Lymphoma

Question 1

What is lymphoma?

Answer 1

Malignant proliferation of mature lymphocytes that accumulate in lymph nodes +/- other tissues, often as a solid tumour

Question 2

How can Hodgkins lymphoma be differentiated from Non-Hodgkins lymphoma (NHL)?

Answer 2

Hodgkins = ‘mirror-image’ binucleated Reed-Sternberg cells on light microscopy

Question 3

What are the main features of Hodgkins lymphoma?

Answer 3

Lymphadenopathy
B symtoms (in 25%)
- weight loss
- fever (classical Pel-Ebstein cyclical fever every 2-4 weeks is rare)
- night sweats
- lethargy
- pruritis
- anaemia of chronic disease
- hepatosplenomegaly if advanced

Question 4

Describe the lymphadenopathy seen in lymphoma?

Answer 4

Painless, rubbery nodes
Usually cervical (2/3), axillary or inguinal
Increase and decrease spontaneously
Painful on alcohol consumption
Mediastinal nodes can –> SOB, dry cough, SVC obstruction

Question 5

What are the risk factors for Hodgkins lymphoma?

Answer 5

EBV

Family history

Question 6

How is Hodgkins lymphoma diagnosed?

Answer 6

Biopsy –> lymph node excision +/- bone marrow

• microscopy = Reed-Sternburg cells
• immunohistochemistry (CD30 +/- CD15, EBV)
• flow cytometry + cytogenetics

Question 7

Which imaging is required for lymphoma staging?

Answer 7

CXR for mediastinal widening

Contrast CT head-neck-abdo or PET-CT

Question 8

Which staging system is used for lymphoma and what does it involve?

Answer 8

Ann Arbor staging:

By location

1. 1 LN area
2. 2 or more LN areas on 1 side of diaphragm
3. LN areas on 2 sides of diaphragm
4. beyond LNs e.g. liver, bone marrow

By presence of systemic symptoms:
A. None except pruritis
B. Systemic symptoms

Question 9

What is the management for Hodgkins lymphoma?

Answer 9

Chemotherapy + radiotherapy
Sperm bank pre chemo for men
Autologous stem cell transplant (own bone marrow removed, chemo given, marrow returned)
Pneumococcal + flu vaccine

Question 10

Which type of cells are proliferating in lymphoma?

Answer 10

Usually B cells

10% of NHL are T cell

Question 11

Give some examples of low grade NHLs?

Answer 11

Follicular --> CD20+ve
MALT (mucosa associated lymphoid tissue) - stomach, thyroid, salivary glands
Lymphocytic lymphoma (similar to CLL)
Waldenstrom's macroglobulinaemia --> raised IgM

Question 12

Given some examples of high grade NHLs?

Answer 12

Diffuse large B-cell lymphoma
Mantle cell lymphoma
Peripheral T cell lymphoma
Burkitt's lymphoma
Lymphoblastic lymphoma (similar to ALL)

Question 13

What are the characteristic features of Burkitt’s lymphoma?

Answer 13

Jaw lymphadenopathy in children

Question 14

What are the clinical features of NHL?

Answer 14

Lymphadenopathy:
- presenting complaint in 2/3
- often with splenomegaly
Extranodal: (can be anywhere in the body)
- gut e.g. MALT
- skin e.g. T cell lymphoma
- oropharynx e.g. Waldeyer's ring MALT
- CNS + eyes in Waldenstrom's

Question 15

What are the risk factors for NHL?

Answer 15

Immunodeficiency:
- congenital e.g. Wiskott-Aldrich
- drugs
- HIV: usually high grade lymphomas
Infection:
- HTLV-1
- EBV (Burkitt's, CNS lymphoma in HIV)
- H. pylori (gastric MALT)

Question 16

What is the management for low grade NHLs?

Answer 16

May not be needed if asymptomatic e.g. follicular lymphoma
Otherwise chemotherapy +/- RT
Maintain remission with alpha-interferon or rituximab

Question 17

What is the management for high grade lymphoma?

Answer 17

Chemotherapy –> RCHOP

Stem cell transplant if refractory