
0.
6
0.
4
0.
2
0
0 1 2 3 4 5
p=0.01
59% Rituximab + CHOP
47% CHOP
Probability
of
overall
survival
Coiffier et al.

30. 5
B Cell Neoplasm
I. Precursor B-cell neoplasm : Precursor B-Acute
Lymphoblastic Leukemia/lymphoblastic lymphoma
II. Peripheral B-cell neoplasms
A. B-cell chronic lymphocytic leukemia/small lymphocytic
lymphoma
B. Lymphoplasmacytic lymphoma
C. Mantle cell lymphoma
D. Follicular lymphoma
E. Extranodal marginal zone B-cell lymphoma or MALT type
F. Nodal marginal zone B-cell lymphoma
G. Splenic marginal zone lymphoma
H. Plasmacytoma/ plasma cell myeloma
I. Diffuse large B-cell lymphoma, NOS
J. Diffuse large B cell lymphoma variants.
K. Burkitt’s lymphoma
L. B cell lymphoma inclassifiable with features
intermediate between DLBCL and Burkitt lymphoma
M.B cell lymphoma inclassifiable with features intermediate
between DLBCL and classical Hodgkin lymphoma
TATALAKSANA
Pilihan terapi bergantung pada beberapa hal, antara lain: tipe
limfoma (jenis histologi), stadium, sifat tumor (indolen/agresif), usia,
dan keadaan umum pasien.
I. LNH INDOLEN / Low grade: (Ki-67 < 30%)
Yang termasuk dalam kelompok ini adalah:
 SLL/small lymphocytic lymphoma/CLL =chronic
lymphocytic lymphoma
 MZL (marginal zone lymphoma), nodal, ekstranodal
dan splenic)
 Lymphoplasmacytic lymphoma
 Follicular lymphoma gr 1-2
 Mycosis Fungoides
 Primary cutaneous anaplastic large cell lymphoma )
A. LNH INDOLEN STADIUM I DAN II
Radioterapi memperpanjang disease free survival pada
beberapa pasien. Standar pilihan terapi :
1. Iradiasi
2. Kemoterapi dilanjutkan dengan radiasi
3. Kemoterapi (terutama pada stadium ≥2 menurut kriteria

31. GELF)
4. Kombinasi kemoterapi dan imunoterapi
5. Observasi
B. LNH INDOLEN / low grade STADIUM II bulky, III,
IV Standar pilihan terapi :
indikasi untuk
1. Observasi (kategori 1) bila tidak terdapat
terapi.
Termasuk dalam indikasi untuk terapi:
 Terdapat gejala
 Mengancam fungsi organ
 Sitopenia sekunder terhadap limfoma
 Bulky
 Progresif
 Uji Klinik
2. Terapi yang dapat diberikan:
1. Rituximab dapat diberikan sebagai kombinasi terapi lini
pertama yaitu R-CVP. Pada kondisi dimana Rituximab
tidak dapat diberikan maka kemoterapi kombinasi
merupakan pilihan pertama misalnya: COPP, CHOP dan
FND.
2. Purine nucleoside analogs (Fludarabin) pada LNH primer
3. Alkylating agent oral (dengan/tanpa steroid), bila
kemoterapi kombinasi tidak dapat diberikan/ditoleransi
5
(cyclofosfamid, chlorambucil)
4. Rituximab maintenance dapat dipertimbangkan
5. Kemoterapi intensif ± Total Body irradiation (TBI) diikuti
dengan stem cell resque dapat dipertimbangkan pada
kasus tertentu
6. Raditerapi paliatif, diberikan pada tumor yang besar
(bulky) untuk mengurangi nyeri/obstruksi.
C. LNH INDOLEN/ low grade RELAPS
Standar pilihan terapi:
1. Radiasi paliatif
2. Kemoterapi
3. Transplantasi sumsum tulang
II. LNH AGRESIF / High grade: (Ki-67 > 30%)
Yang termasuk dalam kelompok ini adalah:
 MCL (Mantle cell lymphoma, pleomorphic variant)
 Diffuse large B cell lymphoma, Follicular lymphoma gr III, B
cell lymphoma unclassifiable with features between diffuse
large B cell and Burkitt,
 T cell lymphomas
A. LNH STADIUM I DAN II
Pada kondisi tumor non bulky (diameter tumor <7.5cm)
dengan kriteria: pasien muda risiko rendah atau rendah-
6
6

32. menengah (aaIPI score ≤1) dan risiko tinggi atau
menengah-tinggi (aaIPI ≥2), bila fasilitas memungkinkan,
kemoterapi kombinasi R-CHOP 6 siklus merupakan
protokol standar saat ini serta dapat dipertimbangkan
atau
pemberian radioterapi (untuk konsolidasi),
kemoterapi 3 siklus dilanjutkan dengan radioterapi.
B. LNH STADIUM I-II (BULKY), III DAN IV
• Bila memungkinkan, pemberian kemoterpi RCHOP
6siklus ± radioterapi konsolidasi, dipertimbangkan
pada stadium I dan II
• Uji klinik pada stadium III dan IV
C. LNH REFRAKTER/RELAPS
• Pasien LNH refrakter yang gagal mencapai remisi,
dapat diberikan terapi salvage dengan radioterapi
jika area yang terkena tidak ekstensif. Terapi pilihan
bila memungkinakan adalah kemoterapi salvage
diikuti dengan transplantasi sumsum tulang
• Kemoterapi salvage seperti R-DHAP maupun R-ICE
III. LNH “LEUKEMIA-LIKE”: Lymphoblastic, Burkitt, “double hit”
lymphoma.
• High dose chemotherapy plus radioterapi diikuti
dengan transplantasi sumsum tulang
7

33. 15
REGIMEN TERAPI YANG DISARANKAN17
Terapi Lini Pertama

Rituximab + CHOP (Cyclophosphamide, doxorubicine, vincristine, prednisone) (kategori 1)
 Dosed dense RCHOP 14 (Kategori 3)
 Dosed adjusted R- EPOCH (Rituximab, Etoposide, Prednison, Vincristin, Cyclophosphamide,
doxorubicin) (kategori 2B)
Terapi Lini Pertama pada pasien dengan fungsi ventrikuler kiri buruk atau sangat rentan
 RCEPP–rituximab, cyclophosphamide, etoposide, prednisone, procarbazine
 RCDOP–rituximab, cyclophosphamide, liposomal doxorubicin, vincristine, prednisone
 DA-EPOCH – etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin+ rituximab
 RCEOP – rituximab, cyclophosphamide, etoposide, vincristine, prednisone
 RGCVP – rituximab, gemcitabine, cyclophosphamide, vincristine, prednisolone
Pasien > 80 tahun dengan komorbiditas
 R-mini CHOP
 RGCVP – rituximab, gemcitabine, cyclophosphamide, vincristine, prednisolone
Terapi Lini Pertama Konsolidasi (Opsional)
 Age-adjusted IPI high risk disease: Terapi dosis tinggi dengan penyelamatan stem sel autolog
 Double-hit DLBCL: Terapi dosis tinggi dengan penyelamatan stem sel autolog
Keberadaan penyakit bersamaan dengan manifestasi pada SSP (CNS disease)
 Parenkimal: methotrexate sistemik 3 g/m2 atau lebih, pada hari ke-15 dari 21 hari pemberian
siklus R-CHOP yang didukung dengan pemberian growth factors
 Leptomeningeal : methotrexate/cytarabine intratekal, pertimbangkan pemasangan Ommaya
reservoir dan/atau methotrexate sistemik
(3 – 3.5 g/m2)

34. 16
REGIMEN TERAPI YANG DISARANKAN17
Terapi Lini Kedua dan Terapi Lanjutan (dengan intensi untuk high-dose therapy)
 DHAP - dexamethasone, cisplatin, cytarabine + rituximab
 ESHAP - etoposide, methylprednisolone, cytarabine, cisplatin + rituximab
 GDP – gemcitabine, dexametason, cisplatin + rituximab atau gemcitabine,
dexametason, carboplatin + R
 GemOx – gemcitabine, oxaliplatin + rituximab
 ICE - ifosfamide, carboplatin, etoposide + rituximab
 miniBEAM – carmustine, etoposide, cytarabine, melphalan + rituximab
 MINE - mesna, ifosfamide, mitoxantrone, etoposide + rituximab
Terapi Lini Kedua dan Terapi Lanjutan (tanpa intensi untuk high-dose therapy)
 Bendmustine + rituximab
 Brentuximab vedotin untuk pasien dengan CD30+ (kategori 2B)
 CEPP + rituximab (cyclophosphamide, etoposide, prednisone, procarbazine) – PO
dan IV
 CEOP (cyclophosphamide, etoposide, vincristine, prednisone) + rituximab
 DA-EPOCH – etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin +
rituximab
 GDP + rituximab atau gemcitabine, dexametason, carboplatin + rituximab
 GemOR + rituximab
 Lenalidomide + rituximab (non-GCB DLBCL)
 Rituximab

35. 2
7
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