eha-tsh hematology tutorial on lymphoma · 2019-04-12 · lugano classification (derived from...
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EHA-TSH Hematology Tutorial on Lymphoma
Tutored Clinical Case 1
Speaker: Pervin Topcuoglu
[Ankara University]
İzmir, Turkey
April 6-7, 2019
Clinical history
‒ A 39-year-old man has painless progressive swelling on the right neck about one month.
‒ No significant medical history
‒ No B symptoms
‒ His occupation: Mechanic in automobile industry.
Physical Examination
‒ ECOG performance status: 0
‒ Vital sign is normal
‒ Palpable LAP at right anterior cervical (2,5x2 cm)
‒ No other peripheral lymphadenopathy
‒ No hepatosplenomegaly
Initial Examination
‒ WBC: 6.6x109/L (Normal range: 4.5-11x109/L)
‒ Leukocyte differentiation:
• Neutrophil: 3.98x109/L (1.8-7.7x109/L)
• Lymphocyte: 1.76x109/L (1.5-4x109/L)
• Monocyte: 0.64x109/L (0.2-0.95x109/L)
• Eosinophil: 0.21x109/L (0-0.7x109/L)
• Basophil: 0.7x109/L (0.0-0.15x109/L)
Initial Examination
‒ Albumin: 4.55x109/L (3.5-5.2x109/L)
‒ LDH: 205 U/L (<248 U/L)
‒ Alkaline phosphatase: 85 U/L (30-120 U/L)
‒ Renal and liver function tests were normal
‒ Sedimentation Rate: 3 mm/h
‒ Viral serology for hepatitis and HIV negative
Excisional biopsy
Neck Ultrasonography: anterior right cervical LAP (3x2 cm)
FNB: Atypical lymphoid proliferation
Excisional biopsy of cervical LN
Reed-Sternberg Cells
IHC:CD30+, CD15+, EBV-LMP-1+, PAX5 focal +
Reactivelymphoid cells:
CD3+ and CD20+
Luca DC. Weil Cornell Medicine. Pathology&Laboratory Medicine. 2002-2017, PathologyOutlines.com, Inc
MC-
cHL
PET/CT Scan
SUV Max: 20.1
Ann-Arbor Staging with Cotswolds-Modification
Stage I Involvement of a single lymphatic site or
localized involvement of a single extranodal (EN) organ or site (IE)
Stage II Involvement of two or more lymph node regions on the same side of the
diaphragm or
localized involvement of a single EN organ or site in association with regional
lymph node involvement on the same side of the diaphragm (IIE)
Stage III Involvement of two or more lymph node regions or of EN organs on both sides of
the diaphragm
Stage IV Non-localized, diffuse or disseminated involvement of one or more EN organs,
with or without associated lymph node involvement
Addendum A B symptoms are absent.
Addendum B B symptoms are present: fever (temperature >38ºC), drenching night sweats,
and/or unexplained loss of >10% of body weight within the preceding 6 months.
Addendum X Bulky disease present (nodal mass >1/3 of intrathoracic diameter or 10 cm in
dimension)
Lugano Classification (Derived from Ann-Arbor Staging with Cotswolds- Modification)
Stage I Involvement of a single lymph node ((LN) region (eg, cervical, axillary, inguinal,
mediastinal) or lymphoid structure such as the spleen, thymus, or Waldeyer's ring.
Stage II Involvement of two or more LN regions or LN structures on the same side of the
diaphragm. Hilar nodes should be considered to be "lateralized" and when involved on
both sides, constitute stage II disease.
For the purpose of defining the number of anatomic regions, all nodal disease within
the mediastinum is considered to be a single LN region, and hilar involvement
constitutes an additional site of involvement. The number of anatomic regions should
be indicated by a subscript (eg, II-3).
Stage III Involvement of LN regions or lymphoid structures on both sides of the diaphragm. This
may be subdivided stage III-1 or III-2: stage III-1 is used for patients with involvement of
the spleen or splenic hilar, celiac, or portal nodes; and stage III-2 is used for patients
with involvement of the paraaortic, iliac, inguinal, or mesenteric nodes.
Stage IV Diffuse or disseminated involvement of one or more extranodal organs or tissue beyond
that designated E, with or without associated lymph node involvement.
Cheson BD, et al. J Clin Oncol 2014; 32: 3059-3068
Stage II Involvement of two or more lymph node regions on the
same side of the diaphragm or
localized involvement of a single EN organ or site in
association with regional lymph node involvement on the
same side of the diaphragm
Addendum A B symptoms are absent.
Treatment
Early stage HL-favorable (No risk factor)
‒ 2xABVD
‒ Interim PET/CT
‒ Complete Metabolic Response
‒ 20 Gy ISRT
‒ Today, he is complete remission in 18th months.
Discussion‒ Early stage is clinical stage I or II.
‒ Subsequent stratification is favorable and unfavorable
prognosis.
Bröckelmann PJ, et al. Blood 2018; 131(15):1666-1678
Discussion
H10F trial in early-stage favorable HL with 754 patients randomized
RFs: • age ≥50 ys, • large mediastinal
mass, ESR>30mm/h with B-symptoms (BS),
• ESR without BS >50mm/h,
• ≥3 nodal• areas
André MPA, et al. J Clin Oncol 35:1786-1794.
Discussion
‒ iPET (-) patients
André MPA, et al. J Clin Oncol 35:1786-1794.
Favorable Unfavorable
Discussion
‒ iPET (+) patients
André MPA, et al. J Clin Oncol 35:1786-1794.
Discussion
‒ Long-term follow-up data of the four randomized trials (HD7, HD8, HD10 and HD11) largely support the current risk-adapted therapeutic strategies in early-stage HL.
‒ They confirmed excellent efficacy of two cycles of ABVD followed by 20 Gy IFRT in early favorable HL.
Sase S, et al. J Clin Oncol 2017;35:1999-2007.
Discussion
‒ Favorable early stage HL
HD16 trial in early-stage favorable HL with 1150 patients randomized
RFs: age ≥50 ys, large mediastinal mass, ESR>30mm/h with BS, ESR without BS >50mm/h, ≥3 nodalareas
Fuchs M, et al. ASH 2018 Oral presentation
Discussion‒ Favorable early stage HL
HD16 trial in early-stage favorable HL with 1150 patients randomized
Fuchs M, et al. ASH 2018 Oral presentation
PET - patients