Lymphoma

Question 1

What is lymphoma?

Answer 1

a malignant growth of white blood cells predominantly in the lymph nodes
(but can also occur in the blood, bone marrow, liver, spleen and anywhere where there are lymphocytes)

Question 2

What are the causes of lymphoma?

Answer 2

primary immunodeficiency 
secondary immunodeficiency (HIV< transplant recipient)
infection (EBV, H. pylori, HTLV-1)
autoimmune disorders eg RA

Question 3

At what age is Hodgkin’s lymphoma most common?

Answer 3

15-34 is the predominant peak and there is another peak at 65 yrs old

Question 4

What is the pathophysiology of lymphoma?

Answer 4

80% are B cell in origin - B cells escape regulation and proliferate autonomously

Question 5

How is lymphoma classified?

Answer 5

split into Hodgkins and Non-hodgkins

Non- hodgkins are further classified according to growth rate: low grade and high grade

Question 6

What is the name of the characteristic histological cell type seen in Hodgkin’s lymphoma?

Answer 6

Reed-Sternberg cell = lacunar histiocyte

they are a type of not fully developed B cell

Question 7

What are the signs and symptoms of lymphoma?

Answer 7

nodal disease = lymphadenopathy: painless, rubbery, non-tender lymph nodes
hepatosplenomegaly chest symptoms or SVCO
spinal cord compression
B symptoms: fever, night sweats, weight loss, loss os appetite
bone marrow failure: anaemia, thrombocytopenia, leucopenia
other organ involvement: eg GI and MALT ie extranodal disease

Question 8

How is lymphoma diagnosed?

Answer 8

1. lymph nodes biopsy + histology
2. bone marrow biopsy 3. immunohistochemistry of biopsy samples eg for CD20+
3. FBC - to see if bone marrow failure
4. Blood film
5. cytogenetics: FISH and karyotype analysis, done for classification
6. molecular techniques: PCR

Question 9

What can be used to stage lymphoma?

Answer 9

PET scan
CT scan
blood tests
bone marrow biopsy

Question 10

What is done after the pt has been diagnosed with lymphoma?

Answer 10

staging
find out how fit the pt is for treatment
make a plan for treatment in MDT meeting

Question 11

How is the pt assessed to see how fit they are for treatment?

Answer 11

history and examination 
bloods: FBC, U+Es, LFTs, Viral serology for HIV, Hep B, hep C
CXR
ECHO
PFTs
WHO Performance status

Question 12

What are the stages of the WHO performance status

Answer 12

0 - asymptomatic, activities without restriction
1 - symptomatic but completely ambulatory (restricted strenuous activity, but can do light work)
2 - symptomatic, <50% of time in bed during the day (ambulatory and capable of all self care, but unable to carry out any work activities)
3- symptomatic and more than 50% of the time in bed, limited self-care
4- bedbound - cannot carry out any self care
5 -death

Question 13

which WHO statuses are fit for chemo?

Answer 13

0-2

Question 14

Name a low grade non-Hodgkin’s lymphoma

Answer 14

Follicular lymphoma

Question 15

Name a high grade lymphoma

Answer 15

Diffuse large B cell lymphoma

Question 16

Name a very high grade lymphoma

Answer 16

Burkitt’s

Question 17

What are the four stages of Hodgkin’s lymphoma?

Answer 17

Stage 1 - single lymph node region or single extralymphatic site
stage 2 - two or more lymph node regions on the same side of the diaphragm (or one lymph nodes region and one extralyphatic region)
stage 3 - involvement of lymph regions on both sides of the diaphragm
stage 4- disseminated involvement of one or more extralymphatic organs with or without node involvement

Question 18

Which stages of HL cannot be treated with radiotherapy?

Answer 18

stage 3 and 4

Question 19

What is the treatment for HL?

Answer 19

stage 1-2A: combination chemo and radiotherapy

stage 2B-4: combination chemo (as widespread disease so radiotherapy doesn’t work)

Question 20

What is the prognosis for HL and what is the implication of this for treatment?

Answer 20

HL has a good prognosis - >80% can be cured
this means that young people who are cured have a high risk of developing complications due to the effect of treatment, so de-escalation of treatment is being done for those who are likely to respond better to treatment

Question 21

Give examples of long term side effects from chemo treatment used in HL

Answer 21

infertility
cardiomyopathy 
lung damage 
peripheral neuropathy 
second cancers

Question 22

What is the disadvantage of having a slow growing NHL like follicular lymphoma?

Answer 22

usually advanced at presentation

incurable

Question 23

What treatment may be offered to those with indolent ie slow growing NHL?

Answer 23

do nothing
alkylating agents 
combination chemo 
monoclonal antibodies 
radio-immunocongugates 
radiotherapy
bone marrow transplant

Question 24

What is the disease progression of indolent NHL?

Answer 24

all pts with follicular lymphoma treated with chemo will relapse and some may transform into diffuse large B cell lymphoma

Question 25

What is the difference between HL and high grade NHL?

Answer 25

in HL, the disease is mainly limited to the lymph system, but in high grade NHL, the disease can spread outside the lymph nodes ie extranodal

Question 26

What is the treatment for high grade NHL?

Answer 26

combination chemo and monoclonal Abs

Question 27

Give an example of a monoclonal Ab that can be used in the treatment of lymphoma and how it works

Answer 27

Rituximab
monoclonal Ab that targets CD20 expressed on the surface of B cells
it is a chimeric mouse/human protein