![Page 1: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/1.jpg)
LYMPHOMA FOR THE GENERALISTLee Berkowitz, MD
![Page 2: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/2.jpg)
GOALS AND OBJECTIVES
1. Understand the importance of pathology and staging in the approach to management of patients with lymphoma.
2. Recognize that a lymph node biopsy is the correct procedure to diagnose lymphoma.
3. Appreciate that the approach to the management of patients with lymphoma is varied and idividualized.
![Page 3: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/3.jpg)
NON-HODGKINS
![Page 4: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/4.jpg)
EPIDEMIOLOGY
5th most common cancer in adults Incidence is increasing 2-3% per year
![Page 5: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/5.jpg)
PATHOGENESIS
1. Immune suppression/dysregulation – HIV, organ transplant, RA, SCID
2. H. pylori – MALT 3. EBV – Burkitts, ? Hodgkins 4. HHV 8 – Castlemans 5. HTLV 1 – T cell leukemia, lymphoma 6. t(14;18) – follicular 7. t(11;14) – Mantle cell 8. t(8;14) - Burkitts
![Page 6: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/6.jpg)
Pathology Staging
![Page 7: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/7.jpg)
NON-HODGKINS The indolent lymphomas B-cell neoplasms Small
lymphocytic lymphoma/B-cell chronic lymphocytic leukemia Lymphoplasmacytic lymphoma (± Waldenstrom's macroglobulinemia) Plasma cell myeloma/plasmacytoma Hairy cell leukemia Follicular lymphoma (grade I and II) Marginal zone B-cell lymphoma Mantle cell lymphoma T-cell neoplasms T-cell large granular lymphocyte leukemia Mycosis fungoides T-cell prolymphocytic leukemia Natural killer cell neoplasms Natural killer cell large granular lymphocyte leukemia
The aggressive lymphomas B-cell neoplasms Follicular lymphoma (grade III) Diffuse large B-cell lymphoma Mantle cell lymphoma T-cell neoplasms Peripheral T-cell lymphoma Anaplastic large cell lymphoma, T/null cell
The highly aggressive lymphomas B-cell neoplasms Burkitt's lymphoma Precursor B lymphoblastic leukemia/lymphoma T-cell neoplasms Adult T-cell lymphoma/leukemia Precursor T lymphoblastic
![Page 8: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/8.jpg)
PATHOLOGY
Key aspects – follicular vs diffuse size of the cells in their normal environment
![Page 9: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/9.jpg)
FOLLICULAR PATTERN
![Page 10: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/10.jpg)
DIFFUSE PATTERN
![Page 11: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/11.jpg)
PATHOLOGY
Nodal architecture The ONLY way to get this information
is to biopsy or excise a node. A fine needle aspiration will not be adequate.
![Page 12: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/12.jpg)
PATHOLOGY
Indolent Aggressive follicular grades I,II follicular grade III marginal zone diffuse large cell MALT mantle cell Burkitts
![Page 13: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/13.jpg)
NATURAL HISTORY OF LYMPHOMAS
Indolent(Follicular) – mean survival of 8 years Aggressive(Diffuse)– mean survival of 12
months Highly aggressive – mean survival of 8- 10
weeks
![Page 14: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/14.jpg)
STAGING
I. 1 nodal group II. 2 nodal groups on the same side of the
diaphragm III. Disease above and below the diaphragm IV. Disease in other organs
![Page 15: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/15.jpg)
STAGING
Physical examination CT scans Bone marrow biopsies
![Page 16: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/16.jpg)
STAGING NON-HODGKINS
Low –Grade I-II III- IV
![Page 17: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/17.jpg)
STAGING NON-HODGKINS
Low-Grade I-II 5% III-IV 95%
![Page 18: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/18.jpg)
STAGINGNON-HODGKINS
Intermediate Grade I-II 30% III-IV 70%
![Page 19: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/19.jpg)
INTERNATIONAL PROGNOSTIC INDEX(IPI) DIFFUSE LYMPHOMAS
Age>60 LDH> normal Performance status Stage III or IV Two or more extra nodal sites
![Page 20: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/20.jpg)
IPI
Risk Risk sum 5 yr survival % Low 0-1 73 Low –Interm 2 51 High –Interm 3 43 High 4-5 26
![Page 21: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/21.jpg)
FOLLICULAR LYMPHOMA IPI Age>60 Stage III/IV LDH>normal Anemia 5 or more nodal sites
![Page 22: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/22.jpg)
FLIPI
Risk Risk score 10 yr survival Low 0-1 70% Interm 2 50% High 3 36%
![Page 23: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/23.jpg)
TREATMENT LOW-GRADE
1. These cells over express bcl 2 2. The median survival for these patients
untreated is 8 years
![Page 24: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/24.jpg)
TREATMENTNON-HODGKINS LOW-GRADE
1. Observation 2. Standard chemo 3. Monoclonal antibodies – rituximab 4. Stem-cell transplants
![Page 25: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/25.jpg)
TREATMENTNON-HODGKINS
Intermediate and High-grade – Cure with chemotherapy
![Page 26: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/26.jpg)
HODGKINS
![Page 27: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/27.jpg)
EPIDEMIOLOGY
8000 new patients per year Bimodal distribution – one peak at 30 years one peak at 50 years
![Page 28: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/28.jpg)
PATHOGENESIS - HODGKINS
1. EBV 2 NF- kB ( nuclear factor kappa B)
![Page 29: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/29.jpg)
HODGKINS
1. Lymphocyte Predominant2. Nodular Sclerosing3. Mixed Cellularity4. Lymphocyte Depleted
![Page 30: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/30.jpg)
STAGINGHODGKINS
I. 15% II. 35% III.35% IV.15%
![Page 31: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/31.jpg)
TREATMENTHODGKINS
Stage I – Cure with radiation therapy Stage II, III, IV – Cure with chemotherapy
![Page 32: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/32.jpg)
WHEN TO SUSPECT LYMPHOMA
1. Patients with impaired immune systems HIV, Transplant, Autoimmune diseases 2. Patients with unexplained fever, night
sweats, weight loss 3. Patients with lymphadenopathy
![Page 33: L YMPHOMA FOR THE G ENERALIST Lee Berkowitz, MD. G OALS AND O BJECTIVES 1. Understand the importance of pathology and staging in the approach to management](https://reader036.vdocument.in/reader036/viewer/2022062518/56649e995503460f94b9c3dc/html5/thumbnails/33.jpg)
LYMPHADENOPATHY
Medicine 79:338 – 47, 2000 Biopsy or not
Neg Positive Tenderness Generalized Pruritus Size < 1cm Supraclavicular Hard Size > 2 cm