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1er manuel. Low grade -diffuse lymphocytic Stage Rating -nodular lymphocytic I class 3 = pp2yrs,std 7th yr -nodular histiocytic II class 2= pp3yrs,std 8th yr III class 1= pp5yrs,std 11th yr IV DEC to 100, cl1Intermediate-High grade Stage Rating -diffuse lymphocytic, poorly diff I 25
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1. LYMPHOMES NON HODGKINIENS François Sestier, MD, PhD
Abdelouahed Naslafkih, MD, PhD
AQTV, Montréal, 14 Mai 2009
Programme de médecine d’assurance et expertise en sciences de la santé,
Université de Montréal
www.mae.umontreal.ca
2. 1er manuel Low grade
-diffuse lymphocytic Stage Rating
-nodular lymphocytic I class 3 = pp2yrs,std 7th yr
-nodular histiocytic II class 2= pp3yrs,std 8th yr
III class 1= pp5yrs,std 11th yr
IV DEC to +100, +cl1
Intermediate-High grade Stage Rating
-diffuse lymphocytic, poorly diff I class 2
-diffuse lymphocytic-histiocytic II class 1
-Burkitt’s lymphoma III +100, + class 1
-Unclassified IV DEC to +200 + class 1
3. 2ième manuel Low grade lymphomas:
-Stage 1 : PP 3yrs , then
+50 and 10$ x 7 yrs
11th yr : +50
-Stage II: PP 3 yrs , then
+50 and $15 x 7 yrs
11th yr : + 50
-Other stages : PP 10 yrs, then
15$ x 5yrs
16th yr : std
4. Les LNH sont-ils des risques standards s’ils survivent
7 à 16 ans ??
5. OBJECTIFS Identifier la littérature médicale la plus récente concernant la mortalité des LNH
Calculer la mortalité observée en utilisant une méthodologie actuarielle
6. LNH: définition et épidémiologie Definition: malignant disease of the lymphoid system, highly heterogeneous, both histologically and clinically, with several classifications
2. Epidemiology:
- annual incidence: 5-10 new cases per 100 000 persons,
- age distribution: middle-age patients and the elderly,
- males are affected more often than females (1.5:1.0).
11. Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) 1. Low grade
2. Intermediate grade
3. High grade
12. Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF)
Low grade
A - Small lymphocytic cell.
B - Follicular, predominantly small cleaved cell
C - Follicular mixed, small cleaved and large cell.
13. Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) Intermediate grade
D - Follicular, predominantly large cell.
E - Diffuse small cleaved cell.
F - Diffuse mixed, small and large cell.
G - Diffuse large cell.
14. Histologic classification of non-Hodgkin’s lymphomas - Working Formulation (WF) High grade
H -Large cell immunoblastic.
I -Lymphoblastic.
J -Small noncleaved cell: Burkitt’s
16. Staging: Ann Arbor I. 1 lymph node region or structure
II. >1 lymph node region or structure, same side of diaphragm
III. Both sides of diaphragm
IV. Extranodal sites beyond “E” designation
subscripts: A, B, E, S
22. Follicular lymphoma and long term survival Gandhi, Blood Rewiews,2005,19:165-178
29. Figure 2. Development of a Molecular Predictor of Survival in Follicular Lymphoma. Panel A shows overall survival among the patients with biopsy specimens in the test set, according to the quartile of the survival-predictor score (SPS). Panel B shows overall survival according to the International Prognostic Index (IPI) risk group for all the patients for whom these data were available. Panel C shows overall survival among the patients with specimens in the test set for the indicated IPI risk group, stratified according to the quartile of the SPS.Figure 2. Development of a Molecular Predictor of Survival in Follicular Lymphoma. Panel A shows overall survival among the patients with biopsy specimens in the test set, according to the quartile of the survival-predictor score (SPS). Panel B shows overall survival according to the International Prognostic Index (IPI) risk group for all the patients for whom these data were available. Panel C shows overall survival among the patients with specimens in the test set for the indicated IPI risk group, stratified according to the quartile of the SPS.
30. LYMPHOMA SURVIVAL: a textbook approach
31. Southwest Oncology Group lymphoma survival
32. LNH Surviennent chez le jeune adulte et la personne agée
Il faut dond tenir compte de l’âge dans le calcul de la mortalité
36. Netherlands, 1981-89
1164 patients, age : 64 yrs, 50% women
40. CCCW-NHL Registry Netherlands, 1981-89
1167 Patients, age : 64 yrs, 50% women
Follow-up: 8 years
45. Localized aggressive lymphomaRey et al. NEJM 2005;352:1197 France, 1993-2000
647 patients (318 ACVBP, 329 CHOP+RX)
Age : 46 years, 60% men
Stage I : 66%
Stage II : 32%
Stage IV : 2%
95% IPI score= 0
Follow-up : 8 years
Deaths = 115
Mortality Ratio* = 560%
48. Follicular lymphomaMontoto et al. Ann Oncol 2002;13:523-530 Spain, 1977-1997
201 patients, 53% men
Age : 54 years
Stage I: 10%, II: 9%, III: 15%, IV: 66%
Overall survival : 71% at 5 years, 48% at 10 years
MR* = 973% at 5 years
= 785% at 10 years
50. Survival of 389 follicular lymphomas : std at 10 yrs????
51. Diffuse large B-cell lymphoma( aggressive lymphomas) US,1987-1998
128 Patients, (46% men)
Age : 65 years
5-year overall survival: 43%
Mortality Ratio* = 722%
52. Indolent lymphomaFollicular vs. Non Follicular lymphomaCorradini et al. J Clin Oncol 2004;22:1460-1468 Italy,1990-99
70 patients,60% men
Age: 47 years
87% stage IV
Overall survival at 12 yrs
Follicular subtype: 76%, MR = 514%
Non-Follicular : 49%, MR = 1311%
53. Relapsed Follicular LymphomaAutologous Bone Marrow TransplantationFreedman et al. Blood 1999;94:3325-3333 USA, 1985-1995
153 Patients, 53% men
Age: 43 years
(66%: stage IV, 24% stage III, 7% stage II, 3% stage I)
Survival : 69% at 12 years
MR* = 1330%
57. Localized Intermediate and high-grade Non-hodgkin's lymphoma
Soutwest Oncology Group, 1988-1995
442 patients (CHOP: 201; CHOP+RX :200)
Age : 59 years
5-year overall survival :
CHOP : 72%
CHOP+RX : 82%
60. Intermediate or high-grade Non-Hodgkin lymphoma Italy, 1984-1998
186 patients, 52% men
Age: 56 years
Overall survival : 60.4% at 10 years
Mortality ratio = 495%
61. Intermediate or high-grade Non-Hodgkin lymphoma MR by stage
Stage I-II = 431%
Stage III-IV = 995%
MR by IPI
IPI 1 = 260%
IPI 2 = 495%
IPI 3 = 800%
IPI 4 = 1170%
66. The International Lymphoma Study Group Classification of Non-Hodgkin’s Lymphoma 1403 cases (untreated) from 8 countries, 1988-90
Omaha, NE: 200
Vancouver, Canada: 202
Cape Town, South Africa: 196
London, UK: 120
Locarno, Switzerland: 80
Lyon, France: 195
Wurzburg, Germany: 210
Hong Kong: 200
71. Lymphomes indolents Sont incurables
Invasion moelle osseuse
Rémission spontanée dans 25 % des cas
Rechutes 2-3 après et ensuite de plus en plus rapidement
Sur-mortalité persist e après 10 ans
Certains LNH chez les personnes agées peuvent être assurés avec surprime (?)
Les LNH indolents doivent être refusés