LYMPHOMA DIAGNOSIS and PROGNOSIS LC Lim Dept of Hematology Singapore General Hospital
OUTLINE Accurate diagnosis Define subtype : WHO classification Staging : Defines extent of involvement Prognosis Determining Prognosis Prognostic scores Communication of Diagnosis & Prognosis Six Steps
LYMPHOMA DIAGNOSIS
DIAGNOSIS OF LYMPHOMA Tissue diagnosis is essential excisional lymph node biopsy is definitive procedure Attempt to remove intact lymph node to avoid trauma to nodal architecture Fine needle aspiration (FNA) should not be used for definitive diagnosis and subtyping Lymph node Well, prepared, formalin-fixed, paraffinembedded sections required
Tissue Diagnosis (Lymph Node Biopsy) Consider performing lymph node biopsy if >40yrs Supraclavicular location Node diameter >2cm Firm to hard texture Lack of tenderness Do Full blood count and CXR before biopsy
WHO Classification of Lymphoma (2008) Internationally accepted taxonomy for lymphoma Fundamental to the classification, diagnosis and management of lymphoma 1. B-cell 2. T-cell and NK-cell 3. Hodgkin s 4. B-cell proliferations of uncertain malignant potential
Staging of Disease Stages - I, II, III, IV A or B - Based on presence/not of B symptoms fever night sweats weight loss
LYMPHOMA PROGNOSIS
Determining Prognosis Forecast of probable course and outcome of a disorder or disease Life expectancy Prognostication is both art and science, and is imperfect at best
How to Determine Prognosis? Sources physician predictions stage-specific survival data tumor-specific prognostic factors (eg, molecular markers, stage, grade, etc) integrated models of prognosis IPI, FLIPI, Hasenclever index for Hodgkin s lymphoma treatment- and patient-specific factors (eg, comorbid illness, performance status, and disease signs and symptoms)
LOW GRADE LYMPHOMA Indolent survival of untreated disease measured in years usually not curable by conventional therapy may have prolonged survival even if treatment results in only partial response EG Follicular lymphoma, CLL, Marginal zone lymphoma (eg SLVL), Hairy cell leukemia
AGGRESSIVE LYMPHOMA Comprises at least 10 distinct WHO categories About 50% of NHL Eg Diffuse large cell peripheral T cell anaplastic large cell lymphoma
AGGRESSIVE LYMPHOMA survival of untreated disease measured in months possibility of cure with conventional therapy only patients attaining complete response to therapy can expect reasonable survival or cure rapidly fatal within weeks to months if untreated or unresponsive to therapy
INTERNATIONAL PROGNOSTIC INDEX AGGRESSIVE NHL
FOLLICULAR LYMPHOMA IPI
Assessing Performance Status Performance status quantifies the functional status of cancer patients Tools such as the Karnofsky Scale, ECOG also captures medical care requirements Since the beginning of modern oncology in the 1940s, the ability of a patient to perform routine activities of daily living has shown the best correlation with prognosis.
ECOG Performance Scale 0 = fully active, able to carry out all normal activities 1 = symptoms present but able to carry out normal activities, some difficulty with more strenuous activities 2 = able to carry out normal self-care activities but limited in ability to work. Up and about more than 50% of time 3 = capable of only limited self-care. Confined to bed or chair more than 50% of waking hours 4 = completely disabled. Needs full time assistance with normal self-care activities
LYMPHOMA COMMUNICATING DIAGNOSIS & PROGNOSIS
Disclosing Diagnosis and Prognosis Research has shown that physicians are systematically overly optimistic in formulating survival estimates and even more optimistic when they disclose prognostic information to patients and/or their families Physicians' estimates of prognosis for patients in palliative care programs are overly optimistic by a factor of 3- to 5-fold -- that is 300% to 500% more optimistic than observed
6-Step Protocol: SPIKES SPIKES Setting 6-Step Protocol to Clarify Diagnosis and Prognosis 1. Getting started Perception Invitation Knowledge Emotion 2. What does the patient know? 3. How much does the patient want to know? 4. Share the information 5. Respond to feelings Subsequent 6. Plan next steps and follow up
Key Take Home Points Accurate assessment and disclosure of diagnosis and prognosis are essential for both treatment and personal decision-making for patients with cancer Consider 6-step SPIKES protocol for effective communication
Thank You Medicine Review Course 2011 Haematology Lymphoma Diagnosis & Prognosis