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Lymphoma

Danielle Fishman

Background

  • Classically characterized by lymphadenopathy & constitutional “B” symptoms: fevers, drenching night sweats and weight loss
  • Hodgkin:
    • 10%
    • superficial, nodal disease with orderly spread
    • Bimodal Distribution: 15-35 years and >50 years; M>F
    • CD15+, CD30+ (Reed Sternberg cells “owl eyes”)
    • Associated with EBV in immunocompromised patient
  • Non-Hodgkin:
    • 90%
    • diffuse, nodal and extranodal disease with noncontiguous spread
    • Average 65 years, M>F, 85-90% B-cell
    • Associated with immunodeficiency (HIV, post-transplant), autoimmune disease, infection (EBV, HTLV-1, H pylori, HCV, Borrelia, C psittacosis, Coxiella)

General Evaluation

  • History
    • B symptoms; pruritus (10-15% of pt with HL); history of radiation
  • Physical Exam
    • Head & neck, tonsils, axilla, testes, liver, spleen
    • Lymphadenopathy: painless, firm, fixed, >1cm
  • Lab tests:
    • CBC, CMP, LDH, Uric Acid, Phosphorus
    • Consider HBV, HCV, HIV, EBV, Quant gold, Treponemal Ab, ANA
  • Imaging:
    • CT chest, abdomen, pelvis
    • Most will eventually need PET-CT; MRI brain if neuro symptoms
  • Consider LP for NHL with high risk of CNS involvement or presence of neurological symptoms
    • Risk factors: Burkitt, Lymphoblastic, testicular involvement, double/triple hit
    • Multiple LPs may be required to diagnose CNS lymphoma

  • Diagnosis requires tissue

    • Excisional Lymph node biopsy (Surg Onc Consult)
    • Core biopsy (CT guided procedure consult)
    • Of note, steroids may impact value of biopsy results

  • Lugano Classification: staging of lymphoma

    • I. 1 LN region or single extra lymphatic organ/site without nodal involvement
    • II. >2 LN regions, same side of diaphragm
    • III. LN regions on both sides of diaphragm
    • IV. Disseminated disease w/ 1+ extralymphatic organ

  • Hodgkin:

    • IPS negative prognostic calculator: albumin <4, hemoglobin <10.5, male, stage IV disease, age>45, WBC count> 15K, lymphocyte <8% of WBC count
  • Non-Hodgkin:
    • Good prognosis: Follicular, Marginal Zone, Mycosis Fungoides/Sezary Syndrome
    • Poor prognosis: DLBCL – can arise from low grade lymphoma Richter transformation), Double/Triple Hit: bcl-2, bcl-6, or myc aberrations, Mantle Cell, Burkitt, Lymphoblastic Lymphoma, and Anaplastic Large Cell Lymphoma

General Management

  • ECG and TTE to establish pre-chemotherapy cardiac function – many chemo regimens with anthracyclines
  • Daily labs: CBC, TLS, LDH
  • TLS prophylaxis: mIVF, allopurinol

Common Chemotherapy Regimens for Lymphoma

Regimen Components Use
R-CHOP Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone NHL
R-EPOCH

Etoposide plus the drugs above

(dosing is different)

NHL

(Double/Triple hit)
Hyper-CVAD Cyclophosphamide, vincristine, doxorubicin, and dexamethasone NHL
HD-MTX + R High Dose methotrexate + Rituxumab Primary CNS Lymphoma
ABVD Doxorubicin, bleomycin, vinblastine, dacarbazine HL
Last update: 2022-06-25 02:05:01