Please enable JavaScript.
Coggle requires JavaScript to display documents.
Low Grade Lymphomas - Coggle Diagram
Low Grade Lymphomas
B cell origin
Follicular lymphoma (MC) (grade 3 is more like DLBCL)
Marginal zone lymphoma (same as MALT but that’s extra nodal)
Primary cutaneous lymphomas, splenic MZL
Limited stage (indolent lymphoma): RT along :radioactive_sign:
Advanced disease. (Stage III-IV): obs :eyes:, then palliativeLook at ILROG guidelines for each of these topics
- 6-7 pgs, straightforward read
Class
3 classes :building_construction:
Indolent
Aggressive
Highly aggressive
Ann Arbor Staging system
Indolent Lymphomas are rarely curable
- common to have relapsing remitting
- sometimes can resolve without therapy
Indolent
Presentation
- immunosuppressive, AI dz
- slow grow LAD of neck axilla, inguinal
- rash bx
H&P
- Chlamydia psittaci: orbital Malt
- H pylori
- HBV, HCV, HIV
Workup
- Excisional biopsy
- not FNA :forbidden::syringe:
- EGD bx for gastric MALT
- BMB :meat_on_bone:
- except a MZL in multiple nodes, bc diffuse
- LP for CNS involvement
- not really the territory of indolent lymphomas
CBC
ESR
LDH
etc
B2 macroglobin (for follicular lymphomas)
HIV
HBV,BCV : to direct therapy
H Pylori: for gastric malt
Imaging
PET: SUV >10 suggests transformation into high grade, and necessitates a biopsy
MRI brain for syumptoms
ECG MUGA prior to anthracycline
Common Genes
- Follicular NHL: t(14:18)
- 28% transformation risk in 10y, favor early treatment in young/middle age
- MZL: Trisomy 3, t(11:18)
- :construction:
-
Managment
Chemo reserved for later stage III/IV
- G3B follicular NHL treated with DLBCL
- consider indolent stage III to IV
- rate of progression
- end organ function
- cytopenia, bulk of dz, symptoms
CHT
rituximab
- a-CD20
- prolongs PFS
- viable for relapse or refractory or as combo (RCHOP)
- HBV reactivation possible
- infusion related rx
- mucocutaneouls reactions
- PML
- can appear as CNS lymphoma or CNS relapse (so get bx)
RCHOP
RCVP
SEER Data
:construction:
Trials
- 10 Y data says ~60%
- 10Y freedom from relapse ~50%
- 1 more item...
-
-
-
Highly Aggressive
- Burkitts
- Lymphoblastic leukemia
Pathway of histo
Naive B Cell
Mantle cell
Follicular B Blast
B blast and Centroblast
This is a large cell
- diffuse large B cell lymphoma
-
Follicular Lymphoma
- can have mixture of centroblasts :construction:
Cyto:
Grade 1: small cleaved
Advanced: non-cleaved, diffuse chromatin
Prognostic Factors -FLIPI (now FLIPI-2)
- prior to rituxumab
- 5 adverse prog factors
:construction:
Make sure for board you can understand the prog factors for determining risk
old survival outcomes
0-1: 71%
2: 51%
3-5: 36%
Paradigm
-
-
-
Field Design
- 1 more item...
Marginal Zone Lymphomas
:pencil2:
- cutaneous MZL treated the same as Follicular cutaneous
Goda et al
Stage IE and IIE MALT treated w/ IFRT
Orbital sites 24 Gy
- Dose reducing in the conjunctiva (keeping under 26 Gy), for dry eyes
Median dose to non orbital sites was 30 Gy
- 99% CR,
8 people aren’t expected to die with MALT
- they do recur in other sites of the body
- MALT recurs in Paired organs :dancers:
- eg. same contra lateral organ (both parotid)
- can be tricky with Orbit malt, wedged pairs both orbits :eyes:can torch the chiasm: so IMRT
Gastric Lymphoma
- besides orbital lymphoma, gastric is also MC
- Tx H. Pylori first :pill:
- if insufficient response, rescope
- and if persistent, symptomatic, or relapse, we will treat (and treat the whole stomach
Workup
- PET/CT
- good for primary dz, perigastric node eval, distant met eval
- BMB :meat_on_bone:
- HIV, HBV, HCV
SIM
- NPO
- IV contrast
- can use PO contrast but only using 25cc. Do not overfill stomach
- IMRT
- Arms up
- 4DCT to document movement, can use DIBH
See slides for volume definitions
:construction:
- CTV add 1cm to GTV
- ST does entirety of stomach for CTV and adds extra for ITV motion then 1cm for PTV
- Large volume dz needs IMRT
Tx
- PPI :pill:
- usually not needed long term
- ISRT : entire stomach
- 30 Gy in 1.5Gy fx
- historically used to reduce the nausea
- probably can dose reduce, but no evidence yet
:construction:
Non-Gastric MALT
Ocular adnexa
Salivary gland
Skin
Breast
Thyroid
- RT for early stake
Lower dose
24-30 Gy
:pencil2: Confusion about eyes :eye:
Ocular Lymphoma: CNS lymphoma :forbidden: not a MALT
Ocular Adnexa: MALT
Orbital Lymphoma
Orbital MALT
- ~25 Gy
- Assd w/ C. Psittaci
- can treat w/ abx but most go straight to RT
CTV: entire bony orbit and any extra orbital extansion
- Conjuctiva: only time ST doesn’t treat entire orbit, uses electrons :zap:
Volume
Whole or partial orbit
Rx
24 vs 30 vs 4
Binkley
Orbital lymphoma partial orbit treatment
median dose 30.6Gy
- 5yOS 100%
- 5Y LF 5%
if conjunctival: partial radiation makes sense
- 1 more item...
Target volume: Whole organ is CTV
- no ppx nodal coverage
- Adjacent or 1st echelon included only if it is involved
- in large organs (ie skin and bone) target volume is the lesion with a margin
-
Breast MALT
- WBI
- PBI is possible, if morbidity is too costly to justify relapse risk
- CTV for primary or consolidation is whole breast
- Sim arms up.
- 3D conformal
Lymph node regions
- cervical
- infraclav
- walleyes ring
- SCV
- etc :construction:
- if only above diaphragm (stage I)
- if above and below (Stage II)
77k annually
20k mortality annually
indolent MC in older >70 peak
Follicular type : 22%
SLL/CLL: 6% of NHL
MALT/MZL: 5%
- we see them a lot bc referred for definitive radiation :radioactive_sign:
NHL vs HD
- more nodes in NHL, spreads out
- more likely to be extranodal
- more likely to be in bone marrow
- subtype dictates aggressiveness
- contiguous nodes more likely HD