LINFOMA NO HODKINGRODRIGUEZ BRAVO PERCYMEDICINA INTERNA

Linfomas No HodgkinGrupo heterogneo de neoplasias de linfocitos(generalmente B pero tambin T)Proliferan en ganglios linfticos (adenopatias) y rganos linfoides ( esplenomegalia)Puede infiltrar medula osea(leucemizacion) y otros tejidos

Linfomas No HodgkinDiferencias entre linfomas y leucemias linfoides:Leucemias linfoides son acumulos de linfocitos neoplsicos en sangre perifrica; y estas tienden a infiltrar rganos linfoides Linfomas acumulos de las mismas clulas, pero en rganos linfoides ( ganglios linfticos, hgado, bazo,piel, etc); estos llegan a infiltrar la sangre. se leucemizan

Linfomas No HodgkinCriterios de Clasificacin de LNH:Morfologa celular:se dividen en linfomas de clulas pequeas y grandes; por otro lado en linfomas de clulas hendidas y no hendidas Patrn de crecimiento: Nodular (folicular) y difusondice de proliferacin: evaluado por la expresin de la molcula Ki-67 o por el % de clulas que estn en fase S del ciclo celularInmunofenotipo: entre linfomas B y linfomas TCitogentica y biologa molecularGrado de malignidad: linfomas de alto, bajo e intermedio grado

Linfomas No HodgkinAlgunas clasificaciones de los linfomas son:Rappaport(1966)Lukes y Collins(1974)Kiel(Lennert, 1976)Working Formulationdel National Cancer Institute(1982)REAL(1994)OMS(1999)

Linfomas No HodgkinEsta enfermedad suele aparecer a cualquier edad, pero es mas frecuente en torno a los 50-60 aos y si lo hace antes de los 30 aos lo mas probable es que sea de alto grado de malignidad

Linfomas No HodgkinClnica y Biologa: Estadios clnicos y pruebas de laboratorioManifestaciones clnicas generales de los LNH:Derivadas de la infiltracin: 90% tienen adenopatas ( mltiples y generalizadas)50% tienen hepatomegalia o esplenomegalia1/3 tienen infiltrada la medula sea1/3 tienen afectacin extraganglionar, siendo los lugares mas comunes ( tubo digestivo, oro faringe, mediastino, SNC, piel)Sntomas constitucionales= Sntomas BEn el 60% de los LNH, especialmente en estadios avanzadosUn paciente posee sntomas B si tiene uno de tres signos: fiebre inexplicable >38C, sudacin nocturna, perdida de peso no justificada de al menos del 10%

Linfomas No HodgkinEstadios clnicos de Ann Arbor tanto para LNH como para Enfermedad de Hodgkin: Estadio I: afectada 1 sola regin ganglionarEstadio II: 2 o ms regiones afectadas a un mismo lado del diafragmaEstadio III: regiones ganglionares afectadas a ambos lados del diafragmaEstadio III1: afecta parte superior del abdomen ( tronco celiaco, hilio heptico, hilio esplnicoEstadio III2: afecta parte inferior del abdomen ( ganglios paraorticos, iliacos, mesentricos, inguinales)Estadio IV: afectacin difusa o diseminada de uno o mas rganos o tejidos extralinfaticos

Linfomas No HodgkinLos estadios anteriores se acompaan de una serie de sufijos importantes:A: no hay sntomas BB: hay sntomas BS: bazo afectadoE: afectacin extraganglionar pero por continuidad desde una regin linftica a un rgano o tejido X: presencia de masas de mas de 10cm y/o ocupan > 1/3 del mediastino

Linfomas No HodgkinAlteraciones biolgicas mas importantes en los LNH:Aumento de la LDHAumento del cido ricoAumento de la 2 microglobulinaAlteraciones del proteinograma:-Hipoalbuminemia (mal pronostico)-Hipogammaglobulinemia-Componente monoclonalAlteraciones cromosomicas

Linfomas No HodgkinPruebas Diagnosticas:Siempre se realiza la biopsia de la adenopata ( si es posible la extirpacin de la misma)A partir de la misma se hace examen histologico,inmunopatolgico,citogentico y de biologia molecular A veces las adenopatas no son accesibles y hay que recurrir a laparotomas o toracotomas

Linfomas No HodgkinPruebas complementarias que se emplean en el estudio y estadiaje de los linfomasAnamnesis y exploracin fsica completa ( atencin a los sntomas B,adenopatias y visceromegalias)Hemograma,VSGAspirado y biopsia de medula sea ( descarta infiltrado)Bioqumica sanguine:LDH,cido rico, 2 microglobulinaProteinograma:albmina y alteracin de gammaglobulinasPruebas de imagen:Rx(mediastino),TC(cervical,toracica,abdominal y plvica),gammagrafia con galio67

Linfomas No HodgkinPronostico y Tratamiento:El pronostico del linfoma depende de:Caractersticas del enfermo (edad, estado general)Caractersticas intrnsecas de la clula tumoralGrado de extensin del tumor ( estadio clnico de Ann Arbor)

Linfomas No HodgkinFactores independientes de un mal pronostico:Edad >60 aosECOG > o igual 2LDH alta2-microglobulina altaEstadios III y IVAfectacin de dos o mas regiones extraganglionaresSntomas B

Linfomas No HodgkinSupervivencia segn el grado de malignidad de la clasificacin Working FormulationLos de bajo grado son de curso lento y los pacientes suelen vivir bastante tiempo ( supervivencia a los 5aos > 75%)Los de intermedio y alto grado mas frecuentes en jvenes en principio son de peor pronstico por ser mas agresivos, pero logran remisiones completas en un 70% y de ellos aproximadamente la mitad se curan

Linfomas No HodgkinTratamiento:No se tratan todos de la misma forma lo hacen dependiendo de la edad, grado de malignidad, estadio evolutivo, situacin clnica general y presencia de factores de pronostico adverso

Linfomas No HodgkinTratamiento:LOS DE BAJO GRADOPaciente en estadio I o II (formas localizadas) debe tratarse con radio terapia, con altas posibilidades de curacin. Algunos utilizan radioterapia localizada y tres ciclos de quimioterapiaPaciente en estadios III o IV(forma extensa) el asintomtico se puede esperar; mientras que el sintomtico el tratamiento es la quimioterapia que puede ser monoquimioterapia(clorambucil) o generalmente la poliquimioterapia(CHOP)

Linfomas No HodgkinTratamiento:LOS DE INTERMEDIO Y ALTO GARDOSiempre se tratan,y suele hacerse con poliquimiterapia(CHOP)

Linfomas No HodgkinPlanteamiento de transplante de progenitor hematopoyetico en LNHNo es un tratamiento suela realizarse de entrada La posibilidad es un transplante autlogo en pacientes con linfomas de intermedio / alto gradoEl transplante alogenico en caso de recaida,en el linfoma de Burkitt y linfoma linfoblstico si el paciente es joven y hay donante histocompatible

Linfomas No HodgkinClasificacinA la hora de exponer las clasificaciones en las que se tendr mas hincapi, esta son las (REAL y OMS) hay que tener presente que hay muchas mas que toman en cuenta otros detalles mnimos.

Linfomas No HodgkinClasificacin real(1994) y OMS(1999)NEOPLASIAS DE CELULAS BDE CELULAS PRECURSORASLinfoma linfoblsticoDE CELULAS Perifricas ( mayora de los linfomas)Linfoma linfocitico pequeo/leucemia linftica pequeaLeucemia prolinfociticaBLinfoma linfoplasmocitoide/inmunocitoideLinfoma de clulas del mantoLinfoma folicularLinfoma de la zona marginal:Extranodal tipo MALTNodal, con o sin clulas monocitoidesLinfoma esplnico de la zona marginalTricoleucemiaPlasmocitoma Linfoma difuso de clulas grandesLinfoma de Burkitt:Endmico ( africano)No endmicoLinfoma de alto grado Burkitt-like

Linfomas No HodgkinNEOPLASIAS DE CELULAS T y NKDE CELULAS PRECURSORASLeucemia o Linfoma linfoblstico TDE CELULAS MADURASLeucemia prolinfocitica TLeucemia de linfocitos grandes granularesMicosis fungoides/sndrome de SzaryLeucemia/linfoma T del adulto(HTLV1+)Linfomas T perifricos Linfoma angioinmunoblasticosLinfoma angiocentricoLinfoma T intestinalLinfoma anaplasico de clulas grandes (T y nulo)

Ganglionares EXTRAGANGLIONARES

Layered structure of secondary follicle(Liu et al., Immunology Today, 1992)Ki-67 AbBCL2 AbMantle zoneLight zoneDark zone

1. Chromosome translocations and LymphomasMantle cell lymphoma and BCL1/cyclin D1 Follicular lymphoma and BCL2 Burkitts lymphoma and MYC Diffuse Large BCL and BCL6 MALT lymphoma and API2-MALT1, BCL10, MALT1Genomic alterations in lymphoma(Alteraciones genmicas en linfomas)

Linfoma de Burkitt: Translocacionesy sobreexpresin del c-myc La translocacin que afecta a la banda 24 del brazo largo (q24) del cromosoma 8 donde se localiza el oncogn c-myc existe en el 100% de los casos de linfoma de Burkitt( endmico o espordico ) y pequeo % de LNHDCG.Se han descrito 3 translocaciones : t(8;14)(q24;q32), t(2;8)(p12;q24) y t(8;22)(q24;q11)

LINFOMA FOLICULARla translocacin del bcl-2 El 90% del LF muestran la translocacin(t14;18)(q32;q21). El oncogen bcl 2 , localizado en el punto de ruptura del cromosoma l8 codifica una proteina que bloquea la apoptosis . El gen de las cadenas pesadas de inmunoglobulina en el cromooma 14 disregula la expresin del bcl-2 nterfiriendo en la apoptosis dela celulas del foliculo germinal e iniciando la secuencia de malignizacin .

INDICE INTERNACIONAL PRONOSTICO (IPI)

FACTORPRONOSTICOGRUPO DE RIESGOndice internacionalNDE FACTORES DE RIESGOSLE A 5 AOS (%)SG A 5 AOS (%)Edad > de 60 a.DHL elevadaZubrod >= de 2Estado III o IVMs de una localizacin extraganglionarBajo

Bajo intermedio

Alto intermedio

alto0-1

2

3

4-570

50

49

4073

51

43

26

TRATAMIENTORADIOTERAPIA.QUIMIOTERAPIA: CHOP, ESHAP, MINE, ICE.ANTICUERPOS MONOCLONALES: ANTI CD20 RITUXIMAB.TMO.

Background: Disease and ProductMabThera

Production of MoAbsFuse cells and platein selected media

Screen hybrids forsynthesis of desiredantibodyMoAbSelected hybridomaMassculturegrowthHGPRT+lg+B cellsHGPRT-Ig-myeloma cellsMyelomacell cultureImmunizationAdapted from Khler et al. Nature. 1975;256:495.

Cytotoxic Mechanisms of MoAbsEffector cells/ComplementApoptosisRadiation/RadionuclideToxin/Drug

Antigen Expression in B-Cell Lineage Pre-BEarly BMature BPlasmacytoid BCD5 CD19CD20CD22CD52PlasmaIntermediate B???Stem cellBurkitts, FL, DLCL, HCLALL CLL, PLLWMMM

Maloney. Semin Hematol. 2000;37(4 suppl 7):17.Target Antigens: Important Biologic Features for MoAb TherapyExpressed on all tumor cellsNot present on critical host cellsNo significant toxicity if all antigen-positive cells eliminatedHigh copy numberNo mutations or variant antigensRequired for critical biologic function or cell survival Not shed or secretedNot modulated after antibody binding

CD20 Expression in B-Cell MalignanciesHistology 0100200300400500Burkitts lymphomaCLLCLL/PLLFollicular small cellHairy cellLarge cell LP/WaldenstrmsMantle cellMarginal zoneSmall cleavedAdapted with permission from Maloney. Semin Hematol. 2000;37(4 suppl 7):17.Mean Channel Fluorescence

MabThera: A Mouse/Human Chimeric MoAbMurine variable regions bind specifically to CD20 on B cellsHuman kappa constant regionsHuman IgG1 Fc domain works in synergywith human effector mechanismsChimeric IgG1Adapted from Rybak et al. Proc Natl Acad Sci USA. 1992;89:3165.

CD20 Antigen as a Targetfor ImmunotherapyANTIGEN INDEPENDENTANTIGEN DEPENDENTCD20expressionNeoplasias: Precursor B-cell leukemias B-Cell lymphomas/CLLWM/ MyelomaAdapted from Longo. Lymphocytic Lymphomas. In: Cancer: Principles and Practice of Oncology. 1993.Stem CellPre-Pre-B CellPre-B CellImmatureB CellMatureB CellActivatedB CellPlasmaCellIgMIgGIgAsIgMsIgGsIgAsIgM+ DsIgMHCRR/DHCRR/DHCR

Interaction of MabThera With Host Immune Effector CellsAdapted from Male et al. Advanced Immunology. 1996;1:1.MalignantB cellCD20MabTheraMabTheraCD20ComplementKillerleukocyte

Proposed Mechanismsof Action for MoAbsADCC

CDC

Apoptosis

Fc regionAntigenB cellAntibodyNK CellFc receptor(FcRIII)GranulesPores(perforin) Granules release perforins and granzymes; cytokines secreted (eg, IFN- )H20, ions,granzymesLysisADCC

Fc regionAntigenB cellAntibodyC1C1qC1sC1rPores(8-18 C9s)H20/IonsLysisCDC

ApoptosisAntigenB cellAntibody

Randomized Phase III Combination Immunochemotherapy for NHLAMC-010, CWRU-AMC-1400, MabThera +/- CHOP in previously untreated UCLA-9810029HIV-associated NHL UNMC-447-97, NCI-G99-1601, MabThera +/- CHOP in newly diagnosed, UCLA-HSPC-9812071 previously untreated, aggressive B-cell NHLSWS-SAKK-35/98, EU-98009, MabThera consolidation following induction in MabThera ICR-35/98 CD20+ FL or MCLEORTC-20981 CHOP +/- MabThera in relapsed follicular NHL EBMT-EBMTLYM1, MabThera purging and maintenance therapy with EU-99050 Peripheral blood stem cell (PBSC) transplant in relapsed follicular NHL undergoing high-dose chemotherapy E-4494 MabThera +/- CHOP in older patients with diffuse mixed, diffuse large, or immunoblastic large cell NHL MInT CHOP +/- MabThera in younger previously untreated patients with diffuse large B-cell NHL

LINFOMA GASTRICO

Carcinoma CK+ NM Neuroendocrina Sinaptofisina +Linfoma ACL. CD45 +Leiomiosarcoma Actina .vimentina +GIST CD 117+

Sistema de estadificacin de luganoESTADIO I: lesin localizada al tracto GI nico o mltiple no contiguas. ESTADIO II : Compromiso nodal IIa local IIb adistancia.ESTADIO III : Penetracin de la serosa e invasin a rganos vecinos .Perforacin Peritonitis.ESTADIO IV: Diseminacin hemtica. Compromiso ganglionar supradiafragmtico.

LINFOMAS DE LA PIEL

Micosis fungoide, fase de placa: marcado epidermotropismo de las clulas linfoides con los caractersticos acmulos intraepidrmicos (microabscesos de Pautrier).

CLASIFICACIN LC EORTCKerl H Oncol.1997;8(Supp.2):529-532IndolentesLinfoma centrofolicular.Inmunocitoma(LCB de la zona marginal)Grado intermedioLCGB de miembros inferiores.Tipos provisionalesLinfoma Intravascular de CGB.Plasmocitoma. Indolentes Micosis Fungoides.Micosis fungoides-mucinosis folicular.Reticulosis Pagetoide.Linfoma de clulas Grandes T,CD30+ .Anaplsico-Inmunoblstico-Pleomorfico.Papulosis Linfomatoide.AgresivosSndrome de Szary.Linfoma Clulas T Grandes, CD30 (Inmunoblstico-Pleomorfico.)Tipos provisionales Enfermedad granulomatosa de Slack Skin(piel floja)Linfoma cutneo clulas T , pleomrfico tipo celular pequeo/mediano.Linfoma Clulas T tipo paniculitis subcutnea.Linfoma cutneo T/NK. LCPCBLCPCT

CD3 + micosis fungoide granulomatosa

Linfoma cutneoLOAYZALinfoma TLinfoma BNK

***Interest in using antibodies in the treatment of cancer dates back almost 100 years, when immunologist Paul Ehrlich first proposed the use of targeted antibodies as magic bullets against cancer.96In 1975, Khler and Milstein developed the technology for making MoAbs.66MoAbs are so named because they are produced by the progeny of a single cell.66A mouse is repeatedly immunized with an antigen of choice, causing B cells to produce antibodies specific to that antigen.66B cells from the immunized donor are fused to an immortalized myeloma cell whose own antibody synthesis has shut off.66The resulting hybridoma cells can be grown in tissue culture to provide a homogeneous source of antibodies to the immunizing antigen.66

*Once bound to cancer cells, MoAbs can exert tumoricidal effects through a variety of mechanisms.Antibody-dependent cell-mediated cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC) may work in synergy with MoAbs to destroy tumor cells.75Induction of apoptosis (programmed cell death) and inhibition of cell proliferation following antibody binding have been demonstrated in vitro.24,96Antibodies that lack the ability to interact with the host immune system can be conjugated to radionuclides or toxins to produce a cytotoxic effect.24,60

*Individual stages of B-cell differentiation are identified by characteristic morphology and expression patterns of cell-surface antigens (CDs). CD19 is a marker of B-cell commitment, and its expression is first detected during the preB-cell stage. Changes in morphology and antigen expression during B-cell differentiation are reflected in the malignant counterparts of individual B cells. Detection of specific subsets of antigens has become an important method for identifying leukemia and lymphoma subtypes. For example, CLL is a malignancy of intermediate B cells characterized by expression of CD19, CD20, CD23, and CD5 antigens.37 The malignant clone of FL is a more mature B cell, expressing CD19, CD20, and CD22, but not CD5.124 Several anti-CD20, CD22, and CD52 MoAbs are currently being investigated for the treatment of B-cell malignancies.With the advent of MoAb therapy, understanding of specific patterns of antigen expression will be critical for successful treatments.

ALL = acute lymphoblastic leukemia; CLL = chronic lymphocytic leukemia; PLL = prolymphocytic leukemia; FL = follicular lymphoma; DLCL = diffuse large B-cell lymphoma; HCL = hairy cell leukemia; WM = Waldenstrms macroglobulinemia; MM = multiple myeloma.

*Several antigenic characteristics have been associated with increased efficacy of MoAbs.77It is critical that the target antigen be expressed on all tumor cells.High levels of antigen expression are important, as cells with low expression levels may be eliminated less effectively.It is also important that the antigen provides a critical biologic function.The presence of mutated/variant antigens, or antigens that are shed, secreted, or modulated, may decrease antibody binding and thus therapeutic efficacy.

*CD20 is expressed by virtually all B-cell NHLs, with intensity of expression varying among NHL subtypes and among individual patients. The highest levels of CD20 expression are usually found in patients with hairy cell, large cell, Burkitts, marginal zone, and follicular small cell lymphoma (FSCL).

*MabThera binds to the CD20 antigen present on normal and malignant pre-B and B cells.95 MabThera is an engineered immunoglobulin (Ig) produced from the variable regions (Fab) of a mouse (murine) anti-CD20 MoAb and human IgG1 and kappa constant regions (Fc).The human Fc domain and kappa constant regions may contribute to the infrequency of host antibody response.

*CD20 is a membrane-embedded protein that is restricted in expression to B-cell precursors and B cells.73,76This antigen is not found on stem cells and is lost when normal B cells differentiate to form antibody-producing plasma cells.73CD20 is expressed on >95% of malignant cells in B-cell NHL.76CD20 does not circulate as a free antigen in the plasma, and therefore free antigen does not compete for antibody binding.Due to these characteristics, CD20 is an excellent candidate target antigen for MoAb therapy for B-cell NHL.

HCR = heavy chain rearrangements; m = mu heavy chain synthesis; R/D = kappa chain rearrangement or deletion; R/D = lambda chain rearrangement or deletion; SIgM, SIgG, SIgA = surface immunoglobulins M, G, and A, respectively.

*MabThera binds CD20 cell surface markers on pre-B and B cells, including normal and malignant B cells.75It also binds to Fc receptors on human effector cells (such as macrophages and natural killer [NK] cells) and induces ADCC through its human Fc domain. Analysis by flow cytometry has demonstrated that MabThera can also mediate CDC.95Importantly, CD20 does not internalize or shed from the cell surface upon binding of antibody.

*Like endogenous antibodies, MoAbs eliminate cells expressing target antigens by ADCC, CDC, and apoptosis.13,106,118

*The initial event in ADCC involves binding of NK cells to antibodies bound to cell-surface antigens.118 Binding occurs between the NK receptor, FcRIII, and the Fc region of antibodies. This binding triggers cell lysis by localized discharge of lytic proteins (perforins) and granzymes, enzymes from granules within NK cells. Perforins, which are structurally homologous to the complement component of the membrane attack complex (MAC), form pores in target cell membranes, inducing osmotic swelling and cell lysis. The pores also function as a channel through which granzymes enter the target cell and induce apoptosis.

*Apoptosis is defined as physiologic or programmed cell death that is characterized by specific morphologic features. Chromatin becomes fragmented and clumped, the plasma membrane becomes ruffled and blebbed, and the cell shrinks progressively. Ultimately, the cell fragments and is phagocytosed by adjacent cells. The mechanism by which MoAbs induce apoptosis is not fully understood, but it is thought to involve activation of protein tyrosine kinases, increases in intracellular Ca2+, caspase activation, and cleavage of caspase substrates.13,106

*There are several phase III trials being conducted worldwide to further evaluate the safety and efficacy of MabThera for patients with lymphoma. Collectively, these trials have enrolled newly diagnosed, relapsed, indolent and aggressive lymphoma patients and are attempting to elucidate optimal dosing regimens of MabThera both alone and in combination with chemotherapy.