GeriQBank · Paper III · Q11

Non-Hodgkin Lymphoma — Presentation, Prognosis & Principles of Therapy

Moderate YieldAsked ×17-mark note

Topic: Haematology, Oncology & Screening
Chapter: Haematology
Years asked: Not recorded in the source
Frequency: Set 1× in Paper III (2009–2025)

As set in the university paper

What are the types of Non-Hodgkin’s lymphoma? What are their clinical presentations and prognosis, and what are the principles of therapy?
Paper III · Haematology & Oncology · asked ×1 · 7-mark note · see in paper list

Detailed answer

Pro · free in beta

Attempt it firstOutline your answer as a 7-mark note before revealing it — definition, causes, evaluation, management and the geriatric angle.Reveal answer

Therapy

Textbook gap: No NHL chapter. Only links: Ch. 24 (lymphoma causing marrow infiltration/thrombocytopenia, acquired FVIII inhibitors); Ch. 26 (lymphoma treatment as MDS/AML risk). Geriatric-oncology philosophy transfers directly — median NHL diagnosis age is 65–70.

High-Yield Points

A. Definition, Epidemiology & Classification

Heterogeneous clonal lymphoid proliferations — 85–90% B-cell. WHO-HAEM5 recognises >60 entities. 5–6× commoner than Hodgkin lymphoma.

Risk factors: age (dominant), immunosuppression, autoimmune disease, infections (EBV, HTLV-1, H. pylori→gastric MALT, HCV), pesticides.

Group Examples Behaviour

Indolent Follicular (1–2), marginal zone, SLL/CLL Incurable but long survival; watch and wait Aggressive DLBCL (commonest, 30–40%), mantle cell Fatal in months untreated, but curable 50–60% Very aggressive Burkitt, lymphoblastic Rapidly fatal untreated, highly curable B. Clinical Presentation

Painless, generalised lymphadenopathy; non-contiguous, unpredictable spread — most present stage III/IV.

Extranodal disease in 25–40% (far commoner than HL) — stomach, bowel, Waldeyer's ring, CNS, testis, skin.

B symptoms in 30–40%. Marrow involvement common (40–70% in indolent NHL).

Oncological emergencies: SVC obstruction, cord compression, tumour lysis syndrome.

In the elderly: often atypical — weight loss, falls, recurrent infection, or simply raised LDH.

C. Diagnosis & Prognosis

Excisional biopsy essential — FNA inadequate. PET-CT staging (Lugano). IPI (mnemonic "APLES"), one point each: Age >60, Performance status ECOG≥2, LDH above normal, Extranodal sites ≥2, Stage III/IV. In rituximab era, 5-yr OS ranges 90% (low risk) to ~50% (high risk). NCCN-IPI uses age bands and specific extranodal sites for better discrimination in the elderly.

Principles of Therapy

10.

Treatment dictated by subtype, stage and fitness — never age alone.

11.

Indolent NHL: watch and wait legitimate until GELF/BNLI criteria met.

12.

Aggressive NHL: potentially curable — treat promptly with curative intent where tolerated.

13.

Anti-CD20 antibody (rituximab/obinutuzumab) added to chemotherapy for all CD20+ B-cell NHL.

14.

Geriatric assessment BEFORE choosing intensity — first decision is curative vs palliative intent.

Treatment at a Glance

Setting Approach

DLBCL, advanced, fit R-CHOP×6 or Pola-R-CHP×6

DLBCL, ≥80 or frail R-miniCHOP — 2-yr PFS ~47%, OS ~59% Gastric MALT H. pylori eradication alone cures 60–80% Relapsed, fit Salvage → ASCT, or CD19 CAR-T (now 2nd line)

Relapsed, CAR-T ineligible CD20×CD3 bispecifics (glofitamab, epcoritamab), polatuzumab-BR Latest Updates (2023–Present)

MD Geriatrics – Haematology Compendium Page 23 of 34 POLARIX (NEJM 2022): Pola-R-CHP improved 2-yr PFS to 76.7% vs 70.2% (trial capped age at 80). POLAR BEAR trial (Nordic, patients ≥80 or ≥75+frail): R-pola-mini-CHP had MORE serious/fatal adverse events than R-miniCHOP — R-miniCHOP remains a sound standard in the very old. Bispecific antibodies (glofitamab, epcoritamab — FDA 2023) transformed relapsed disease, especially valuable in older patients ineligible for CAR-T — off-the-shelf, no apheresis delay. ZUMA-7/TRANSFORM: CD19 CAR-T now superior to salvage+ASCT in early relapse; PILOT trial shows liso-cel effective in transplant-ineligible second line.

Current Practice Update

Domain Pathy's (2022) Current evidence

Coverage None Fully covered by WHO-HAEM5/NCCN/ESMO First-line DLBCL Not addressed R-CHOP or Pola-R-CHP; R-miniCHOP for ≥80/frail Relapsed disease Not addressed CAR-T (2nd line); bispecifics for CAR-T-ineligible MD Geriatrics – Haematology Compendium Page 24 of 34

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References

PAPERS-2-3-4_COMBINED.pdf — page 862
GeriQBank source PDF — p. 862

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