MANAGEMENT OF LYMPHADENOPATHY :

FOCUSED ON LYMPHOMA

Irza Wahid,
Subdivision of Hematology & Medical Oncology
Departement of Internal Medicine
Faculty of Medicine, Andalas University
Padang, 2017
INTRODUCTION

LYMPHADENOPATHY

• Lymph nodes that are abnormal in size,

consistency or number

• Generalized / Localized
Lymphatic System
• Network that filters antigens from the interstitial fluid

• Primary site of immune response from tissue antigens

• Lymphatic drainage in all organs of the body except

brain, eyes, marrow and cartilage

• 600 lymph nodes in body

• Slow flow, low pressure system returns interstitial fluid

to the blood system
 Lymph nodes

• Capsular shell
• Fibroblasts and reticulin
fibers
• Macrophages
• Dendritic cells
• T cells
• B cells
Peripheral lymphadenopathy

• Most cases benign, self limited illness

• Primary or secondary manifestation of many illnesses

• The CHALLENGE is to decide if it is representative of a

serious illness…
Parameters to help distinguish between
benign and serious illness

•Age
•Character
•Duration
•Location
“Malignancy much more
common in patients greater 50
yrs of age”
 Lymph node character
Size
• Greater than one centimeter generally considered --abnormal
• Exception inguinal area, lymph nodes commonly palpated (>1.5 cm)
• Supraclavicula, iliaca , poplitea in any size are abnormal, epitrochlear > 5 mm is
abnormal.
• Size does not indicate a specific disease process

 Pain
• Indication of rapid increase in size: stretch of capsular shell
• NOT useful in determining benign vs malignant state
• Inflammation, suppuration, hemorrhage

Consistensy
• Stone hard: typical of cancer usually metastatic
• Firm rubbery: can suggest lymphoma
• Soft: infection or inflammation
Duration

Lymphadenopathy :

- onset < 2 weeks

- duration > 1 year usually benign

- no progression
 Location

• Post cervical: scalp, neck skin of arms thorax cervical and axillary nodes (lymphoma, head/neck ca)
Location
 DIFFERENTIAL DIAGNOSIS
M ALIGNANT

I NFECTION

A UTOIMMUNE

M ISCELLANEOUS/UNUSUAL

I ATROGENIC
DIAGNOSIS  BIOPSY

LYMPHADENOPHATY

NEOPLASM NON NEOPLASM

PRIMARY METASTATIC

HODGKIN NON HODGKIN

B-CELL T-CELL
 INTRODUCTION

• Non Hodkins lymphomas :

Neoplasms of lymphoid origin, typically causing lymphadenopathy,
there are many different subtypes, morphology,
immunophenotype, molecular, cytogenetics, prognosis and respons
thy.

• Treatment generally depends on the aggressiveness of the disease

(indolent, aggressive, or very aggressive)

• Current ICD-9-CM diagnosis code range 200.0_ – 200.8_ and 202.0_ –

202.9_
 ETIOLOGI DAN FAKTOR RISIKO
 Etiologi pasti tidak diketahui  beberapa faktor risiko
:
• Immundefisiensi
• Agen infeksius seperti EBV, HIV
• Paparan lingkungan dan pekerjaan seperti peternak
pekerja hutan / pertanian yang disebabkan paparan
herbisida dan pelarut organic serta paparan ultraviolet
• Diet tinggi lemak hewani dan merokok
CA Cancer J Clin 2011;61:212-236. VC 2011 American Cancer Society.
Jacqueline Kennedy Onassis

Former First Lady

King Hussein of Jordan
 “Mr. T”
(Lawrence Tureaud)

Television star, The A-Team.

Sylvester Stallone's adversary in "Rocky III.”
 LYMPHOMA GRADATION ( NCCN 2010 )
Indolent (slow growing) B-cell lymphomas
•Follicular lymphoma
•Chronic lymphocytic leukemia / small lymphocytic lymphoma
•MALT
•Splenic marginal zone lymphoma
•Nodal marginal zone
Aggressive (fast growing) B-cell lymphomas
• Diffuse large B-cell lymphoma
•Mantle cell lymphoma
Highly aggressive B-cell lymphomas
•Burkitt lymphoma
•Lymphoblastic lymphoma
•AIDS-related B-cell
Diffuse Large B-Cell Lymphoma
(DLBCL)
• Indonesia:
– DLBCL is the most common subtypes
of B-cell lymphomas (68.2%)1

• DLBCL is biologically aggressive, but can

be cured
in >50% of cases, even in advanced
stages2,3
• However, up to one-third of patients
have
refractory disease or relapse after
treatment4
1. Reksodiputro AH et al. Multicentre Epidemiology and Survival Study of B Cell Non Hodgkin Lymphoma Patients in Indonesia. J Blood Disord Transfus 6:257. doi:
10.4172/2155-9864.1000257
2.
Armitage, J. O. My treatment approach to patients with diffuse large B-cell lymphoma. Mayo Clin. Proc. 87, 161–171 (2012).
3.
Roschewski M et al. Diffuse large B-cell lymphoma—treatment approaches in the molecular era. Nat. Rev. Clin. Oncol. 11, 12–23 (2014)
4.
Friedberg, J. W. Relapsed/refractory diffuse large B-cell lymphoma. Hematology Am. Soc. Hematol. Educ. Program 2011, 498–505 (2011).
PENDEKATAN DIAGNOSTIK
1. Anamnesis
 Umum
Pembesaran KGB atau organ
BB menurun ≥ 10 % dalam waktu 3 bulan
Demam tinggi ≥ 38 C ≥ 1 minggu tanpa sebab
Keringat malam
Keluhan anemia
Keluhan organ ( seperti lambung, nasofaring )

 Khusus
Penyakit autoimun ( SLE, syogren, reuma )
Kelainan darah
Infeksi ( Toxoplasmosis, mononucleosis, tuberculosis, HIV

2. Pemeriksaan fisik
Pembesaran KGB
Kelainan / pembesaran organ
Performance status : WHO, Karnofsky
Laboratorium
* Rutin  Darah perifer lengkap ( DPL ), Gambaran darah
tepi ( GDT )
 Urine lengkap
* Kimia Klinik
* Imunophenotyping  parafin panel  CD 20, CD 3

 Radiologi
* Foto torak  CT Scan torak
* USG Abdomen  CT Scan abdomen
* Limfografi

 Biopsi KGB

 BMP & biopsi SST

Minimal immunohistochemistry CD20 is mandatory
MANAGEMENT

CHOP Regimen
• Cyclophosphamide 750mg/m2, iv, day 1
• Doxorubicine 50mg/m2, iv, day 1
• Vincristine 1.4mg/m2, max. dose 2mg, iv, day1
• Prednisone 100 mg/day, oral, days 1-5

• 6-8 cycles, 3-weekly schedule

• OR 80%-90%, CR 50%-60%
• Curative < 40%
CHOP was a good standard

• It was associated with 100 CHOP

MACOP-B
a good efficacy 80 ProMACE-CytaBOM
m-BACOD
• It was easy to use 60

Overall survival (%)

• It gave reproducible 40

results 20

0 5 10 15
GELA-LNH 98.5: CHOP vs MabThera +
CHOP in previously untreated DLBCL
GELA phase III trial

Cyclophosphamide 750mg/m²
Doxorubicin (Doxotil) 50mg/m²
Vincristine 1.4mg/m²
Prednisone 100mg /day x 5 days

3 weeks 8 cycles

MabThera + CHOP 375mg/m²

Coiffier B, et al. N Engl J Med 2002;346:235–43

 LIMFOMA MALIGNUM HODGKIN
 Khas sel Reed – Steinberg

Klasifikasi
1. Tipe lymphocyte predominant  prognosis baik

2. Tipe mixed cellularity  prognosis lebih buruk

3. Tipe lymphocyte depleted  prognosis buruk

4. Tipe nodular sclerosis  prognosis: diantaranya

 PENATALAKSANAAN

1. Radioterapi
2. Radioterapi + Kemoterapi
3. Kemoterapi
 ABVD
 CHOP
 CVP
 EPOCH ( CHOP + Etoposide)