Lymphoma (CH) Flashcards
What is a lymphoma?
Malignant proliferation of lymphocytes (B and T cells) which accumulate in lymph nodes or other organs
What are the two main types of lymphoma?
- Hodgkin’s lymphoma
- non-Hodgkin’s lymphoma
What is a Hodgkin’s lymphoma?
Malignant lymphoma of B-cell origin with no antibody expression
How common is Hodgkin’s lymphoma?
Uncommon
What is Hodgkin’s lymphoma characterised by?
Reed-Sternberg cells
What types of Hodgkin’s lymphoma are there? (4)
- nodular sclerosing - associated with lacunar cells (most common)
- mixed cellularity
- lymphocyte predominant (best prognosis)
- lymphocyte depleted (worst prognosis)
Describe the epidemiology of Hodgkin’s lymphoma.
- M>F
- bimodal age distribution:
- 1st peak: 25-30 years
- 2nd peak: 50-70 years
What is 50% of Hodgkin’s lymphoma associated with?
EBV - viral particles allow infected abnormal B cells to evade apoptosis and/or replicate in an uncontrolled manner
What conditions are associated with Hodgkin’s lymphoma? (3)
- EBV (50%)
- immunodeficiency
- autoimmune diseases e.g. RA, sarcoidosis
What are some signs of poor prognosis of Hodgkin’s lymphoma? (4)
- B-symptoms (fever, weight loss, night sweats)
- male
- increasing age
- stage IV disease and lymphocyte depleted subtype
What is a non-Hodgkin’s lymphoma?
Every other type of lymphoma that is not Hodgkin’s lymphoma (no Reed-Sternberg cells)
May affect B or T cells: 85% B cell, 15% T cell and NK form
How common is non-Hodgkin’s lymphoma?
More common than HL
What does incidence of non-Hodgkin’s lymphoma increase with?
Age
What are some causes of non-Hodgkin’s lymphoma? (4)
- chromosomal translocations
- infections - EBV, HIV, H. pylori
- immunodeficiency
- autoimmune diseases
What are some subtypes of non-Hodgkin’s lymphoma? (3)
- diffuse large B-cell lymphoma
- Burkitt’s lymphoma
- MALT lymphoma
What is the most common form of lymphoma in the UK?
Diffuse large cell B-lymphoma (type of non-Hodgkin’s lymphoma)
What is Burkitt’s lymphoma?
Rapidly proliferating B cell tumour - type of non-Hodgkin’s lymphoma
What would you see on microscopy in Burkitt’s lymphoma?
‘Starry sky’ appearance
(‘Sky’ due to densely packed malignant B cells which appear blue on H&E stain due to minimal cytoplasm; ‘starry’ due to fixation artefact derived from debris-filled macrophages)
Which patients is Burkitt’s lymphoma common in?
HIV patients (or generally immunosuppressed) and young patients
Associated with EBV
How can Burkitt’s lymphoma present?
Unusual ways due to rapid proliferation e.g. nerve root compression due to mass effect of lesion
What is a common complication of Burkitt’s lymphoma?
Tumour lysis syndrome (PUKe calcium)
What is a gastric MALT lymphoma?
- associated with H. pylori infection in 95% of cases
- good prognosis
- if low grade, 80% respond to H. pylori eradication
- paraproteinaemia may be present
- type of non-Hodgkin’s lymphoma
What are the clinical features of Hodgkin’s lymphoma? (5)
- painless lymphadenopathy - cervical / supraclavicular nodes
- involvement of single group of lymph nodes
- alcohol-induced pain (at sites of lymphadenopathy)
- pruritus
- B-symptoms - fever >38, weight loss (>10% in 6m), night sweats
What are the clinical features of non-Hodgkin’s lymphoma? (6+3)
- rubbery painless lymphadenopathy (associated with fatigue)
- affects multiple nodes
- Waldeyer’s ring - oropharyngeal involvement
- splenomegaly + sometimes hepatomegaly
- B-symptoms (less common vs HL)
- fatigue and malaise
- extranodal disease:
- GI - dyspepsia, dysphagia, abdominal pain
- bone marrow - bone pain
- neurological - headache
What systems can non-Hodgkin’s lymphoma affect? (3)
- GI - dyspepsia, dysphagia, abdominal pain
- bone marrow - bone pain
- neurological - headache
Which type of lymphoma has alcohol-induced pain?
Hodgkin’s lymphoma
What are the B symptoms? (3)
- unexplained fevers >38
- unexplained weight loss >10% in 6 months
- unexplained night sweats
When do B symptoms occur in Hodgkin’s vs non-Hodgkin’s lymphoma?
Typically occur earlier in Hodgkin’s lymphoma
What are some risk factors for lymphoma? (5)
- age>50
- male
- viruses - EBV, HIV, hep C
- hereditary immunodeficiency syndromes
- autoimmune conditions - RA, Sjogren’s, Coeliac
What are the first-line investigations for lymphoma? (4)
- lymph node biopsy
- PET/CT scan
- PET scan
- FBC with differential
What does histology and biopsy show in Hodgkin’s lymphoma?
Reed-Sternberg cells:
- binucleate lymphocytes
- large multinucleate cells with eosinophilic nucleoli
- mirror image nucleoli
What does lymph node biopsy show in non-Hodgkin’s lymphoma?
Positive
What does FBC show in lymphoma?
Lymphocytosis
What is immunohistochemistry useful for in non-Hodgkin’s lymphoma?
Determines specific cell type and identifies specific markers
When is ESR high in lymphoma?
Non-Hodgkin’s lymphoma - ESR high
Adverse prognostic factor: >50mm/hr without B symptoms or >30mm/hr with B symptoms
What is PET-CT CAP used for in lymphoma?
Staging (Ann-Arbor staging)
What might be seen in blood film in lymphoma?
- lymphoma cells may be seen
- nucleated RBCs, left-shift (WBC precursors) from bone marrow involvement
What is the Ann-Arbor staging system for lymphoma?
- stage I - 1 node affected
- stage II - >1 node affected on same side of diaphragm
- stage III - nodes affected on both sides of diaphragm
- stage IV - extra-nodal involvement e.g. spleen, bone marrow, CNS
- A - no B symptoms
- B - B symptoms
- X - bulky diseases (widening of mediastinum)
- E - involvement of extra-nodal site
What do we see on CXR in lymphoma? (2)
- widened mediastinum
- bilateral hilar lymphadenopathy
What is elevated LDH an indicator of in lymphoma?
Poor prognosis
What are some differential diagnoses for lymphoma? (10)
- non-Hodgkin’s lymphoma (Waldeyer ring + extra-nodal sites)
- Hodgkin’s lymphoma (Reed-Sternberg cells, alcohol-triggered pain)
- CLL - peripheral blood lymphocytosis (precursors but not blasts), lymphadenopathy, hepatosplenomegaly
- ALL - acute, purpura, bleeding, infection, blasts
- infectious mononucleosis - pharyngitis, rash, myalgia, positive heterophile AB test
- hepatitis C
- CMV infection
- TB
- HIV infection
- sarcoidosis
What is the management plan for Hodgkin’s lymphoma?
Chemotherapy +/- adjuvant radiotherapy
What specific chemotherapy drugs are taken for Hodgkin’s lymphoma?
ABVD
- Adriamycin/doxorubicin
- Bleomycin
- Vinblastine
- Dacarbazine
What is the management plan for non-Hodgkin’s lymphoma?
Chemotherapy +/- radiotherapy
What specific chemotherapy drugs are taken for non-Hodgkin’s lymphoma?
R-CHOP-21
Rituximab + Cyclophosphamide, doxorubicin, vincristine, Prednisolone for 21 days
What are some complications of lymphomas?
- radiotherapy-related thyroid abnormalities (hypothyroidism most common)
- chemotherapy and radiotherapy - secondary malignancies (AML, non-Hodgkin’s lymphoma)
- chemotherapy and radiotherapy –> accelerated diseases e.g. CAD
- immunosuppression, infections, myelosuppression, renal failure etc
Which lymphoma has better prognosis?
Hodgkin’s lymphoma has better prognosis than non-Hodgkin’s lymphoma
