Peripheral T-Cell Lymphoma Facts No. 25 in a series providing the latest information for patients, caregivers and healthcare professionals www.LLS.org • Information Specialist: 800.955.4572 Highlights Introduction Peripheral T-cell lymphomas (PTCLs) are uncommon and l Peripheral T-cell lymphomas (PTCLs) comprise a aggressive types of non-Hodgkin lymphoma (NHL) that diverse group of uncommon and aggressive diseases develop in mature white blood cells called “T cells” and in which the patient’s T cells become cancerous. T-cell “natural killer (NK) cells.” lymphomas account for between 10 percent and 15 percent of all non-Hodgkin lymphomas (NHLs). NHL is the name for many different types of cancer that l The World Health Organization (WHO) divides start in cells called “lymphocytes,” a type of white blood PTCLs into three categories (nodal, extranodal cell that helps the body fight infection. There are three and leukemic) and classified subtypes within these types of lymphocytes: B lymphocytes (B cells), categories of PTCLs. Getting an accurate diagnosis T lymphocytes (T cells) and natural killer cells (NK cells). and knowing your PTCL subtype is important. NHL may arise in B cells or T cells. B-cell lymphomas are more common than T-cell lymphomas. NHLs may be l PTCLs are rare in the United States and are more indolent (slow growing) or aggressive (fast growing). For common in Asia, Africa and the Caribbean, possibly more information about NHL, please see the free Leukemia due to exposure to specific viruses, such as the & Lymphoma Society (LLS) booklets Non-Hodgkin Epstein-Barr virus (EBV) and the human T-cell Lymphoma and The Lymphoma Guide – Information for leukemia virus-1 (HTLV-1). Patients and Caregivers. l PTCLs generally affect people older than 60 years, although they can occur anytime during adulthood. This publication provides descriptions of the various subtypes of PTCL. It also includes specific information on l Although the signs and symptoms of PTCLs vary the diagnosis, stages and treatment of PTCLs; new drugs according to the subtype, some common signs and being studied in clinical trials; and support resources. symptoms of the diseases include fatigue, a painless swelling in the neck, armpit or groin (due to an enlarged lymph node), night sweats, rash and weight loss. About Peripheral T-Cell Lymphoma l New therapies are showing some effectiveness in Between 10 percent and 15 percent of all patients with treating patients who have certain subtypes of PTCL, NHL have a T-cell lymphoma subtype. PTCLs generally and other potential therapies are being studied in affect people aged 60 years and older and are diagnosed clinical trials. However, standards of care have not slightly more often in men than in women. However, been established for newly diagnosed PTCL patients younger adults and children are also diagnosed with PTCLs. or for patients who have disease that has relapsed PTCL is an uncommon disease in the United States. Some (recurred) or is refractory (resistant to treatment). forms of PTCL are more common in Asia, Africa and the Caribbean, possibly as a result of exposure to specific l More research and clinical trials focusing specifically on the various subtypes of PTCL are needed to define viruses, such as the Epstein-Barr virus (EBV) and the the best management of patients who have these human T-cell leukemia virus-1 (HTLV-1). diseases. The World Health Organization (WHO) classification system recognizes subtypes of PTCL and has grouped the diseases into three categories: nodal, extranodal and leukemic. WHO has also divided T-cell lymphomas into two groups: aggressive (fast growing) and indolent (slow growing). PTCLs are a varied group of diseases that differ from B-cell This publication was supported in part by a grant from lymphomas. Because PTCLs are less common than B-cell FS25 Peripheral T-Cell Lymphoma Facts I page 1 Revised July 2014 Peripheral T-Cell Lymphoma Facts lymphomas, they are not as well understood. Techniques so that the hematopathologist (a doctor who specializes in to distinguish and study the various subtypes of PTCL interpreting and diagnosing the physical changes caused have only recently been developed. As a result, standards of by diseases of the blood and marrow) has enough tissue to care for how best to treat PTCLs have not been established make a firm diagnosis. Lymph node biopsy tissue can often for newly diagnosed patients or for patients whose be removed after the administration of a local anesthetic. disease has relapsed (recurred) or is refractory (resistant The cells in many subtypes of PTCLs look alike; therefore, to treatment). In general, treatment outcomes have been making an accurate diagnosis may require the use of poor with conventional chemotherapy regimens. However, additional diagnostic tests, including blood tests, CT a greater understanding of PTCLs and new genetic and (computerized axial tomography), PET (positron emission molecular testing techniques have led to the development tomography) scans, MRI (magnetic resonance imaging), of new targeted drugs (see Treatment Under Study on and bone marrow biopsy. page 4). Other therapies are being explored and tested in research laboratories and in human clinical trials designed An accurate diagnosis is the start for planning the treatment specifically for T-cell lymphomas (see Peripheral T-Cell approach. An experienced hematopathologist is needed Lymphoma Subtypes on pages 5 and 6). to analyze the biopsy slides. A second opinion by another hematopathologist may be necessary if there is any doubt Because PTCLs are so uncommon, it is best to seek about the diagnosis. treatment at a medical center specializing in the diagnosis and treatment of NHL (see the free LLS fact sheet Choosing a Blood Cancer Specialist or Treatment Center for more Treatment Planning information). Every patient’s medical situation is different and should be Another group of T-cell lymphomas is called “cutaneous evaluated individually by an oncologist who specializes in T-cell lymphomas (CTCLs),” or skin lymphomas. CTCLs treating NHL. It is important for you and members of your consist of a number of different diseases with various signs oncology team to discuss all treatment options, including and symptoms, treatment approaches and outcomes. While treatments being studied in clinical trials. there may be skin involvement with some PTCLs, CTCLs originate in the skin. CTCLs are primarily slow growing. Staging This group of diseases is described in detail in the free LLS Knowing the stage of your disease helps members of your fact sheet Cutaneous T-Cell Lymphoma Facts. health care team determine the most effective course of treatment for you. The Ann Arbor Staging System is the most Signs and Symptoms common system used for classifying all subtypes of NHL. The first signs of PTCL vary depending on the disease The system is divided into four stages and is based on where subtype. Because lymph nodes in several different areas of the disease is located in the body: the body are frequently involved, the most common sign of PTCL is an enlarged, painless lymph node in the neck, l Stage I—The cancer is in a single lymph node or lymph armpit or groin. Enlarged lymph nodes can also appear near node region or, the cancer is in an organ or site other than a the ears or elbows. These lymphomas also affect various lymph node (extranodal) but has not spread to other organs organs in the body, including the bone marrow, liver, or lymph nodes. spleen, stomach and skin. Other symptoms may include l Stage II—The cancer is in two or more lymph node regions l Night sweats on the same side of the diaphragm. l Fever l Stage III—The cancer is in lymph node regions on both l Weight loss sides of the diaphragm, with or without partial involve- ment of an extranodal organ or site above or below the l Rash. diaphragm. Diagnosis l Stage IV—The cancer is widespread, including multiple Most PTCLs are diagnosed by taking a small sample (a involvements in one or more extranodal sites, such as the “biopsy”) of an enlarged lymph node and then examining bone marrow. the cells under a microscope. Generally, either the lymph node, or a part of the lymph node, is surgically removed FS25 Peripheral T-Cell Lymphoma Facts I page 2 Peripheral T-Cell Lymphoma Facts Treatment for Newly Diagnosed The number of IPI ‘risk factors’ a person has defines the IPI risk group to help predict the risk of relapse. Each point Patients represents some increased risk for disease recurrence. The Currently, newly diagnosed PTCL patients are usually total number of points identifies the following risk groups: treated with anthracycline-based chemotherapy regimens. low risk (0-1 points); low-intermediate risk (2 points); Most subtypes of PTCL are treated as follows high-intermediate risk (3 points); high risk (4-5 points). For l CHOP (cyclophosphamide, hydroxydoxorubicin patients younger than 60 years, the risk categories are slightly [doxorubicin], Oncovin® [vincristine], prednisone) different; low risk (0 points); low-intermediate risk (1 point); high-intermediate risk (2 points); high risk (3 points). l CHOEP (cyclophosphamide, hydroxydoxorubicin [doxorubicin], Oncovin® [vincristine], etoposide, The Prognostic Index for PTCL (PIT). PIT is a prognostic prednisone) index used mainly for peripheral T-cell lymphoma, not l EPOCH (etoposide, prednisone, Oncovin® [vincristine], otherwise specified (PTCL-NOS). PIT separates PTCL- cyclophosphamide, hydroxydoxorubicin [doxorubicin]) NOS patients into more specific prognostic groups than the IPI. PIT is based on four risk factors: age, performance l Hyper-CVAD (cyclophosphamide, Oncovin® status, serum lactate dehydrogenase (LDH) and bone [vincristine], Adriamycin® [doxorubicin], dexamethasone); marrow involvement. By using these risk factors instead “hyper” refers to “hyperfractionation of the dose,” of the risk factors associated with the IPI, PIT has a better meaning that the chemotherapy is given in small, frequent predictive capacity for PTCL-NOS.