This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #22
The majority of lymphomas occur in older adults.
Modern classification systems for lymphomas are evolving rapidly and incorporate immunophenotyping and genetics.
Comorbidity and frailty are strong modifiers of prognosis and must be incorporated into treatment planning.
Immunotherapies play an increasing role in treatment of some lymphomas; consider life expectancy when planning treatment.
NON-HODGKIN AND HODGKIN LYMPHOMA: INTRODUCTION
The intimate interplay between the aging process and the development of malignancy in many ways ensures that cancer is a disease of older individuals and the lymphoid malignancies are no exception. The lymphoid malignancies comprise over 60 heterogeneous and complex entities as identified in the World Health Organization (WHO) classification 2008. The median age at diagnosis of representative entities such as diffuse large B-cell lymphoma (DLBCL), multiple myeloma (MM), and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) are 64, 71, and 72 years, respectively. Consequently, the care of this patient population frequently requires the care of the older patient. In this chapter we focus on Non-Hodgkin lymphomas (NHLs) and Hodgkin lymphomas (HLs); acute leukemia and CLL/SLL are addressed in Chapter 104.
NHLs are the most common lymphoid malignancy, representing a heterogeneous group of lymphoproliferative disorders that originate from cells of the immune system, including B lymphocytes, T lymphocytes, or natural killer (NK) cells. In the United States, the B-cell lymphomas predominate, making up 80% to 85% of lymphoma diagnoses, with T-cell histologies representing 15% to 20% of the balance; NK-cell lymphomas are rare at less than 1%.
The spectrum of clinical presentations for lymphoma can be quite protean, dependent on the type of lymphoma, the disease subtype, each with variable disease courses, and the presence of nodal or extranodal involvement. Broadly speaking, lymphomas can be characterized as either indolent behaving with median survivals measured in decades or aggressive behaving, with life-threatening consequences in a matter of weeks or months if left untreated.
Indolent lymphomas are more often identified incidentally during routine physical examination or laboratory evaluation, particularly with increased reliance on routine blood testing and imaging in the modern era. Often, these entities present with slowly progressive lymphadenopathy, splenomegaly, and potential cytopenias from bone marrow involvement. Examples include the prototypic follicular lymphoma (FL), marginal zone lymphomas, and CLL/SLL.
In contrast, aggressive lymphomas are more likely to present with acute or subacute symptoms including a rapidly growing mass, systemic B symptoms (fevers, night sweats, weight loss), elevated serum lactate dehydrogenase, hypercalcemia, and hyperuricemia. Examples include DLBCL, peripheral T-cell lymphomas (PTCL), and Burkitt lymphoma (BL).
Clinical characteristics of NHLs include “B” symptoms, defined as fever greater than 38°C, unexplained weight loss greater than 10% of body weight over the past 6 months, and drenching night sweats. Up to 40% of patients with NHL may have B symptoms; ...