CME INDIA Presentation by Dr. Avinash Kumar Singh, DM (Hematology), Consultant haematologist and BMT physician, Paras HMRI hospital and Patna Haematology clinic, Patna, Bihar.
Based on a talk at APICON-2022, Jaipur.
Cancer Prediction is Frightening
What is Lymphoma?
- Lymphoma is a group of hematological malignancy arising from lymphocytes. Broadly they are divided into Non-Hodgkin’s lymphoma and Hodgkin’s lymphoma.
- Depending upon cell of origin lymphoma can be divided in B cell, T cell or NK/T cell lymphoma.
- Depending upon aggressiveness, lymphoma can be divided in to indolent, aggressive and highly aggressive lymphoma.
Know about Primary and Secondary Lymphoid Organs
What are the Risk Factors?
- Male Sex
- Late middle-aged and older persons with a median age at diagnosis of approximately 65 years.
- Body mass index,
- Tobacco and Alcohol use, and inflammatory states.
|Risk factors for lymphoma include:|
|A lowered immune system|
Causes of lymphoma
- In most cases, there is no known cause for lymphoma.
- For or a few types of lymphoma, scientists have identified a cause.
- Most cases of gastric MALT lymphoma are caused by a common bacterial infection called Helicobacter pylori
- Almost all people who get gastric MALT lymphoma have Helicobacter pylori infection.
- Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is caused by having textured breast implants.
- Most people with breast implants do not develop BIA-ALCL – but everyone who develops BIA-ALCL has breast implants.
How Lymphoma develops?
- Origin of Non-Hodgkin B cell lymphomas and mechanisms related to their development During development B cells can acquire translocations, deletions or mutations that make a subtype of lymphoma.
- Pre-germinal centre derived lymphomas are CLL unmutated and mantle cell lymphoma and some follicular lymphomas.
- Germinal centre derived lymphomas are derived by transformation from either variable region gene recombination (BCL-2-IgH) in follicular lymphoma, somatic hypermutation (BCL-6) in diffuse large B cell lymphoma, or class switching in c-myc sporadic Burkitt ́s lymphoma.
- Post-germinal centre B cell lymphomas are marginal zone lymphoma, small lymphocytic lymphoma/chronic lymphocytic leukaemia and plasmacytoma and are derived from memory B cells and plasma cells.
- B-Cell Lymphoma: A hallmark of many types of B-cell lymphoma is reciprocal chromosomal translocations involving one of the immunoglobulin loci and a proto-oncogene. As a consequence of such translocations, the oncogene comes under the control of an active immunoglobulin locus, causing deregulated, constitutive expression of the translocated gene.
- Non-responding fever
- B symptoms
- Persistent painless node enlargement
- Skin rash
- Can involve any organ from head to toe
Difference between NHL and Hodgkins
|COMMON AGE||ADULTS AND ELDERLY||BIMODAL|
|PEL EBSTEIN FEVER||NO||MAY HAVE|
|RELATION WITH ALCOHOL||NO||PAINFUL NODES|
|INCIDENCE||MORE COMMON||RELATIVELY LESS COMMON|
Diagnosis and Classification
- FNAC is not sufficient
- Don’t use steroid in suspected case of lymphoma
- Urgent referral should be done in cases of aggressive or very aggressive lymphoma
- BIOPSY IS MUST to know D/D
- IHC is must: MCL/FL/PTCL/PBL/HL
- Molecular Tests are Must: DHL/THL/TARGETS
Courtesy: Management of Lymphomas: Consensus Document 2018 by an Indian Expert Group Indian J Hematol Blood Transfus (July-Sept 2018) 34(3):398–421 https://doi.org/10.1007/s12288-018-0991-4
- Performance status – ECOG/KARNOFSKI
- Co morbidity
- Emergencies –TLS/SVC/Pericardial tamponade/Luminal obstruction
- Consent before chemotherapy
- Definitive Treatment – as Per Type of Lymphoma – NCCN Guideline
- Chemotherapy –CHOP/MOPP/ABVD etc.
- Chemo Immunotherapy-RCHOP/BR/ABVD etc.
- Cellular Therapy – HSCT/CAR T Cell Therapy
Survival Trend DLBCL
See a Case
- 30 years old male presented with infradiaphragmatic multiple lymphadenopathy with fever and weight loss for 1 month
- Work up confirmed as DLBCLL stage IIi non-bulky R IPI good
- What treatment options?
- Received 4 cycles of RCHOP
- iPET CT –CR
- 2 more R
- Follow Up
- In Remission for Last 4 Years
See Case 2
- 40 yrs. old lady without any co morbidity presented with right cervical persistent painless lad 2X3 CM for 1 month associated with weight loss fever.
- Work up confirmed it as classical Hodgkin’s lymphoma mixed cellularity type stage 1A Favourable
- What Treatment Options?
- Received 2 Cycle ABVD
- IPET –CR
- Received 2 More Cycle Of ABVD
- Follow Up
- In Remission for Last 6 Years
- Case 1 Of DLBCL Relapsed After 4 Years
- What Options???
What is new in lymphoma management?
Engineering Patients’ Immune Cells to Treat Their Cancers
- A type of treatment in which a patient’s T cells (a type of immune system cell) are changed in the laboratory so they will attack cancer cells.
- T cells are taken from a patient’s blood.
- Then the gene for a special receptor that binds to a certain protein on the patient’s cancer cells is added to the T cells in the laboratory.
- The special receptor is called a chimeric antigen receptor (CAR).
- Large numbers of the CAR T cells are grown in the laboratory and given to the patient by infusion. CAR T-cell therapy is used to treat certain blood cancers, and it is being studied in the treatment of other types of cancer.
- Lymphoma is a common hematological malignancy encountered in day-to-day practice.
- Awareness is the key to detect cases on time.
- Signs and symptoms are mostly nonspecific and difficult to differentiate from infections.
- For diagnosis tissue biopsy/IHC is must and molecular tests too are important
- PET CT is important for staging and response assessment.
- With better understanding of tumor biology, newer targets and therapy survival has improved.
- Relapse refractory disease is a challenge and most of the time ASCT is needed to consolidate.
- Management of Lymphomas: Consensus Document 2018 by an Indian Expert Group Indian J Hematol Blood Transfus (July-Sept 2018) 34(3):398–421 https://doi.org/10.1007/s12288-018-0991-4
- Brentjens R, et al. “Driving CAR T cells forward.” Nat Rev Clin Oncol. 2016 13, 370–383.
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