Lymphoma tx

Lymphoma tx

Management varies with type of lymphoma and pt factors (co-morbidities, age, performance status, pt preferences)

Goal of tx can be curative, to prolong life, or palliative

Multidisciplinary team (haematologists, medical oncologists, radiation oncologists, anatomical pathologists, surgeons, allied health profs, plus ongoing GP care)

Therapeutic Modalities

Chemotherapy – systemic control Radiation therapy – local control Immunotherapy - targeted

monoclonals (like that CD20 guy) Allogeneic haematopoeitic stem cell

transplantation Autologous haematopoietic stem cell

transplantation

Non-Hodgkin’s Tx

Tx depends on stage (Ann Arbor) Indolent low-grade, aggressive Intermediate-grade, aggressive High-grade Special forms

Indolent Usually disseminated by time of diagnosis and

therefore not curable Not bulky, not symptomatic no initial tx

necessary Some tx options available, no consensus Rituximab (the anti-CD20 guy) can be used (low

toxicity, avoid chemotherapy) Or, common chemotherapy regimens (R-CHOP,

R-CVP) Low grade – aggressive allogeneic

haematopoeitic stem cell transplantation

Intermediate grade, aggressive (diffuse large B-cell lymphoma) Tx with curative intent Short course chemo (x3) R-CHOP + localised

radiation or, 6-8 cycles R-CHOP w/o radiation

(especially more advanced) Very high risk lymphoma autologous

haematopoeitic stem cell transplantation High grade (Burkitt’s, lymphoblastic)

Intense, cyclic chemo + intrathecal chemo as CNS prophylaxis

Special cases

MALT lymphoma of stomach – kill pylori with combo antibiotics; or, whole stomach radiation

Mantle cell – doesn’t respond to standard chemo; intensive chemo + autologous haematopoeitic stem cell transplantation

Primary CNS lymphoma – repeated cycles of high-dose methotrexate w/ rituximab

R-CHOP

R – Rituximab (Mabthera) that monoclonal that binds to CD20

C - Cyclophosphamide Nitrogen mustard alkylating agent – adds alkyl group to

DNA causing irreversible cross-links H - Hydroxydaunorubicin (Doxorubicin,

Adriamycin) intercalating agent - damages DNA by inserting itself

between DNA bases O - Oncovin (Vincristine)

prevents cell proliferation by binding to tubulin P - Prednisone (or prednisolone)

corticosteroid

Side effects of R-CHOP

Nausea/vomiting (antiemetics), Allopecia Neutropenia Tumour-lysis syndrome

caused by the break-down products of dying cancer cells and include hyperkalaemia, hyperphosphataemia, hyperuricaemia and hyperuricosuria, hypocalcaemia, and consequent acute uric acid nephropathy and acute renal failure

Allopurinol - prophylactic to prevent hyperuricaemia

Prognosis – Non-Hodgkin’s Indolent - med surv 10-15yrs

Intermediate uses IPI (International Prognostic Index) Factors – age >60, high serum LDH, stage III/IV dis, poor

performance status, more than 1 extranodal site 0-1 factor 5y surv 73% 2 factors 5y surv 51% 3 factors 5y surv 43% 4-5 factors 5y surv 26%

Relapse after initial chemo autologous haematopoeitic stem cell transplantation 50% long term lymphoma-free survival

Not pie charts

Hodgkin’s Tx

All should be treated with curative intent

Stage IA w/ high cervical lymph node and low ESR – radiation

Stage I/II – short course chemo ABVD + involved-field radiation

Stage III/IV – full course ABVD Stage II w/ lge mediastinal mass –

full course ABVD + mediastinal radiotherapy

ABVD

A - Adriamycin (the H in R-CHOP)

B - Bleomycin antibiotic that also induces DNA strands to

break

V - Vincristine (the O in R-CHOP)

D - Dacarbazine Alkylating agent – adds alkyl groups to DNA

ABVD side effects

Acute Alopecia, nausea/vomiting (antiemetics

can be given), myelosuppression, allergic reactions to bleomycin (test dose often given first), neuropathy (temp or perm)

Delayed Infertility, pulm tox (again bleomycin),

cardiac tox (adriamycin), secondary malignancies

Prognosis - Hodgkin’s

Influenced by 7 features – stage, age, gender, haemoglobin, albumin, WBC, lymphocyte count

0-2 features 75% cure 3+ features 55% Stage IA/IIA 10y surv >90% Stage III/IV 10y surv 50-60%

Poor outcomes – older folk, bulky disease, lymphocyte depletion, mixed-cellularity on histo

Relapse after intial chemo autologous haematopoeitic stem cell transplatation 35-50% cure

Champions of sports day jumping castle races

Paul Conway

Rob Illingworth