Lymphoma Flashcards
What are the types of lymphoma
Hodgkin’s = Neoplasm of lymphoid cells
Non-Hodgkin’s = malignancy of lymphoid cells (85% B cell, 15% T cell and NK forms)
What is the difference between lymphoblastic lymphomas and lymphoblastic leukaemias
Lymphoblastic lymphomas develop from immature precursor lymphoblasts
Bone marrow infiltration <25% = lymphoblastic lymphoma
Bone marrow infiltration >25% = lymphoblastic leukaemia
What is the epidemiology of Hodgkin’s lymphoma
Makes up 15% of lymphomas
Bimodal age distribution (20-30 and >50s)
Males > Females
What are the risk factors for Hodgkin’s lymphoma
Linked to EBV (50%)
Family History Hodgkin’s
Higher socio-economic class
Immunodeficiency
What is the epidemiology of Non-hodgkin’s lymphoma
Incidence increases with age
Males > Females
More prevalent in the West
What are the causes and risk factors of Non-Hodgkin’s lymphoma
Chronic antigenic stimulation:
EBV → Burkitt’s lymphoma
HTLV-1 → Adult T-cell lymphoma/leukaemia (ATLL)
HHV-8
RF:
Viral infection
Radiotherapy/Chemotherapy
Connective tissue diseases e.g. SLE
Immunodeficiency, mmunosuppression
CLL (Richter’s transformation)
What are the types of Hodgkin’s lymphoma
Classic (85%)
- Nodular sclerosis (70%)
- Mixed cellularity
- Lymphocyte-rich
- Lymphocyte-depleted
Non-classical: nodular lymphocyte-predominant HL (NLPHL)
What are the types of non-hodgkin’s lymphoma
B cell
High grade
Burkitt’s lymphoma (50-60%)
Large B-cell lymphomas* (10-15%)
Mantle cell lymphoma
Low grade
Follicular lymphoma
Marginal zone lymphoma (MALToma)
Precursor
Precursor B-lymphoblastic lymphoma
T cell
High grade
Anaplastic large-cell lymphoma
Peripheral T-cell lymphoma
Adult T cell leukaemia lymphoma (ATLL)
Enteropathy-associated T-cell lymphoma (EATL)
Mycosis fungoides and cutaneous T-cell lymphomas
Precursor T-lymphoblastic lymphoma (15%)
What are the symptoms of Hodgkin’s lymphoma
Painless enlarging mass (neck, axilla and groin) - Painful after alcohol and ingestion
B symptoms: Fever, night sweats, weight loss (>10% in last 6 months), fatigue
Pruritus
Dry cough
Preceding infection
What are the symptoms of Non- Hodgkin’s lymphoma
Painless enlarging mass (Neck/axilla/groin)
B symptoms: Fever, night sweats, weight loss (>10% in last 6 months), fatigue
Hypercalcaemia: stones, thrones, abdominal groans, psych moans
Extra-nodal: skin rash, headache, sore throat, abdominal discomfort, testicular swelling, urinary retention, behavioural change, headache
Bone marrow: anaemia, infections, purpura
What are the differentials for lymphoma
Leukaemia
TB
URTI
Infectious mononucleosis
CMV, rubella, measles
HIV
HHV-6
Typhoid
Syphilis
Toxoplasmosis
Cervical lymphadenitis
What investigations should be done for lymphoma
Bedside: throat swab, urine dip, ECG (exclude infection, baseline)
Bloods:
- FBC: microcytic anaemia, raised WCC, raised neutrophils + eosinophils, reduced lymphocytes
- U&Es
- LFTs: raised LDH, raised transaminases in liver involvement
- ESR: raised
- Monospot (exclude EBV)
- Hep B/HIV serology
- G6PD (before rasburicase due to haemolytic crisis risk)
Other:
CXR (Mediastinal mass, large mediastinal adenopathy)
CT/MRI/PET: enlarged lymph nodes and spread
Biopsy of enlarged lymph nodes for staining
Bone marrow aspirate and trephine biopsy
What film feature is specific to Hodgkin’s lymphoma
Reed-sternberg cells: Large cell with abundant pale cytoplasm and ≥2 oval lobulated nuclei containing prominent “owl-eye” eosinophilic nucleoli (lacunar or popcorn cells)
What are the diagnostic features specific to Non-hodgkin’s lymphoma
EBV detection
Splenomegaly
Describe the staging for lymphoma
Ann Arbor Staging
A = B symptoms absent
B = B symptoms present
E = involvement of single, contiguous, or proximal extranodal site
I: One node region involved on 1 side of the diaphragm
II: 2+ ipsilateral regions involved on 1 side of the diaphragm
III: Bilateral node involvement on both sides of the diaphragm
IV:
HL: Involvement of extranodal sites beyond those designated by ‘E’ (below)
NHL: Disseminated/multifocal involvement of ≥1 extralymphatic site OR isolated extralymphatic organ involvement with distant node involvement
What is the management for Hodgkin’s lymphoma
Chemotherapy: ABVD
± radiotherapy
+ PET scan follow up
What is the management for Non-hodgkin’s lymphoma
Treat any antigenic stimulation causes e.g. H. pylori
Chemotherapy: R-CHOP
Biologics: Rituximab (anti CD20 antibody) is the standard of care in high-risk mature B-cell NHL.
Radiotherapy
Bone marrow transplant (BMT): high dose chemotherapy with BMT can be used for relapsed patients.
Lymphoblastic lymphoma is treated according to chemotherapy protocols for ALL.
What are the complications of chemotherapy for lymphoma
Short-term
- Neutropenic sepsis
- Mucositis, diarrhoea
- Anorexia and weight loss
- Alopecia
- Nausea and vomiting
- Fatigue
- Tumour lysis syndrome
Long term
- Secondary cancers
- Cardiotoxicity
- Pulmonary toxicity
- Renal impairment
- Growth impairment
- Infertility
What are the complications of lymphoma
Superior vena cava obstruction
Bowel obstruction/perforation
Cytopenias
Pericardial or pleural effusions
Pain from tumour invasion
Tumour lysis syndrome
What is the prognosis for lymphoma
Approximately 90% of patients with Hodgkin’s lymphoma and >90% of children with Non-Hodgkin’s lymphoma achieve remission.
However, excellent survival rates mean that the long-term effects of treatment can be significant. Children require long-term follow-up, assessing for recurrence and the onset of any late side effects.
What are the causes of Burkitt’s lymphoma
B-cell NHL, most aggressive
Associated with EBV infection
- Malaria may reduce resistance - seen in malaria endemic regions
Associated with HIV infection
What are the diagnostic features of Burkitt’s lymphoma
Arises from germinal centre cells
Starry-sky appearance
C-myc translocation (8;14, 2;8 or 8;22)
What are the signs of Hodgkin’s lymphoma
Lymphadenopathy (Cervical, axillary, inguinal) - Non-tender, firm, rubbery
Splenomegaly (EBV)
Hepatomegaly
What are the signs of non-Hodgkin’s lymphoma
Neck mass (Painless, firm, rubbery lymphadenopathy, Oropharyngeal (Waldeyer’s ring of lymph node) involvement)
Skin rash: Mycosis fungoides (well-defined indurated scaly plaque-like lesions with raised ulcerated nodules caused by cutaneous T cell lymphoma) and Sezary’s syndrome
Hepatosplenomegaly
Abdominal mass
Bone marrow involvement: Purpura
