ESMO Afr frica, , 2019 NHL &HIV Case Presentation 16 February - - PowerPoint PPT Presentation

ESMO Afr frica, , 2019 NHL &HIV Case Presentation 16 February ry 2 2019, Cape Town SA

• Dr. A.M. Nyakabau

Consultant Oncologist, Harare Parirenyatwa Hospital College of Health Sciences, Zimbabwe

Demographics

Mr T.M 32 year old banker Married with 2 children (5years; 18 months) Lives in Harare

Presenting History ry

• Diagnosed HIV positive June 2013 (discordant couple)
• July 2013 started on ART (Tenolam-E) & Cotrimoxzole prophylaxis
• Six months later: Developed painless right groin mass
• Physician initially attributed the mass to IRIS
• No history of B symptoms

Presenting History ry

• By July 2014 mass enlarged significantly
• Referred to surgeons, biopsy August 2014
• Oct 2014, oncologist referral then haematologist
• Further inv & treatment by haematologist

Past medical & & Family history ry

• No history cancer or other chronic illnesses
• Never previous treatment with chemo/RT
• No Family history of cancer
• Does not drink or smoke, banker, married 2 daughters

Examination fi findings at presentation

• Stable, apyrexial, ECOG Performance Status 0
• Approx7cm enlarged firm right groin lymph node mass
• No lymphadenopathy elsewhere
• CVS/RS & other systems: normal

In Investigations (S (Sept 2014)

• Full blood count
• Wcc 7,2 Hb 15,2 Plt 379
• U&E
• Na 135 K 4.8 U 6 Cr 90
• LFT
• Serum Bil 3.2 AST 23 ALT 30 ALP 129 Albumin 46
• Hep B & C negative

In Investigations (S (Sept 2014)

• Serum LDH: 699 U/L (normal 60- 350)
• Uric Acid: 369 U/l (normal 230-350)
• Viral load 40 copies/ml
• CD4 count: 552cells/uL
• ECHO: Normal heart structure & function, EF 75%

Histopathology

• Large cell diffuse Non-Hodgkin's lymphoma with
• Large atypical lymphoid cells with rounded nuclei
• Frequent mitosis
• Prominent apoptosis
• Partial necrosis
• Immunohistochemistry: CD20 positive
• Bone marrow- no evidence of malignancy

Staging CT Scan chest, abdomen + pelvis

• Large lobulated mass in the inguino-femoral region
• Approx. 7cm x 7cm
• Infiltrating the right pectineus and sartorius muscles
• Enlarged left internal iliac lymph nodes
• Urinary bladder, ureters & kidneys normal
• Normal liver, chest & bones

In International Prognostic In Index

SCORE Age <60 years LDH level elevated 1 ECOG Score Disease stage <3 Extranodal disease sites <2

TOTAL 1 (LOW RISK)

Diagnosis

1. Diffuse Large Cell Non-Hodgkin's Lymphoma

• STAGE I/II (Ann Arbor)
• IPI low risk

2. HIV positive and no features of AIDS

Treatment options considered

1. Immunochemotherapy Plus IFRT

• Rituximab plus CHOP (3 cycles) then Involved Field External

Beam Radiotherapy (IFRT)

2. Immunochemotherapy alone

• Rituximab plus CHOP (6 cycles)

3. Chemotherapy alone

• CHOP

Treatment given to Mr TM

• R-CHOP three weekly up to 6 cycles
• Rituximab 375mg/m2
• Cyclophosphamide 750mg/m2
• Doxorubicin 50mg/m2
• Prednisolone 100mg PO Od x 5 days

Treatment Details

• From November 2014- February 2015
• Tolerated therapy well; had alopecia at the 5th cycle
• No treatment delays
• Declined referral back to oncology for RT

Progress to date

• In remission for 3 years post-treatment
• Being followed up by a primary care physician
• HIV infection well controlled
• CD4 count – 630cell/uL; VL undetectable
• 2nd child 18/12months,Wife & two daughters HIV negative

Discussion Points

Mr T.M. was treated privately on Health Insurance Public pts cannot afford Immunochemotherapy Antenatal HIV diagnosis by gynecologist-good clinical practice Presentation post- HIV treatment –IRIS Optimum waiting period post-chemo to father children?

Discussion

• CT scan enlarged internal iliac nodes ? Tumour/

Inflammation ? PET/CT scan value

• What is the role of RT role after Immunochemotherapy ?
• How well tolerated is R-CHOP in HIV positive patients
• What is the recommended follow up protocol?

Zimbabwe Cancer Facts Total :7 165 (2015)

New Cases Cancer Deaths

Chokunonga E, et al, Zimbabwe Cancer Registry 2015 Annual Report

Acknowledgements

• Patient & family
• Parirenyatwa hospital Colleagues & staff

Thank You