Non Hodgkin Lymphoma in Clinically Difficult Situations James - - PDF document

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non hodgkin lymphoma in clinically difficult situations
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Non Hodgkin Lymphoma in Clinically Difficult Situations James - - PDF document

Jun 16, 2023 211 likes •396 views

Winship Cancer Institute of Emory University Non Hodgkin Lymphoma in Clinically Difficult Situations James Armitage, MD Professor, Department of Internal Medicine Joe Shapiro Distinguished Chair of Oncology University of Nebraska Medical Center

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Winship Cancer Institute of Emory University

Non‐Hodgkin Lymphoma in Clinically Difficult Situations

James Armitage, MD Professor, Department of Internal Medicine Joe Shapiro Distinguished Chair of Oncology University of Nebraska Medical Center

Disclosures

  • Consulting fees from:

– GlaxoSmithKline, Genentech, Roche, Seattle Genetics, Spectrum, Ziopharm – Board of Director’s for: Tesaro Bio., Inc.

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Lymphoma In Pregnancy

Diagnosis – Still requires an adequate biopsy Staging – Avoid CT and PET/CT Therapy – Different issues in 1st vs. 2nd and 3rd trimesters

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Lancet 2012; 379: 580

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5 Joe Connors 6

Maternal And Fetal Complications Based On Lymphoma Type And Therapy (n = 72)

JCO 2013; 31:4132

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Survival - DLBCL

Evens A M et al. JCO 2013;31:4132-4139

Survival - HL

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Evens A M et al. JCO 2013;31:4132-4139

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  • Q1. The safest treatment for a four month

pregnant 23 year old with stage IIA classical Hodgkin’s disease would be?

  • A. ABVD
  • B. Stanford V
  • C. Radiotherapy
  • D. BEACOPP
  • E. ChlVPP

A. ABVD B. Stanford V C. Radiotherapy D. BEACOPP E. ChlVPP

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Relative Risk of Lymphoma Treatments During Pregnancy (based on limited data)

Highest Lowest

  • XRT, methotrexate,

procarbazine

  • Alkylating agents,

antimetabolites

  • ABVD, CHOP, rituximab (?)
  • Q2. A 58-year-old man with recently diagnosed

diffuse large B-cell lymphoma was referred. He complains of drenching night sweats and also has a history of coronary artery disease and congestive heart failure with a recent ejection fraction of 35%. Staging evaluation showed an elevated LDH and disease above and below the diaphragm but no extra nodal disease.

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1. CVP-R 2. CHOP-R 3. COPP-R 4. CVP plus etoposide plus R

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Based on recent data, the best approach would be?

Regimens For Patients With Congestive Heart Failure

Delete doxorubicin and add: mitoxantrone liposomal doxorubicin etoposide procarbazine

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CHOP-R vs CEOP-R In Patients With DLBCL (Vancouver)

  • Patients with a contra-indication to anthracycline (88%

cardiac, 9% previous anthracycline) received etoposide 50 mg/m2 D1 and 100 mg/m2 D2,3

  • CHOP-R

CEOP-R Patients 162 (matched controls) 81 5 Year TTP 62% 57% (p=NS) 5 Year OS 64% 49% (p=.02)

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ASH Abstract #408, Blood 2009;114:170

1. CVP-R 2. CHOP-R 3. COPP-R 4. CVP plus etoposide plus R

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ALCL And Breast Implants

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Primary Breast Anaplastic Large Cell Lymphoma In Women With Breast Implants

  • 1st report in 1997, although cases as early as

1994 have been found

  • Mostly silicone filled/coated
  • Incidence is low (i.e. 11 cases in Holland in 17

years)

  • However, when a breast lymphoma develops in

a patient with an implant, the odds ratio for ALCL was 181

JAMA 2008;300:2030

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Clinical Characteristics (15 patients)

  • Age 13-68 years (median 41)
  • Unilateral 81%
  • Usual presentation is pain and swelling

Sites of involvement: Local - 58% Regional nodes - 16% Distant mets - 26%

  • >90% ALK negative

JAMA 2008;300:2030

Treatment For ALCL Associated With A Breast Implant

  • Remove prosthesis and fibrous

capsule

  • Surgery alone vs radiotherapy vs

chemotherapy +/- radiotherapy

  • Reported 5 year OS 80-90%

Oncologist 2013;18:301

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Follicular Lymphoma “In Situ”

  • Partial colonization of follicles by

neoplastic cells in a patient with no

  • vert follicular or other lymphoma
  • The same concept has been applied

to mantle cell lymphoma

Follicular Lymphoma “In Situ”

  • A distinction has been made

between this and “partial involvement” by follicular lymphoma

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FLIS PFL Architecture intact Altered architecture Follicle size normal Follicle size often expanded Involved follicles widely scattered Involved follicles grouped together in LN Intact cuff with sharp edge to GC Blurred edge to GC and attenuated cuff Very strong expression of BCL2 and CD10 BCL2 and CD10 more variable in intensity Almost pure centrocytes Centrocytes with few centroblasts Atypical cells confined to GC Atypical cells (CD10+/BCL2+ B cells) may be found outside the GC

Jegalian, Blood 2011;118:2976

Diagnostic features of FLIS and PFL

Clinical Results In 21 Cases (NCI)

  • Age 23-76 years (median 52)
  • Female – 67%
  • Developed follicular lymphoma – 5%

Blood 2011;118:2976

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Management Approach For In Situ Follicular Lymphoma

  • Stage as for overt FL with

appropriate biopsies

  • Watch and wait, even with positive

flow on peripheral blood

  • Careful follow-up

Carbone, Blood 2011;117:39545

Mediastinal Gray (or Grey) Zone Lymphoma

  • Not composite mediastinal DLBCL and HL
  • CD 20 (usually), CD 30 and CD 15 positive
  • CD10 and ALK negative
  • Male predominance
  • Usually age 20-40 yrs

Joe Connors

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Mediastinal Gray Zone Lymphoma

PMBCL MGZL NSHL Median age 32 34 32 Female 55-70% <50% ~50% Local/regional 70% 90% 50% LDH ~70% ~70% ~20% Extra nodal disease ~60% ~35% ~30% Pleural effusion ~50% ~20% ~10%

Joe Connors

Comparative Outcomes of Primary Mediastinal B-Cell and Mediastinal Grey Zone Lymphomas Treated with Dose-adjusted EPOCH-R

OS PFS

Dunlevy, Blood 2009;114 (Abstract #106)

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Conclusions – Mediastinal Gray Zone Lymphoma

  • It appears to be a distinct entity
  • More often localized than PMBCL
  • Most patients will require

radiotherapy for cure

  • A 52 year old man is sent to you

because of a scalp nodule that was found to be a cutaneous diffuse large B- cell lymphoma on excisional biopsy. The patient was asymptomatic with a normal physical examination. CBC, serum LDH, CT scan of the chest, abdomen and pelvis, and PET scan were all normal after the surgery.

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  • Q3. Which would be the best treatment for the

completely resected cutaneous diffuse large B-cell lymphoma presenting in the scalp? A. CHOP plus rituximab for 6 cycles B. CHOP plus rituximab for 3 cycles followed by involved field radiotherapy C. 4 weekly doses of rituximab followed by 2 years of maintenance therapy D. Involved field radiotherapy

Cutaneous B-cell Lymphomas

  • MALT
  • Primary follicle center (indolent

DLBCL)

  • Large B-cell lymphoma leg type

(aggressive)

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A. CHOP plus rituximab for 6 cycles B. CHOP plus rituximab for 3 cycles followed by involved field radiotherapy C. 4 weekly doses of rituximab followed by 2 years of maintenance therapy D. Involved field radiotherapy