ESMO Afr frica, , 2019 NHL &HIV Case Presentation 16 February ry 2 2019, Cape Town SA Dr. A.M. Nyakabau Consultant Oncologist, Harare Parirenyatwa Hospital College of Health Sciences, Zimbabwe
Demographics Mr T.M 32 year old banker Married with 2 children (5years; 18 months) Lives in Harare
Presenting History ry • Diagnosed HIV positive June 2013 (discordant couple) • July 2013 started on ART (Tenolam-E) & Cotrimoxzole prophylaxis • Six months later: Developed painless right groin mass • Physician initially attributed the mass to IRIS • No history of B symptoms
Presenting History ry • By July 2014 mass enlarged significantly • Referred to surgeons, biopsy August 2014 • Oct 2014, oncologist referral then haematologist • Further inv & treatment by haematologist
Past medical & & Family history ry • No history cancer or other chronic illnesses • Never previous treatment with chemo/RT • No Family history of cancer • Does not drink or smoke, banker, married 2 daughters
Examination fi findings at presentation • Stable, apyrexial, ECOG Performance Status 0 • Approx7cm enlarged firm right groin lymph node mass • No lymphadenopathy elsewhere • CVS/RS & other systems: normal
In Investigations (S (Sept 2014) • Full blood count • Wcc 7,2 Hb 15,2 Plt 379 • U&E • Na 135 K 4.8 U 6 Cr 90 • LFT • Serum Bil 3.2 AST 23 ALT 30 ALP 129 Albumin 46 • Hep B & C negative
In Investigations (S (Sept 2014) • Serum LDH: 699 U/L (normal 60- 350) • Uric Acid: 369 U/l (normal 230-350) • Viral load 40 copies/ml • CD4 count: 552cells/uL • ECHO: Normal heart structure & function, EF 75%
Histopathology • Large cell diffuse Non-Hodgkin's lymphoma with • Large atypical lymphoid cells with rounded nuclei • Frequent mitosis • Prominent apoptosis • Partial necrosis • Immunohistochemistry: CD20 positive • Bone marrow- no evidence of malignancy
Staging CT Scan chest, abdomen + pelvis • Large lobulated mass in the inguino-femoral region • Approx. 7cm x 7cm • Infiltrating the right pectineus and sartorius muscles • Enlarged left internal iliac lymph nodes • Urinary bladder, ureters & kidneys normal • Normal liver, chest & bones
In International Prognostic In Index SCORE Age <60 years 0 LDH level elevated 1 ECOG Score 0 0 Disease stage <3 0 Extranodal <2 0 disease sites TOTAL 1 ( LOW RISK )
Diagnosis 1. Diffuse Large Cell Non-Hodgkin's Lymphoma • STAGE I/II (Ann Arbor) • IPI low risk 2. HIV positive and no features of AIDS
Treatment options considered 1. Immunochemotherapy Plus IFRT • Rituximab plus CHOP (3 cycles) then Involved Field External Beam Radiotherapy (IFRT) 2. Immunochemotherapy alone • Rituximab plus CHOP (6 cycles) 3. Chemotherapy alone • CHOP
Treatment given to Mr TM • R-CHOP three weekly up to 6 cycles • Rituximab 375mg/m 2 • Cyclophosphamide 750mg/m 2 • Doxorubicin 50mg/m 2 • Prednisolone 100mg PO Od x 5 days
Treatment Details • From November 2014- February 2015 • Tolerated therapy well; had alopecia at the 5 th cycle • No treatment delays • Declined referral back to oncology for RT
Progress to date • In remission for 3 years post-treatment • Being followed up by a primary care physician • HIV infection well controlled • CD4 count – 630cell/uL; VL undetectable • 2 nd child 18/12months,Wife & two daughters HIV negative
Discussion Points Mr T.M. was treated privately on Health Insurance Public pts cannot afford Immunochemotherapy Antenatal HIV diagnosis by gynecologist-good clinical practice Presentation post- HIV treatment – IRIS Optimum waiting period post-chemo to father children?
Discussion • CT scan enlarged internal iliac nodes ? Tumour/ Inflammation ? PET/CT scan value • What is the role of RT role after Immunochemotherapy ? • How well tolerated is R-CHOP in HIV positive patients • What is the recommended follow up protocol?
Zimbabwe Cancer Facts Total :7 165 (2015) New Cases Cancer Deaths Chokunonga E, et al, Zimbabwe Cancer Registry 2015 Annual Report
Acknowledgements • Patient & family • Parirenyatwa hospital Colleagues & staff
Thank You
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