Documente Academic
Documente Profesional
Documente Cultură
Heri Sutrisno
SMF / Bagian Penyakit Dalam RSUD Prof Dr WZ Johannes
Hematopoietic Malignancies
Neoplasms of lymphoid
origin, characterized by the
abnormal proliferation B or
T cells in lymphoid tissue
typically causing
lymphadenopathy
Clonal expansions of cells at
certain developmental
stages
What is Lymphoma
Multipotential Multipotential
myeloid cells lymphocytic cells
B-lymphocytes
Plasma
Lymphoid cells
progenitor T-lymphocytes
Eosinophils
Basophils
Monocytes
Platelets
Red cells
Classification
Follicular lymphoma
Diffuse large B-cell lymphoma
Hodgkin lymphoma
Relative frequencies of
different lymphomas
Non-Hodgkin Lymphomas
Other NHL
Genetic alterations
Infection
Antigen stimulation
Immunosuppression
Epidemiology of lymphomas
0
20
40
60
80
100
0-1
1-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Age (years)
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Age distribution of new NHL
Risk factors for NHL
immunosuppression or immunodeficiency
connective tissue disease
family history of lymphoma
infectious agents
ionizing radiation
Clinical manifestations
Variable
severity: asymptomatic to extremely ill
time course: evolution over weeks, months, or years
Systemic manifestations
fever, night sweats, weight loss, anorexia, pruritis
Local manifestations
lymphadenopathy, splenomegaly most common
any tissue potentially can be infiltrated
Other complications of
lymphoma
bone marrow failure (infiltration)
CNS infiltration
immune hemolysis or thrombocytopenia
compression of structures (eg spinal cord, ureters)
pleural/pericardial effusions, ascites
>10 cm
Bulky disease
Lymphoma Staging
A: absence of B symptoms
B: fever, night sweats, weight loss
Staging
Stage I : Involvement of single LN region (I) or
extra lymphatic site (IAE )
Stage II : Two or more LN regions involved (II)
or an extra lymphatic site and lymph node
regions on the same side of diaphragm
Stage III : Involvement of lymph node regions
on both sides of diaphragm, with (IIIE) or without
(III) localized extra lymphatic involvement or
involvement of the spleen (IIS) or both (IISE)
Stage IV : Involvement outside LN areas (Liver,
bone marrow)
A : Absence of B symptoms
B : B symptoms present
Diagnosis
Anamnesis Khusus
Penyakit autoimun (SLE, Sjorgen, Rheuma)
Kelainan Darah
Penyakit Infeksi (Toxoplasma, Mononukleosis, Tuberkulosis, Lepara )
PROSEDUR DIAGNOSTIK
2. Pemeriksaan Fisik
Pembesaran KGB
Kelainan/pembesaran organ
Performance status: ECOG atau WHO/karnofsky
3. Pemeriksaan Diagnostik
Biopsi
Biopsi KGB dilakukan cukup pada 1 kelenjar yang paling representatif,
superfisial, dan perifer. Jika terdapat kelenjar superfisial/perifer yang paling
representatif, maka tidak perlu biopsi intraabdominal atau intratorakal. Spesimen
kelenjar diperiksa:
Rutin: Histopatologi: sesuai kriteria REAL-WHO
Khusus: Imunohistokimia
PROSEDUR DIAGNOSTIK
3. Pemeriksaan Diagnostik
Biopsi
Diagnosis harus ditegakkan berdasarkan histopatologi dan tidak cukup hanya
dengan sitologi. Pada kondisi tertentu dimana KGB sulit dibiopsi, maka
kombinasi core biopsy FNAB bersama-sama dengan teknik lain (IHK, Flowcytometri
dan lain-lain) mungkin mencukupi untuk diagnosis
Tidak diperlukan penentuan stadium dengan laparotomy
Laboratorium
Rutin: DPL, gbrn darah tepi, UL
Kimia klinik: GOT, GPT, Bilirubin , LDH, Protein total, Albumin-globulin, Alkali
fosfatase, asam urat, ureum, kreatinin, Gula Darah Sewaktu, Elektrolit: Na, K, Cl, Ca,
P, HIV, TBC, Hepatitis C (anti HCV, HBsAg)
Khusus: Gamma GT, Serum Protein Elektroforesis (SPE), Imunoelektroforesa (IEP),
Tes Coomb, B2 mikroglobulin
PROSEDUR DIAGNOSTIK
Aspirasi Sumsum Tulang (BMP) dan biopsi sumsum tulang dari 2 sisi spina
illiaca dengan hasil spesimen 1-2 cm
Radiologi: Untuk pemeriksaan rutin/standard dilakukan pemeriksaan CT Scan
thorak/abdomen. Bila hal ini tidak memungkinkan, evaluasi sekurang-
kurangnya dapat dilakukan dengan : Toraks foto PA dan Lateral dan USG
seluruh abdomen.
Konsultasi THT Bila Cincin Waldeyer terkena dilakukan laringoskopi
Cairan tubuh lain (Cairan pleura, cairan asites, cairan liquor
serebrospinal)
Imunofenotyping: Minimal dilakukan pemeriksaan imunohitstokimia (IHK)
untuk CD 20 dan akan lebih ideal bila ditambahkan dengan pemeriksaan
CD45, CD3 dan CD56 dengan format pelaporan sesuai dengan kriteria
WHO (kuantitatif).
Konsultasi jantung: Menggunakan echogardiogram untuk melihat fungsi
jantung
Bone Marrow Aspiration/Biopsy
Differential Diagnosis
Ca Nasopharynx
TB Kelenjar
Metastasis tumor
Infectioan: Viral,
Treatment
RT
Chemo
BMT / SCT
Antibody treatment: Rituximab target CD-20
Supportive
Treatment - Guidelines
Indications for RT:
Stage I disease
Stage II disease with 3 or lesser areas involved
For Bulky disease
For pressure problems
Indications for CT
All with B symptoms
Stage II disease with >3 areas involved
Stage III and IV disease
Treatment
Stage IA , Stage IIA with 3 or < 3 areas
involved: Radiotherapy
Prednisolonone
Chemotherapy pro LH
MOPP :
Nitrogen
Mustard,
Vincristine (Oncovin),
Procarbazine,
Prednisolone
ABVD:
Adriamycin,
Bleomycin,
Vinblastine,
Dacarbazine
Prognosis
Terima kasih . . .