Lymphoma

David Lee MD, FRCPC

Overview
Concepts, classification, biology pidemiology Clinical presentation Diagnosis !taging "hree important types of lymphoma

Concept#ali$ing lymphoma
neoplasms of lymphoid origin, typically ca#sing lymphadenopathy le#%emia vs lymphoma lymphomas as clonal e&pansions of cells at certain developmental stages

'LL

CLL
nave

Lymphomas

MM

*+lymphocytes Plasma cells "+lymphocytes

Lymphoid progenitor

'ML
(ematopoietic stem cell Myeloid progenitor

Myeloproliferative disorders
)e#trophils osinophils *asophils Monocytes Platelets Red cells

*+cell development
stem cell lymphoid progenitor progenitor+*

CLL

mat#re naive *+cell

germinal center *+cell

memory *+cell

MM DLBCL, FL, HL

ALL

pre+* immat#re *+cell

plasma cell

Classification
Biologically rational classification
Diseases that have distinct morphology imm#nophenotype genetic feat#res clinical feat#res

Clinically useful classification

Diseases that have distinct clinical feat#res nat#ral history prognosis treatment

Lymphoma classification
,-../ 0(O1
*+cell neoplasms
2 prec#rsor 2 mat#re
)on+ (odg%in Lymphomas

"+cell 3 )4+cell neoplasms

2 prec#rsor 2 mat#re

(odg%in lymphoma

' practical way to thin% of lymphoma

Category Survival of untreated patients 6ears Curability To treat or not to treat

)on+ (odg%in lymphoma

5ndolent

7enerally not c#rable C#rable in some C#rable in some C#rable in most

Generally defer Rx if asymptomatic "reat

'ggressive

Months

8ery aggressive (odg%in lymphoma 'll types

0ee%s

"reat

8ariable 2 months to years

"reat

Mechanisms of lymphomagenesis
7enetic alterations 5nfection 'ntigen stim#lation 5mm#nos#ppression

pidemiology of lymphomas
9th most fre:#ently diagnosed cancer in both se&es males ; females incidence
2 )(L increasing 2 (odg%in lymphoma stable

5ncidence of lymphomas in comparison with other cancers in Canada

age ad>#sted incidence?/..,...?yr C. B. 9. A. @. -. /. . /<=9 /<<. /<<9 6ear
)(L (odg%in lymphoma l#ng colorectal breast

-...

5ncidence?/..,...?ann#m /.. -. A. B. =. .

'ge distrib#tion of new )(L cases in Canada

'ge ,years1

.+/ /+A 9+< /.+/A /9+/< -.+-A -9+-< @.+@A @9+@< A.+AA A9+A< 9.+9A 99+9< B.+BA B9+B< C.+CA C9+C< =.+=A =9D

incidence?/..,...?ann#m . / @ A 9 B

'ge distrib#tion of new (odg%in lymphoma cases in Canada

'ge ,years1

.+/ /+A 9+< /.+/A /9+/< -.+-A -9+-< @.+@A @9+@< A.+AA A9+A< 9.+9A 99+9< B.+BA B9+B< C.+CA C9+C< =.+=A =9D

Ris% factors for )(L

imm#nos#ppression or imm#nodeficiency connective tiss#e disease family history of lymphoma infectio#s agents ioni$ing radiation

Clinical manifestations
8ariable
severityE asymptomatic to e&tremely ill time co#rseE evol#tion over wee%s, months, or years

!ystemic manifestations
fever, night sweats, weight loss, anore&ia, pr#ritis

Local manifestations
lymphadenopathy, splenomegaly most common any tiss#e potentially can be infiltrated

Other complications of lymphoma

bone marrow fail#re ,infiltration1 C)! infiltration imm#ne hemolysis or thrombocytopenia compression of str#ct#res ,eg spinal cord, #reters1 ple#ral?pericardial eff#sions, ascites

Diagnosis re:#ires an ade:#ate biopsy

Diagnosis sho#ld be biopsy+proven before treatment is initiated )eed eno#gh tiss#e to assess cells and architect#re
2 open b& vs core needle b& vs F)'

!taging of lymphoma
!tage 5 !tage 55 !tage 555 !tage 58

'E absence of * symptoms *E fever, night sweats, weight loss

"hree common lymphomas

Follic#lar lymphoma Diff#se large *+cell lymphoma (odg%in lymphoma

Relative fre:#encies of different lymphomas

)on+(odg%in Lymphomas

Diff#se large *+cell (odg%in lymphoma )(L Follic#lar Other )(L

F=9G of )(L are *+lineage

Follic#lar lymphoma
most common type of HindolentI lymphoma #s#ally widespread at presentation often asymptomatic not c#rable ,some e&ceptions1 associated with *CL+- gene rearrangement Jt,/AK/=1L cell of originE germinal center *+cell

 defer treatment if asymptomatic ,Hwatch+and+waitI1 several chemotherapy options if symptomatic median s#rvivalE years despite HindolentI label, morbidity and mortality can be considerable transformation to aggressive lymphoma can occ#r

Diff#se large *+cell lymphoma

most common type of HaggressiveI lymphoma #s#ally symptomatic e&tranodal involvement is common cell of originE germinal center *+cell treatment sho#ld be offered c#rable in F A.G

(odg%in lymphoma

"homas (odg%in ,/C<=+/=BB1

Classical Hodgkin Lymphoma

(odg%in lymphoma
cell of originE germinal centre *+cell Reed+!ternberg cells ,or R! variants1 in the affected tiss#es most cells in affected lymph node are polyclonal reactive lymphoid cells, not neoplastic cells

Reed+!ternberg cell

R! cell and variants

classic R! cell
,mi&ed cell#larity1

lac#nar cell
,nod#lar sclerosis1

popcorn cell
,lymphocyte predominance1

' possible model of pathogenesis

transforming event,s1 EBV? loss of apoptosis

cytokines germinal centre * cell R! cell

inflammatory response

(odg%in lymphoma (istologic s#btypes

Classical (odg%in lymphoma
2 nod#lar sclerosis ,most common s#btype1 2 mi&ed cell#larity 2 lymphocyte+rich 2 lymphocyte depleted

pidemiology
less fre:#ent than non+(odg%in lymphoma overall M;F pea% incidence in @rd decade

'ssociated ,etiologicalM1 factors

*8 infection smaller family si$e higher socio+economic stat#s ca#casian ; non+ca#casian possible genetic predisposition otherE (58M occ#pationM herbicidesM

Clinical manifestationsE
lymphadenopathy contig#o#s spread e&tranodal sites relatively #ncommon e&cept in advanced disease H*I symptoms

"reatment and Prognosis

Stage Treatment Failure free survival C.+=.G !verall " year survival =.+<.G

5,55

'*8D & A 3 radiation '*8D & B

555,58

B.+C.G

C.+=.G

Long term complications of treatment

infertility
2 MOPP ; '*8DK males ; females 2 sperm ban%ing sho#ld be disc#ssed 2 premat#re menopa#se

secondary malignancy
2 s%in, 'ML, l#ng, MD!, )(L, thyroid, breastNNN

cardiac disease

Overview
Concepts, classification, biology pidemiology Clinical presentation Diagnosis !taging "hree important types of lymphoma