Harmesh Naik, MD. GME Presentation to Family Practice Residents October 16, 2013.

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1 Harmesh Naik, MD. GME Presentation to Family Practice Residents October 16, 2013.

2 Lymphoma: Lympho-proliferative disorders arising from lymphocytes Heterogeneous group of disorders Differing patterns of behaviors and response to treatment One of the most curable and treatable malignancy Lymphoma biology and management has led to several major breakthroughs in cancer treatments

3 Blood cell development

4 Incidence Lymphoma incidence is increasing About 79,000 new cases with 20,000 deaths from lymphoma in 2013 per ACS estimate About 9200 cases annually with about 1180 deaths annually (2013 estimate)

5 Lymphomas T cell/nk cell 10% HL 10% B Cell NHL 80%

6 Ann Arbor staging : Summary I: Involvement of a single nodal site or local involvement of single extra nodal site - IE II: Two or more nodal areas on same side of diaphragm III: Involvement of nodal areas on both sides of diaphragm IV: Diffuse or disseminated involvement of one or more extra lymphatic organs, with or without associated lymph node involvement

7 B symptoms A notation of B symptoms is made along with stage Unexplained loss of more than 10% of body weight in the 6 months before diagnosis. Unexplained fever with temperatures above 38 C. Drenching night sweats.

9 HODGKIN S LYMPHOMA B cell neoplasm Characteristic cell is Sternberg Reed cell Disease spread is generally contiguous Exploratory laparotomy and splenectomy are no longer used for staging Over 75% of cases are potentially cured

11 RISK FACTORS Etiology is unknown Association with EB virus Risk of HD is increased 3 fold in people with history of infectious mononucleosis About half of Hodgkin nodes show evidence of EBV DNA in Stenberg reed cells genome Not all Hodgkin s cases are EBV positive.

12 SYMPTOMS / SIGNS Pain less lymphadenopathy Splenomegaly B symptoms: Fever, drenching night seats, weight loss Pruritus Pain in nodal area after alcohol consumption

13 HISTOLOGY: WHO classification Classical Hodgkin s lymphoma 95% of all cases Nodular Lymphocyte predominant Hodgkin s lymphoma -About 5% of total cases % cases Classic Lym Predom

14 STAGING WORK UP History and physical examination Excisional lymph node biopsy with histology and immune phenotype CBC diff, Liver enzyme testing, LDH, Sed rate Chest x-ray or CT chest CT abdomen and pelvis PET scan Bone marrow aspiration and biopsy (if advanced stage or B symptoms)

15 ADDITIONAL MEASURES Fertility preservation evaluation if applicable Pulmonary function testing Cardiac ejection fraction tests HIV testing Vaccination if splenectomy is planned or splenic RT is given

16 PROGNOSIC FACTORS: International prognostic Score (IPS) FDG PET scan after two cycles of ABVD

17 TREATMENT Curable in majority of patients Combination chemotherapy is standard of care for Classical Hodgkin s disease Number of courses of chemotherapy varies with stage Involved field radiotherapy is used following short course of chemotherapy in early stage Hodgkin s disease Role of radiotherapy is undergoing reevaluation.

18 TREATMENT Early favorable: Stage IA and IIA non- bulky favorable Short course of chemotherapy (2-4 cycles ) followed by involved field radiation therapy (20 Gy) Cure rate of 90-95% Early unfavorable Stage I and II with bulky disease / Bulky disease : Six cycles of chemotherapy followed by involved field Radiation

19 TREATMENT Advanced disease: Stage III and IV up to 30% are at risk of death ABVD is standard of care in United States ABVD is more effective and less toxic than MOPP Stanford V and BEACOPP regimens are designed to reduce cumulative toxicity of several drugs and to improve outcomes Role of consolidation RT in patients with stage III and IV disease remain controversial

20 RELAPSED HODGKIN S LYMPHOMA Initial RT alone ABVD -long term disease free survival in 50-80% Initial ABVD Salvage second line regimens (ICE etc.) 15% 5 year disease free survival High dose therapy and stem cell transplant in selected scenarios

21 Nodular Lymphocyte predominant Hodgkin s lymphoma - treatment Early stage / localized Involved field RT is used for early stage local disease Relapse/Recurrence after local RT: Single agent Rituximab (70-100% Response rate) Or with combination ABVD Disseminated Generally it is treated with ABVD. Rituximab has been used successfully as well in some situations.

22 Purpose of long term follow up: To monitor for relapse To monitor for late effects of treatment MDS Leukemia Hypothyroidism Premature coronary artery disease Pulmonary toxicity -Bleomycin Infertility To monitor for new primary cancer

24 NHL: Cell types NHL B cell T cell NK cell

25 NHL: Clinical types Indolent lymphoma: (Slow growing, low grade, incurable) Aggressive lymphoma: ( fast growing, intermediate grade, potential curable) Highly aggressive (high grade, very fast growing, potential curable)

26 Working formulation classification (Old) Low grade Intermediate grade High grade

27 WHO classification: B cell Precursor B-cell neoplasm: precursor B-acute lymphoblastic leukemia/lymphoblastic lymphoma (LBL). Peripheral B-cell neoplasms. B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma. B-cell prolymphocytic leukemia. Lymphoplasmacytic lymphoma/immunocytoma. Mantle cell lymphoma. Follicular lymphoma. Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphatic tissue (MALT) type. Nodal marginal zone B-cell lymphoma (± monocytoid B-cells). Splenic marginal zone lymphoma (± villous lymphocytes). Hairy cell leukemia. Plasmacytoma/plasma cell myeloma. Diffuse large B-cell lymphoma. Burkitt lymphoma.

28 WHO classification: T cell T-cell and putative NK-cell neoplasms Precursor T-cell neoplasm: precursor T-acute lymphoblastic leukemia/lbl. Peripheral T-cell and NK-cell neoplasms. T-cell chronic lymphocytic leukemia/prolymphocytic leukemia. T-cell granular lymphocytic leukemia. Mycosis fungoides/sézary syndrome. Peripheral T-cell lymphoma, not otherwise characterized. Hepatosplenic gamma/delta T-cell lymphoma. Subcutaneous panniculitis-like T-cell lymphoma. Angioimmunoblastic T-cell lymphoma. Extranodal T-/NK-cell lymphoma, nasal type. Enteropathy-type intestinal T-cell lymphoma. Adult T-cell lymphoma/leukemia (human T-lymphotrophic virus [HTLV] 1+). Anaplastic large cell lymphoma, primary systemic type. Anaplastic large cell lymphoma, primary cutaneous type. Aggressive NK-cell leukemia.

29 RISK FACTORS Etiology is unknown for most cases Suspected but not conclusively proven: Pesticides, Chemicals, Smoking, Hair dyes, toxins Immuno compromised state increase risk of NHL Drug treatments: Cyclosporine, OKT 3 in transplant patients, etc. Infections: HIV Inherited immune defects Collagen vascular diseases: Rheumatoid arthritis Stem cell transplantation or solid organ transplantation

30 Association between infectious agent and specific type of lymphoma Epstein Barr virus Hodgkin s lymphoma Post transplant lympho-proliferative disorders (PTLD) Human Herpes virus 8 Body cavity lymphoma Castleman disease HIV related Kaposi s sarcoma Hepatitis C virus Immunocytoma Splenic marginal zone lymphoma Human T cell Lymphoma virus Adult T cell leukemia/lymphoma Helicobacter pylori Chlamydia Psitacci Campylobacter jejuni Borrelia burgdorferi Gastric mucosa associated lymphoid tissue lymphoma (MALTOMA) Orbital adnexal lymphoma Immunoproliferative small bowel disease Cutaneous MALT lymphoma

31 DIAGNOSIS Excisional node biopsy is preferred for histology and flow cytometry FNA- high false negative Core biopsy helpful at times but may not provide adequate histology Bone marrow biopsy Flow cytometry and molecular genetic studies are increasingly useful in diagnosis

32 STAGING WORK UP History and physical examination CBC diff, Liver enzyme testing, LDH CT chest CT abdomen and pelvis PET scan Bone marrow aspiration and biopsy

33 STAGING SYSTEM Ann Arbor staging system NHL often presents at advanced stage. Ann Arbor staging system is less relevant for NHL then for HL.

35 Indolent (Low grade) NHL Small lymphocytic lymphoma (SLL) / Chronic lymphocytic leukemia (CLL) Follicular lymphoma - grades I and II Marginal zone lymphoma (MZL) Lympho-plasmacytic lymphoma - LPL (Immunocytoma and Waldenstorm s Macroglobulinemia)

36 Indolent (Low grade) NHL Relatively better prognosis Median survival up to 10 years on average Most are non curable Responsive to treatment, however, has constant rate of recurrence Bone marrow involvement is seen in up to 40% indolent lymphoma

37 BCL-2 Rearrangement of the bcl-2 gene is present in more than 90% of patients with follicular lymphoma Over-expression of the bcl-2 protein is associated with the inability to eradicate the lymphoma by inhibiting apoptosis Immortality gene

38 Follicular Lymphoma International Prognostic Index [FLIPI] An international index for follicular lymphoma identified five significant risk factors prognostic of overall survival (OS): Age ( 60 y vs. >60 y). Serum lactate dehydrogenase (LDH) (normal vs. elevated). Stage (stage I or stage II vs. stage III or stage IV). Hemoglobin level ( 120 g/l vs. <120 g/l). Number of nodal areas ( 4 vs. >4).

39 Prognosis: FLIPI index Risk factors and 10 yr OS or more 10 yr OS

40 Follicular lymphoma Grade I and II are treated like indolent lymphoma Grade III are treated like Diffuse large cell lymphoma

41 TREATMENT CHOICES In general there is no consensus on best treatment. Many options are available including observation.

42 Indications for treatment Cancer related symptoms B symptoms Threatened organ function Steady progression Transformation Cytopenias Recurrent infections Patient preference

43 Indolent lymphoma: treatment options Clinical trials Observation- watchful waiting Local RT Rituximab Chemotherapy Chemotherapy-immunotherapy Radio-immunotherapy

44 Treatment selection: Role of molecular markers Alemtuzumab preferred for SLL patients with del 17 p (p 53 mutation)

45 High dose therapy / stem cell transplant For refractory follicular lymphoma cases Generally not curative Under evaluation for upfront therapy

46 Treatment observations Chemotherapy + Rituximab might be better (6-13% benefit at 4 years per meta analysis) in symptomatic patients Rituximab maintenance may improve progression free survival (given for 2 years)

47 Marginal zone lymphoma Stomach MALTOMA Anti H. Pylori therapy is effective t(11,18) predicts poor response to anti H. Pylori treatment Rituximab, Local radiation etc. are reserved for refractory disease Non gastric extra nodal MALTOMAs Surgery + RT Chemo - immunotherapy

48 Splenic marginal zone lymphoma Rituximab very effective Chemo-immunotherapy Splenectomy may produce prolonged remission Chemotherapy might be less effective Hepatitis C treatment may induce remission

49 Remission duration: Indolent NHL First line Second line Third line Fourth line

50 HAIRY CELL LEUKEMIA Splenomegaly, Leukopenia / pancytopenia and marrow infiltration with hairy cells (cytoplasm projections)- TRAP stain positive cells Marrow is fibrotic and hard to aspirate ( Dry tap is common) Purine analogues (Cladarabine or Pentostatin) are effective in inducing prolonged remission lasting for up to 8-12 years Cure is not expected like other indolent lymphomas

51 Waldenström s macroglobulinemia Lymphoplasmacytic lymphoma usually associated with a monoclonal serum paraprotein of immunoglobulin M (IgM) type Hyper viscosity syndrome : Requires plasmapheresis General management is similar to that of other low-grade lymphomas

52 Immune cytopenias in NHL ITP and AIHA Prednisone IVIG Rituximab Splenectomy for refractory cases Chemotherapy Pure red cell aplasia Prednisone ATG or Cyclosporine

53 Recurrent infections in NHL IVIG may help in selected cases particularly with infections from encapsulated organisms

55 DIFFUSE LARGE CELL B CELL LYMPHOMA (DBCL) Most common NHL 30% -35% of total B cells are positive for CD 19 and CD 20 Most present with rapidly developing masses, systemic symptoms or weight loss IPI is used to estimate prognosis and to classify patient in to risk groups

56 Aggressive NHL Diffuse large cell B cell lymphoma (DBCL) Mantle cell lymphoma (MCL) Burkitt s lymphoma Lymphoblastic lymphoma

57 DIFFUSE LARGE CELL B CELL LYMPHOMA (DBCL): Localized DBCL About 20% cases Stage I or non bulky stage II Potentially Curable R-CHOP x 3 with Radiation is used commonly in USA after SWOG trial

58 DIFFUSE LARGE CELL B CELL LYMPHOMA (DBCL): Advanced DBCL CHOP alone % CR and plateau at DFS at around 30% R-CHOP versus CHOP: R-CHOP improved CR, TTP and overall survival in GELA study (Rituximab improves cure rate by about 10-15%) R-CHOP is current standard of care for DBCL More than half can be cured with R-CHOP

59 DIFFUSE LARGE CELL B CELL LYMPHOMA (DBCL): Relapsed DBCL Re-induction with aggressive chemotherapy regimen such as RICE remission is of short duration and few are cured Consolidation stem cell transplantation may cure some relapsed patients with chemo-sensitive disease Stem cell transplant is less effective for primary refractory disease Repeat biopsy may help since 10-15% may have lower grade follicular recurrence

60 MANTLE CELL LYMPHOMA (MCL) Characterized by t (11,14) translocation and over expression of BCL 1 cycling D1 protein May have diffuse bowel involvement (lymphomatous polyposis) Median survival is shorter than other lymphomas Doxorubicin based chemotherapy may not cure MCL Hyper CVAD followed by High dose therapy and stem cell transplantation in first CR is considered better option and is recommended in fit patients

61 BURKITT LYMPHOMA Highly aggressive lymphoma with explosive presentation Starry sky pattern on histology All cases possess c-myc oncogene at band 8q24 {associated with t (8,14) mostly but sometimes with t(2,8) or t (8, 22) } Common in pediatric population ( Endemic in Africa jaw tumors and associated with EBV) Most common lymphoma in AIDS patients Non endemic Burkit s is seen in US GI tract (ileo-cecal mass) is commonly involved LDH is very high

62 BURKITT LYMPHOMA Very intensive treatment regimen (R-hyper CVD or R-CODOX-M/IVAC) and CNS prophylaxis may cure some patients (60% -74% DFS at 5 years in adults) Fatal tumor lysis is possibility precautions are necessary Stem cell transplantation is recommended for those in first CR with high risk of recurrence (Stages III or IV, high LDH and tumor masses more than 10 cm)

63 PRIMARY CNS LYMPHOMA Aggressive B cell lymphoma in cranio-spinal axis without systemic disease Seen Denovo or in immuno compromised patients Age over 60 and HIV are poor prognosticators Whole brain RT is standard but unsatisfactory treatment CHOP does not work well RT with or without chemotherapy is neurotoxic Radiation sparing regimens: Chemotherapy alone with high dose Methotrexate and Leucovorin rescues is being tried with better response than RT.

64 LYMPHOBLASATIC LYMPHOMA Highly aggressive lymphoma of precursor T or B cells Explosive onset: Commonly with blasts in blood, marrow, mediastinal and other adenopathy, younger age, cytopenia. About 30% experience CNS involvement Induction therapy: Intensive multi-agent chemotherapy in hospital setting. Hyper CVAD results in 90% CR in low risk patients Consolidation: Stem cell translation CNS prophylaxis and radiation to bulky tumor are important components of treatment Testis and CNS are sanctuary sites Testicular RT is incorporated in treatment protocols

66 CUTANEOUS T CELL LYMPHOMA CTCL (Mycosis Fungoides) Indolent T cell (helper cell CD 4 phenotype) lymphoma of skin Waxing and waning eczematous skin patches or plaques for long periods (5-15 years) Advanced disease: Nodular tumors with ulceration or systemic visceral involvement Treatment options are many including PUVA (Psoralen and ultraviolet A therapy), local radiation, retinoids, interferon, Denilukin IL2 fusion toxin, topical chemotherapy or purine analogues or liposomal doxorubicin or Vorinostat) Patient can die from infections good skin care and antibiotics are important components

67 CUTANEOUS T CELL LYMPHOMA CTCL (Mycosis Fungoides) Sezary syndrome: Generalized erythema and circulating Sezary cells in blood median survival is short about 2 years with Sezary syndrome The only curative therapy is allergenic stem cell transplant option for a small number of patients

68 PLEASE SEE HANDOUT FOR MORE DETAILED INFORMATION

Large cell immunoblastic Diffuse histiocytic (DHL) Lymphoblastic lymphoma Diffuse lymphoblastic Small non cleaved cell Burkitt s Non- Burkitt s

Large cell immunoblastic Diffuse histiocytic (DHL) Lymphoblastic lymphoma Diffuse lymphoblastic Small non cleaved cell Burkitt s Non- Burkitt s Non Hodgkin s Lymphoma Introduction 6th most common cause of cancer death in United States. Increasing in incidence and mortality. Since 1970, the incidence of has almost doubled. Overview The types of