lymphoma- all you need to know in one hour
DESCRIPTION
Lymphoma- All you Need to know in ONE hour. Cathleen Cook Pediatric Hematology/ Oncology March 12, 2014. Ranking of pediatric m alignancies for children aged 0-14 years. Leukemia. Brain tumors. Lymphoma. http://www.meb.uni-bonn.de/cancer.gov/CDR0000062872.html. - PowerPoint PPT PresentationTRANSCRIPT
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Lymphoma-All you Need to know
in ONE hour
Cathleen CookPediatric Hematology/ OncologyMarch 12, 2014
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Ranking of pediatric malignancies for children aged 0-14 years
http://www.meb.uni-bonn.de/cancer.gov/CDR0000062872.html
Leukemia
Brain tumors
Lymphoma
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Ranking of pediatric malignancies for children aged 15-19 years
http://www.meb.uni-bonn.de/cancer.gov/CDR0000062872.html
Carcinomas and Melanoma
Brain tumors
Lymphoma
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Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Late Effects
Juan PabloNicole
Objectives
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Epidemiology of Hodgkin Lymphoma
O 5% of cancers ≤14 years of ageO 15% of cancers ≥14 years of age
O Bimodal age distribution
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Associations with Hodgkin Lymphoma
EBVCMV
HHV6
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What is Hodgkin Lymphoma?
O Cancer of the lymphoreticular system
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Hodgkin Lymphoma Explained
http://www.youtube.com/watch?v=saYsSIsBObw&list=PLlacjr_GktwC9JDvcxvgGKQ4jMq2JAE0L
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Reed-Sternberg (RS) Cells = Hallmark of classical Hodgkin Lymphoma
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Other Subtypes of Hodgkin Lymphoma
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To where can Hodgkin Lymphoma metastasize?
SpleenLiver
Bone MarrowBone
Brain
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Symptoms of Hodgkin Lymphoma
O Painless, nontender, firm, rubbery lymph node
O CoughO Weight lossO FeverO Night sweatsO Pruritus (itching)O Anorexia (appetite loss)O Tiredness/ LethargyO Pain WORSENING with Alcohol
B symptoms
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1:30 sec. --- 5:00
Nicole’s Symptoms
http://www.youtube.com/watch?v=vsSrdEYjcpc
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So how do we diagnose Nicole?
Physical Exam
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So how do we diagnose Nicole?
Sites of Disease
Source: Metzger M. Hodgkin Lymphoma Lecture. 2009
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So how do we diagnose Nicole?
LabsCBC with differential
CMP
LDH
Uric Acid
ESR
CRP
Ferritin
EBV titers
CMV titers
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Diagnostic Work Up: Chest X-ray
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Diagnostic Work Up: CT CAP
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Diagnostic Work Up: PET Scan
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Diagnostic Work Up: Bilateral Bone Marrow Biopsy/Aspirate
http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Hodgkin-Lymphoma.aspx#Cancer_Summary
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Diagnostic Work Up: Excisional Lymph Node Biopsy
http://www.flickr.com/photos/santoshpath/5453069538/http://tessascancerjourney2.blogspot.com/2010/11/lymph-node-biopsy.html
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Summary of Nicole’s diagnostic work up for Hodgkin Lymphoma?• Physical Exam• CBC• CMP• LDH• Uric Acid• ESR• CRP• Ferritin• EBV titers• CMV titers
• Chest Xray- PA/L• CT scan (CAP)• PET scan• Bone marrow aspirate/biopsy• Excisional LN biopsy
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So how do we stage Hodgkin Lymphoma?
A= no “B symptomsB= fever (>38C), unexplained weight loss (>10%), drenching night sweatsE= extranodal extensionS= splenic involvement Source: Metzger M. Hodgkin Lymphoma Lecture. 2009
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So how do we treat Hodgkin Lymphoma?
CHEMOTHERAPYO Prednisone (P)O Vinblastine (V)O Bleomycin (B)O Doxorubicin (A)O Vincristine (O)O Procarbizine (P)O Etoposide (E)O Cyclophosphamide
(C)
COPPCOPDAC OPPAOEPA
ABVDVAMP
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So how do we treat Hodgkin Lymphoma?
RADIATION
Source: Metzger M. Hodgkin Lymphoma Lecture. 2009
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Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Late Effects
Juan PabloNicole
Objectives
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Epidemiology of Non-Hodgkin Lymphoma (NHL)
O 60% of all lymphomas in children and adolescents
O 8-10% of cancers between 5-19 yo
O >70% have advance disease at diagnosis
Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19 th edition. 2011. pg 8002.
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Associations with Non-Hodgkin Lymphoma
EBVHIV BLOOM SYNDROME
ATAXIA-TELANGIECTASIA
WISKOTT-ALDRICH SYNDROMESCIDDe
NOVO
Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19 th edition. 2011. pg 8002.
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What is Non-Hodgkin Lymphoma?
O Cancer of the lymphocytes
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Non-Hodgkin Lymphoma Explained
https://www.youtube.com/watch?v=x3c9dy3MPZo
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Subtypes of Non-Hodgkin Lymphoma
38% Burkitt lymphoma (BL)
29% Lymphoblastic lymphoma (LL)
20% Diffuse large B-cell lymphoma (DLBCL)
10% Anaplastic large cell lymphoma (ALCL)
0-14 years
Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19 th edition. 2011. pg 8003.
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Subtypes of Non-Hodgkin Lymphoma
37% Diffuse large B-cell lymphoma (DLBCL)
21% Burkitt lymphoma (BL)
19% Lymphoblastic lymphoma (LL)
17% Anaplastic large cell lymphoma (ALCL)
15-19 years
Source: Kliegman R, Staton B, et al. Nelson Textbook of Pediatrics Ebook. 19 th edition. 2011. pg 8003.
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Clinical Presentation of Non-Hodgkin Lymphoma
MASSES
Jaw swelling
Abdominal masses
Orbital swelling
Chest masses
Paraspinal masses
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Clinical Presentation of Non-Hodgkin Lymphoma
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http://www.youtube.com/watch?v=Zx9SjYTr7CU
Juan Pablo’s Symptoms
Initial 1:00min
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Non-Hodgkin Lymphoma- Tumor Lysis Syndrome
Tumor masses (similar to leukocytosis with leukemia)
http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569
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Tumor Lysis Syndrome
http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569
Uric AcidPhosphatePotassium
Calcium SodiumNO CHANG
E
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Tumor Lysis Syndrome
http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569http://www.nytimes.com/health/guides/disease/acute-gouty-arthritis/print.html
Uric AcidPhosphatePotassium RISK OF
Acute Kidney Injury-stones
-renal failure
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Tumor Lysis Syndrome
http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569http://www.pinterest.com/pin/90986854945562677/http://www.aaemrsa.org/communication/modernresident/2012/images/hands-lg.jpg
Calcium RISK OF
Chvostek sign Trousseau's sign
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Emergency Presentations of Non-Hodgkin Lymphoma
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So how do we diagnose Juan Pablo?
Physical Exam
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So how do we diagnose Juan Pablo?
LabsCBC with differential
CMP
LDH
Uric Acid
ESR
CRP
Ferritin
EBV titers
CMV titers
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Diagnostic Work Up: Chest X-ray
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Diagnostic Work Up: CT CAP
http://tmcr.usuhs.edu/tmcr/chapter8/differential3.htmhttp://www.radiologyschools.com/Radiology-Courses/gu/kidneys/lymphoma.html
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Diagnostic Work Up: PET Scan
http://www.hindawi.com/journals/crim/2012/239719/fig2/https://www.mi-lifenet.com/ImagingCenter/zportal/portals/phys/clinical/petct_case_studies/lymphoma/lymphoma_case3
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Diagnostic Work Up: Bilateral Bone Marrow Biopsy/Aspirate
http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Hodgkin-Lymphoma.aspx#Cancer_Summary
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Diagnostic Work Up: Least Invasive Biopsy
http://www.umphysicians.org/cancercare/cancer-information/cancer-library/CDR269299.html#_1
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Diagnostic Work Up: Lumbar Puncture
http://www.webmd.com/cancer/tc/brain-cancer-primary-central-nervous-system-lymphoma-treatment-patient-information-nci-pdq-general
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Summary of diagnostic work up for Non-Hodgkin Lymphoma?• Physical Exam• CBC• CMP• LDH• Uric Acid• ESR• CRP• Ferritin• EBV titers• CMV titers
• Chest Xray- PA/L• CT scan (CAP)• PET scan• Lumbar puncture• Bone marrow aspirate/biopsy• Least invasive Biopsy
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So how do we treat Non-Hodgkin Lymphoma?
CHEMOTHERAPYWITH INTRA-THECAL
CHEMOTHERAPY
O Cyclophosphamide (C)O Vincristine (O)O Prednisone (P)O Doxorubicin (A)
COPAD O Methotrexate (M)O Hydrocortisone (H)
O Cytarabine (A)
+Radiation
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Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Prognosis andLate Effects
Juan PabloNicole
Objectives
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What are prognoses for Lymphoma?
Hodgkin Lymphoma
> 85% - 93+ %
NON-HODGKIN LYMPHOMA
90-95% localized60-90% advanced
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What are Late Effects for Lymphoma?
Based on…
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Late Effects of Chemotherapy- Steroids
Reduced bone mineral density (BMD)
Avascular necrosis (AVN)
Growth asymmetry/Decreased bone growth
Cataracts
Dental caries
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Late Effects of Chemotherapy-
Vincristine/Vinblastine
Peripheral sensory or motor neuropathy Areflexia Weakness Foot drop Paresthesia
Dental caries
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Late Effects of Chemotherapy-
Bleomycin
Interstitial pneumonitisPulmonary fibrosis
Dental caries
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Late Effects of Chemotherapy-
Doxorubicin
CardiomyopathyArrhythmiasSubclinical left ventricular dysfunction (by ECHO or MUGA)
DOSE correlates with cardiotoxicity
Secondary leukemia (AML/MDS)
Dental caries
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Late Effects of Chemotherapy-
Etoposide
Secondary leukemia (AML/MDS)
Dental caries
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Late Effects of Chemotherapy-
Cyclophosphamide
Hemorrhagic cystitisBladder fibrosis
Male GU dysfunction/infertility
Female GU dysfunction/infertility
Cardiomyopathy
Secondary leukemia (AML/MDS)Secondary malignancy (solid tumor)
Dental caries
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Late Effects of Radiation to NECK
Hypothyroidism
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Late Effects of Radiation to CHEST
Restrictive Lung Disease
Late onset breast cancer
Cardiac dysfunctionPericarditisPericardial fibrosis
Growth asymmetry
Secondary malignancy (solid tumor)
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O Painless, nontender, firm, rubbery lymph nodeO CoughO Weight lossO FeverO Night sweatsO Pruritus (itching)O Anorexia (appetite loss)O Tiredness/ Lethargy
B symptoms
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• Physical Exam• CBC• CMP• LDH• Uric Acid• ESR• CRP• Ferritin• EBV titers• CMV titers• Bartonella titers (if + cat exposure)
• Chest Xray- PA/L• CT scan (CAP)• Lumbar puncture (if NHL)• Bone marrow aspirate/biopsy• PET scan• Least invasive Biopsy
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http://www.nejm.org.ezproxy.etsu.edu:2048/doi/pdf/10.1056/NEJMra0904569
Uric AcidPhosphatePotassium
Calcium SodiumNO CHANG
E
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Any Questions?