Indolent non hodgkins lymphoma
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FL, MZL, SLL
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Indolent non hodgkins lymphoma
- 1. Indolent non Hodgkin lymphomas Dr. Rajib Bhattacharjee Junior Resident IPGMER, Kolkata
- 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. Types of NHL based on aggressiveness Low grade Intermediate grade high grade Follicular lymphoma Marginal zone lymphoma SLL/CLL DLBCL PTCL Burkitt’s lymphoma Lymphoblastic lymphoma
- 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. 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. 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. 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. Exam time.. • Lymph node examination • Head and neck – waldeyer’s ring • Chest – Sternal/2nd ICS percussion Pleural effusion • Abdomen- Organomegally, Lump, Ascites Testes • Skin - Nodules
- 10. Investigations .. Lab investigations • CBC, KFT, LFT, Electrolytes • Ca2+ • LDH, Uric acid • HBsAg, IgM HBc • HIV I & II
- 11. Imaging • Chest X-Ray • CT Thorax, abdomen & pelvis • PET CT • Tc-99m Bone Scan • MUGA/ Echocardiography Endoscopy • Upper GI
- 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. 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. Which stage is the disease..???
- 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. Possible histologies for our discussion Follicular Lymphoma Marginal zone Lymphoma SLL/CLL
- 19. 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)
- 20. 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)
- 21. 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
- 22. Bendamustine in 1st line indolent/mantle cell R-B R R-CHOP 69.5mo PFS 31.2mo toxicity
- 23. Maintenance Rituximab Follicular lymphoma RCHOP/RCVP/RFCM mRituximab R Obv 75% PFS 58% 72% CR 52%
- 24. Progressive disease • Elderly, asymptomatic – Obv • 2nd line chemotherapy – Bendamustine FCM • Radioimmunotherapy – Zavaline, Baxxar • mTOR inhibitors – NVP-BEZ235 • Proteasome inhibitors • Stem cell transplant
- 26. Marginal zone lymphoma Three entities • Nodal • Extranodal - MALToma • Splenic Stomach Small intestine Occular Skin Parotid Thyroid
- 27. 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
- 28. 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
- 29. SLL • Localized disease – IFRT (30Gy) • Advanced disease – Chemoimmunotherapy Age>70, co-morbidities Age<70, medically fit Relapse •Obinutuzumab + Chlorambucil •Rituximab + Chlorambucil •Bendamustine + Rituximab •FCR (Fludarabine + Cyclofosfamide + Rituximib) •Ibrutinib
- 30. IFRT
- 31. Fallow up • Physical exam & labwork - 3-6 months for 1st 5 years then annually. • CT scan every 6 months for 2 years then annually.
- 32. THANK YOU