Radiation Oncology/NHL/Overview
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Non-Hodgkin lymphoma: Main Page | Randomized
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Classification
edit- Historically several systems, both in USA and Europe
- WHO classification is used today
WHO classification
edit- B-cell neoplasms
- Precursor B-cell neoplasms
- Precursor B-lymphoblastic leukemia/lymphoma (precursor B-cell acute lymphoblastic leukemia)
- Mature (peripheral) B-cell neoplasms
- B-cell chronic lymphocytic leukemia / small lymphocytic lymphoma
- B-cell prolymphocytic leukemia
- Lymphoplasmacytic lymphoma
- Splenic marginal zone B-cell lymphoma
- Hairy cell leukemia
- Plasma cell myeloma/plasmacytoma
- Extranodal marginal zone B-cell lymphoma of MALT type
- Nodal marginal zone B-cell lymphoma
- Follicular lymphoma
- Mantle cell lymphoma
- Diffuse large B-cell lymphoma
- Burkitt lymphoma / Burkitt cell leukemia
- Precursor B-cell neoplasms
- T-cell and NK-cell neoplasms
- Precursor T-cell neoplasm
- Precursor T-lymphoblastic lymphoma/leukemia (precursor T-cell acute lymphoblastic leukemia)
- Mature (peripheral) T/NK-cell neoplasms
- T-cell prolymphocytic leukemia
- T-cell granular lymphocytic leukemia
- Aggressive NK-cell leukemia
- Adult T-cell lymphoma/leukemia (HTLV1+)
- Extranodal NK/T-cell lymphoma, nasal type
- Enteropathy-type T-cell lymphoma
- Hepatosplenic gamma-delta T-cell lymphoma
- Subcutaneous panniculitis-like T-cell lymphoma
- Mycosis fungoides / Sezary syndrome
- Anaplastic large cell lymphoma, T/null cell, primary cutaneous type
- Anaplastic large cell lymphoma, T/null cell, primary systemic type
- Peripheral T-cell lymphoma, not otherwise characterized
- Angioimmunoblastic T-cell lymphoma
- Precursor T-cell neoplasm
WHO by aggressiveness
editGrade | Histologies |
---|---|
Indolent | B-cell: Follicular (Grade I/II), SLL/CLL, lymphoplasmatic lymphoma, plasma cell/myeloma, hairy cell leukemia, marginal zone B-cell, mantle cell, T-cell: T-cell large granular lymphocyte leukemia, mycosis fungoides, T-cell prolymphocytic leukemia, NK cell |
Aggressive | B-cell: Follicular (Grade III), DLBCL, mantle cell, T-cell: peripheral T-cell lymphoma, anaplastic large cell lymphoma |
Highly aggressive | B-cell: Burkitt's lymphoma, precursor B lymphoblastic leukemia/lymphoma, T-cell: adult T-cell lymphoma/leukemia, precursor T lymphoblastic leukemia/lymphoma |
Translocations
edit- Lymphoma cells generally do not exhibit significant microsatellite instability (unlike many solid tumors)
- Chromosomal translocations are a hallmark of lymphomatous disorders
- t(8;14) - Burkitt's lymphoma (c-myc)
- t(11;14) - mantle cell lymphoma (bcl-1)
- t(11;18) - MALT lymphoma
- t(14;18) - follicular lymphoma (bcl-2)
mnemonic: The common ones (on exams anyway) have 14 in common. The 11 sits on top of 14 (they're in sequence) like something sitting on a mantle. The 8 in Burkitt's resembles the bilaterally swollen neck lymph nodes like you typically see in a picture of a child with Burkitt's. The 8 (18) of follicular resembles two little follicles stuck together to form the 8. The oddball one is MALT which doesn't have the 14.
Epidemiology
edit- USA - 59,000 cases/yr (in 2006)
- ILSG, 1997 PMID 9166827 -- "A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project." ([No authors listed], Blood. 1997 Jun 1;89(11):3909-18.)
- Multinational. 1403 cases at 9 sites around the world classified by 5 pathologists
Adult Type | Proportion |
---|---|
Diffuse large B-cell | 31% |
Follicular | 22% |
Marginal zone B-cell (MALT) | 8% |
Peripheral T-cell | 7% |
CLL | 7% |
Mantle cell | 6% |
Mediastinal large B-cell | 2% |
Anaplastic large T-cell | 2% |
Burkitt-like B-cell | 2% |
Marginal zone B-cell (nodal) | 2% |
Precursor T-lymphoblastic | 2% |
Lymphoplasmacytoid | 1% |
Marginal zone B-cell (splenic) | <1% |
Mycosis fungoides | <1% |
Burkitt's | <1% |
All others | <1% |
- Pediatric (based on Cancer, DeVita, 7th edition, 2005)
Pediatric Type | Proportion |
---|---|
Burkitt's lymphoma | 40-50% |
Precursor T-lymphoblastic | 25% |
Diffuse large B-cell | 15% |
Anaplastic large cell | 10% |
Precursor B-lymphoblastic | 5% |
Staging
edit- Uses the Ann Arbor classification, which was developed for Hodgkin's lymphoma.
- Since disease spread in non-Hodgkin's lymphoma differs from that in Hodgkin's lymphoma, in which spread occurs to adjacent nodal groups in a stepwise fashion, the Ann Arbor classification which relies on nodal staging is not as predictive for NHL.
International Prognostic Index
editRisk factors:
- LDH greater than normal
- Age > 60
- Performance status ECOG 2 or worse
- Extranodal sites of disease (more than 1)
- Stage III or IV
- Mnemonic: LAKES (LDH,age,Karnofsky,Extranodal,Stage)
Risk groups:
- Low - 0 or 1 risk factors
- Low intermediate - 2
- High intermediate - 3
- High - 4 or 5
Prognosis:
- Low risk: 87% CR and 73% OS at 5 years
- High risk: 44% CR and 26% OS
Based on pts with aggressive lymphomas treated with doxorubicin-based combination chemotherapy. It is also useful in indolent lymphomas and T-cell lymphomas. These factors independently predict complete response to therapy, relapse-free survival, and overall survival.
- From PMID 8141877 Full text — "A predictive model for aggressive non-Hodgkin's lymphoma. The International Non-Hodgkin's Lymphoma Prognostic Factors Project." N Engl J Med. 1993 Sep 30;329(14):987-94.
Modifications
editAge-Adjusted International Prognostic Index: Developed for pts younger than 60. Uses tumor stage, performance status, and LDH (but not extranodal sites or age). Assigned score of 0 to 3 based on number of risk factors and assigned same labels (low, low int, high int, or high).
Reference: PMID 8141877 Full text - "A predictive model for aggressive non-Hodgkin's lymphoma. The International Non-Hodgkin's Lymphoma Prognostic Factors Project." N Engl J Med. 1993 Sep 30;329(14):987-94.
- 1982-1987. 3273 pts. Allowed diffuse mixed, diffuse large-cell, or large-cell immunoblastic histologies from the Working Formulation (overlaps with intermediate and high grade but doesn't include all subtypes). Also allowed Kiel and Rappaport. Pts were treated on Phase II-III study. All received combination chemo consisting of doxorubicin. Evaluated potential prognostic factors: sex, age, tumor stage, performance status, B symptoms, sites of involvement, number of extranodal sites, size of tumor, LDH, albumin, and beta-2-microglobulin. Complete information obtained in 1872 pts.
Miller's Stage-Modified IPI:
- (LDH, Age > 60, Performance Status, Stage II). Doesn't include extranodal.
- Used for Stage I-II pts.
- Low 0-1, Intermediate 2, High 3-4
- 5-yr PFS: Low 77%, Int 60%, High 34%
- 5-yr OS: Low 82%, Int 71%, High 48%
- PMID 9647875 (1998)
NCCN IPI:
- Rituximab era
- PMID 24264230 (2014) -- "An enhanced International Prognostic Index (NCCN-IPI) for patients with diffuse large B-cell lymphoma treated in the rituximab era." (Zhou Z,Blood. 2014 Feb 6;123(6):837-42.)
Survival
editEstimates from AJCC staging manual, 6th edition:
- Follicular lymphoma: 2-year OS 85%, 5-year 70%. FFS (failure free survival) 2-year 65%, 5-year 45%.
- Diffuse large B-cell lymphoma: 2-year OS 60%, 5-year 50%. FFS 2-year 50%, 5-year 45%.
- Mantle cell lymphoma: 2-year OS 60%, 5-year 25%. FFS 2-year 30%, 5-year 10%.
- Small lymphocytic lymphoma: 2-year OS 70%, 5-year 50%. FFS 2-year 50%, 5-year 30%.
Response Assessment
edit- Lugano Classification
- 2014 PMID 25113753 -- "Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification." (Cheson DB, J Clin Oncol. 2014 Sep 20;32(27):3059-68.)
- International Harmonization Project on Lymphoma
- 2007 PMID 17242396 -- "Revised response criteria for malignant lymphoma." (Cheson BD, J Clin Oncol. 2007 Feb 10;25(5):579-86.)
Response | Definition | Nodal Masses | Spleen/Liver | Bone Marrow |
---|---|---|---|---|
CR | Disappearance of all disease | 1) If FDG avid prior, FDG cold but can be any size on CT post
2) If FDG variable/cold prior, FDG cold and normal size on CT post |
1) Not palpable
2) No nodules on CT |
Repeat BMBx negative |
PR | Regression of measurable disease and no new sites | >= 50% in SPD in up to 6 largest masses | >=50% in SPD of nodules | If positive prior, irrelevant |
SD | Not CR/PR or PD | No new sites | N/A | N/A |
PD | 1) Any new lesion
2) Increase >=50% in SPD |
1) New lesion >1.5cm
2) >=50% increase in SPD |
>50% increase in SPD | New/recurrent involvement |
- SPD = sum of the product of the diameters
- 2007 PMID 17242397 -- "Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma." (Juweid ME, J Clin Oncol. 2007 Feb 10;25(5):571-8.)
- PET after Chemotherapy/chemoimmunotherapy: at least 3 weeks, preferably 6-8 weeks
- PET after Radiotherapy/Chemoradiotherapy: 8-12 weeks
- 2007 PMID 17242397 -- "Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma." (Juweid ME, J Clin Oncol. 2007 Feb 10;25(5):571-8.)
External links
edit- Heme-Path at UMDNJ - fairly basic overview of different types of lymphomas. Great histology slides.
Molecular diagnosis
edit- See also: List of chromosomal translocations
- Burkitt lymphoma - t(8;14) / c-myc translocation, Ki-67 > 90%, CD10+ and/or BCL-6+, CD19+ or CD20+
- Usually BCL-2 and t(14;18) negative.
- Follicular lymphoma - t(14;18), most common translocation in lmphoma / bcl-2 translocation. Is CD10+
- Mnemonic: "F is for follicular and fourteen"
- Mantle cell lymphoma - t(11;14), bcl-1, CD15-, cyclin D1
- MALT lymphoma - t(11;18)
- Diffuse large B-cell lymphoma - bcl-6 (is favorable)
- Anaplastic lymphoma - CD30+, Ki-1
Radiation technique
editInvolved field
- CALGB guidelines (done for Hodgkin's disease) - PMID 12078908 Full text (2002) — "The involved field is back: issues in delineating the radiation field in Hodgkin's disease." Yahalom J et al. Ann Oncol. 2002;13 Suppl 1:79-83.
- Boundaries of the involved fields.
Whole-Abdomen
- Washington University, 1994 (1978-1990) PMID 8029434 -- "Non-Hodgkin lymphoma: whole-abdomen irradiation as an adjuvant to chemotherapy." (Valicenti RK, Radiology. 1994 Aug;192(2):571-6.)
- Retrospective. 39 patients with abdominal NHL treated with modified whole-abdomen RT. 34 adjunct to chemo, 5 primary
- Toxicity: treatment terminated in 4 patients, interrupted in 19. Four Grade 3-4 late toxicities
- Conclusion: Whole-abdomen RT is safe adjunct in high risk for intraabdominal failure
Reviews
edit- 1985: PMID 2579725 Full text -- "The role of radiation therapy in the management of the non-Hodgkin's lymphomas." (Hoppe RT, Cancer. 1985 May 1;55(9 Suppl):2176-83.)