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Old 03-04-2007, 04:41 PM
Dross Dross is offline
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Default What You Need To Know About Non-Hodgkin's Lymphoma

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What You Need To Know About Non-Hodgkin's Lymphoma

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[B]What Is Non-Hodgkin's Lymphoma?[/B]

Non-Hodgkin's lymphoma (also called NHL) is cancer that begins in the lymphatic system. To understand this disease, it is helpful to know about the lymphatic system.

[B] The Lymphatic System[/B]

The lymphatic system is part of the body's immune system. The immune system fights infections and other diseases. In the lymphatic system, a network of lymph vessels carries clear fluid called lymph. Lymph vessels lead to small, round organs called lymph nodes. Lymph nodes are filled with lymphocytes (a type of white blood cell). The lymph nodes trap and remove bacteria or other harmful substances that may be in the lymph. Groups of lymph nodes are found in the neck, underarms, chest, abdomen, and groin. Other parts of the lymphatic system include the tonsils, spleen, and thymus. Lymphatic tissue is also found in other parts of the body including the stomach, skin, and small intestine. Lymphatic system. Lymphatic system. Non-Hodgkin's Lymphoma There are many types of non-Hodgkin's lymphoma. All types of lymphoma begin in cells of the lymphatic system. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes this process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor. Non-Hodgkin's lymphoma begins when a lymphocyte (a B cell or T cell) becomes abnormal. Usually, non-Hodgkin's lymphoma starts in a B cell in a lymph node. The abnormal cell divides to make copies of itself. The new cells divide again and again, making more and more abnormal cells. The abnormal cells are cancer cells. They do not die when they should. They do not protect the body from infections or other diseases. Also, the cancer cells can spread to nearly any other part of the body.
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Old 05-03-2013, 09:48 AM
gdpawel gdpawel is offline
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Default Lymphoma and Infection: The Need to Take Medication to Prevent Infection

Jessica Lewis, PA

In some instances, patients may be started on medicines to prevent or minimize infection. Infection in patients with impaired immune system function (due to lymphoma or treatment of lymphoma) can be life threatening. Ultimately, your doctor will determine whether to start such medications, but some current literature helps medical providers make this decision.

The National Comprehensive Cancer Network and American Society of Clinical Oncology provide summaries of factors that predict a lymphoma patient’s risk of developing fever and infection. These factors include age, performance status, type of cancer, status of disease (remission vs. active disease), type of treatment, the presence of a low infection-fighting white blood cell count (neutropenic), and prior episodes of fever with chemotherapy treatment. Patients with lymphoma are generally classified as having intermediate risk, although some patients with CLL or T-cell lymphoma may be considered high risk.

Prevention of bacterial infections: Common prophylactic medications include levofloxacin or ciprofloxacin. Prophylaxis is recommended for intermediate or high-risk patients, including patients that are expected to have neutropenia. There have been few randomized-controlled trials that have investigated the use of antibiotics to prevent development of fever and infection in lymphoma patients that are receiving chemotherapy. The largest randomized-controlled study, by Cullen et al in 2005, included 1,565 patients with solid cancers and lymphomas treated with chemotherapy that would lower the white blood cell count. In this study, patients were randomly assigned a placebo or levofloxacin. The authors found a decrease in the incidence of fever and decreased rates of probable infection and hospitalization. However, patients who received levofloxacin did not have a statistically significant decreased rate of severe infection (including lethal infections). As per 2012 NCCN and ASCO guidelines, the use of levofloxacin prophylaxis is only recommended for patients with neutropenia that lasts longer than 7 days.

Prevention of fungal infections: Medications to prevent fungal infections are not usually needed in lymphoma patients. ASCO guidelines recommend considering prophylaxis only for patients with profoundly low white blood cell counts (ANC <100) longer than 7 days. Additionally, patients should limit exposure to construction or demolition sites, and quit cigarette smoking to reduce risk of fungal infections.

Prevention of viral infections: Antiviral medications may be recommended. If you have been exposed to hepatitis B infection, you may be started on medication to prevent this from becoming an active infection. If you had the chicken pox as a child you are at risk of developing shingles, and you may benefit from preventative medication. Patients with lymphoma should not receive the shingles vaccine.

PCP prevention: Some patients are at risk of developing pneumonia, caused by Pneumocytus jirovecii (also referred to as PCP). You may require preventative medication, typically with TMP-SMX, if you are on steroids for a prolonged period of time (>1 month), or are receiving treatment with alemtuzumab or purine analogs (i.e., fludarabine).

Other preventative measures: ASCO 2012 guidelines recommended all patients who are receiving cancer treatment to receive the seasonal flu vaccine, along with their family and household contacts. Guidelines from the Centers for Disease Control (CDC) include administration of a pneumococcal vaccine in all patients with lymphoma.

The Lymphoma Program at New York-Presbyterian Hospital/Weill Cornell Medical Center
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Old 06-28-2013, 10:22 AM
gdpawel gdpawel is offline
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Default How is the subtype of lymphoma determined?

Michael Grossbard, M.D.
Director
Lymphoma Program
Continuum Cancer Centers
New York

There are many different subtypes of lymphoma and these subtypes have different ways in which they manifest themselves in patients. One major way to distinguish lymphomas is to assess whether they are of T-cell or B-cell origin (T and B representing different types of lymphocytes in the body). These subtypes can be distinguished by staining lymphoma cells to determine whether they have T-cell or B-cell antigens on their surface.

Another way to distinguish lymphomas is to examine tumor cells under the microscope and assess their size and shape. For example, some aggressive lymphomas have very large malignant cells (and are known as large cell lymphomas). A third way to evaluate lymphoma subtypes is to assess genetic changes within the tumor cell by using molecular biologic techniques or examining the chromosomes directly (cytogenetic analysis).

By determining the subtype of lymphoma, specific therapy programs can be offered that will optimize the chance for a favorable response. The standard therapy for a diffuse large B-cell lymphoma is different from that of a Burkitt’s lymphoma or a follicular lymphoma. Likewise, these different entities have different prognoses.

What is the role of cytogenetic analysis?

Although cytogenetic testing is often impossible because many patients have dry bone marrow taps, all of the faculty members generally recommend sending adequate specimens for analysis to both assist in diagnosis, especially in excluding other conditions, and to assess prognosis in younger patients being considered for an allotransplant. In addition, most investigators believe the results can affect clinical decision-making, potentially swaying them to employ, for example, an immunomodulatory agent in patients when a 5q deletion has been detected. Significantly, unlike multiple myeloma, where there is no easy standard to consider, cytogenetics in MF from a practical perspective revolve around the factors identified in the Dynamic International Prognostic Scoring System (DIPSS) Plus, giving oncologists a road map of what should be looked at in this regard. - Research To Practice
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Old 07-03-2013, 03:14 PM
gdpawel gdpawel is offline
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Default About the diffuse large B-cell lymphoma

Jason Westin, M.D.
Assistant Professor
Department of Lymphoma.Myeloma
Division of Cancer Medicine
MD Anderson Cancer Center

The diagnosis of diffuse large B-cell lymphoma is made by careful examination of biopsied tissue by an expert hematopathologist. It is important for the pathologist to have enough tissue to examine, and thus a core or excisional biopsy is often required (i.e., a fine needle aspiration is very often insufficient). The pathologist can determine the subtype of non-hodgkin lymphoma (such as diffuse large B-cell lymphoma) through a variety of testing mechanisms including immunohistochemistry, flow cytometry, and cytogenetics.

Diffuse large B-cell lymphoma is generally found in the lymph nodes of the neck, axillae (under arms), chest, abdomen, or groin. It can occasionally develop in non-lymph node sites (often referred to as 'extra nodal') such as liver, lung, brain, or bone. As the disease is a cancer of immune cells, which by their nature are part of the blood system, lymphomas are very often in multiple locations at the time of diagnosis.

When your doctor is suspicious of diffuse large B-cell lymphoma, they will perform a panel of initial tests referred to as "staging" (as in to determine the stage of disease). These tests generally include a CT scan, PET scan, echocardiogram, laboratory assessment of kidney, liver, and bone marrow function, bone marrow biopsy, and assessment of possible viral infections such as HIV and Hepatitis. The imaging scans and biopsies are generally sufficient to determine if and where diffuse large B-cell lymphoma has spread. On occasion, if imaging information is not definitive and treatment will change with the result, a biopsy of a second suspicious site of disease may be indicated.

If diffuse large B-cell lymphoma is localized (that is it only found in one or a few sites), this may change the prognosis and treatment options. Diffuse large B-cell lymphoma prognosis is currently influenced by 5 clinical factors (referred to as the International Prognostic Index) which include age (<60 vs >=60), general symptom burden (ECOG performance status of <=2 or >2,) a blood test called lactate dehydrogenase (LDH, normal vs elevated),disease stage (localized vs extensive), and the presence of extra nodal sites of disease (<=1 vs >1). By these criteria, having localized disease may result in a lower "IPI score," but alone is not sufficient for prognosis.

Localized diffuse large B-cell lymphoma may be considered for a modified treatment: an abbreviated course of chemotherapy to be followed immediately by radiation therapy. A clinical trial in patients with localized diffuse large B-cell lymphoma of chemotherapy (CHOP) for 8 cycles alone or 3 cycles with radiation therapy found they were essentially equal.

The standard therapy for advanced diffuse large B-cell lymphoma remains RCHOP (rituximab and chemotherapies) for 6 – 8 cycles (depending on your local doctors preference – at MD Anderson, we usually stop after 6 cycles). RCHOP was developed in part at MD Anderson in the mid-1970s, and remains essentially unchanged aside from the addition of rituximab in the late 1990s. We now know that diffuse large B-cell lymphoma is made up of at least 3 unique diseases, with different biology and responsiveness to therapy. As a result, I strongly recommend that all patient evaluate their clinical trial options before starting chemotherapy.

The most common side effects are fatigue, nausea (controlled with anti-nausea meds – if not controlled, ask for different anti-nausea medication), and low blood counts. The concern with low blood counts is that the risk of infection is increased, and rarely could lead to fatal infections. I recommend that any patient receiving R-CHOP who develops a fever proceed immediately to their local emergency room for prompt evaluation and IV antibiotics. Not tomorrow, not seeing what happens after trying acetaminophen, but immediately. Very often a source of infection is not identified, but patients who do not seek appropriate medical attention run the risk of potentially preventable severe complications.

It is estimated that less than 5% of all cancer patients in the US participate in clinical trials. Patients who receive standard therapy off a trial may receive benefit, but we cannot improve upon previous results, and develop 'tomorrow's therapies' without patients enrolling on trials today. It is currently estimated that 3 or 4 of every 10 patients diagnosed with diffuse large B-cell lymphoma will die of their disease after treatment with current standard therapies. It is unlikely that many people would purchase a car or television that is 35 years old: would you accept a ~35 year old therapy for a potentially fatal illness?

Relapsed or refractory diffuse large B-cell lymphoma is a challenging disease. If a patient is relatively fit, the typical recommendation is second line chemotherapy to be followed by an autologous stem cell rescue (Auto Stem Cell Transplant). This recommendation is based on a clinical trial that showed that second line chemotherapy alone results in worsened survival when compared with second line chemotherapy followed by autologous stem cell rescue. If a patient is unfit for stem cell transplant (as determined by an oncologist with experience in stem cell transplant evaluation), they may still derive significant benefit from therapy, but the disease is considered incurable. If patients are fit for stem cell transplant but do not respond to second line chemotherapy, it is not likely that they will respond to a third line chemotherapy. As a result, I recommend that all patients with relapsed or refractory diffuse large B-cell lymphoma evaluate their clinical trial options so that they may take advantage of our new drug developments and future patients may benefit from new standard treatments.

Stated another way, of 100 patients with relapsed or refractory diffuse large B-cell lymphoma, only 50 will be eligible for an Auto Stem Cell Transplant. Of those eligible, only 30 will respond to second line chemotherapy. Of those who respond, only 10 – 15 will be cured of their disease. All the other patients may receive benefit from their therapy, but are likely incurable. A careful discussion of treatment options, including potential clinical trials, with a lymphoma specialist is imperative for patients with relapsed or refractory diffuse large B-cell lymphoma to improve upon our results with the currently standard therapies.
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