Non-Hodgkin's Lymphoma

Question 1

Who does Non-Hodgkin’s lymphoma affect? What is Non-Hodgkin’s lymphoma?

Answer 1

Typically affects elderly
All lymphomas without Reed-Sternberg cells
Diffuse (high grade)
Follicular (low grade)
Diffuse large B-cell lymphoma is commonest

Question 2

What are risk factors for Non-hodgkin’s lymphoma?

Answer 2

Elderly
Caucasian
History of EBV infection
FHx
Certain chemical agents - pesticides, solvents
History of chemotherapy or radiotherapy
Immunodeficiency - transplant, HIV, DM
Autoimmune disease (SLE, Coeliac's)

Question 3

What are clinical features of non-Hodgkin’s lymphoma?

Answer 3

Painless lymphadenopathy (non-tender, rubbery, asymmetrical)
Constitutional/B symptoms - fever, weight loss, night sweats, lethargy

Extranodal disease:
Gastric MALT - dyspepsia, dysphagia, weight loss, abdo pain
Skin
Bone marrow - anaemia, infection, bleeding due to pancytopenia, bone pain
CNS nerve palsies

Signs:
Lymphadenopathy
Palpable abdominal mass - heaptomegaly, splenomegaly, lymph nodes
Fever

Question 4

What features can differentiate between Hodgkin’s and non-Hodgkin’s lymphoma?

Answer 4

In Hodgkin’s, lymphadenopathy experiences alcohol induced node pain
B symptoms occur earlier in Hodgkin’s and later in non-Hodgkins
Extra-nodal disease is more common in non-Hodgkin’s

Question 5

What investigations for non-H lymphoma?

Answer 5

Excisional node biopsy
CT CAP - staging
HIV test - risk factor
FBC and blood film - normocytic anaemia, rule to leukaemia
ESR - prognostic indicator
LDH - cell turnover - prognostic indicator
LFTs if liver mets
PET cT or bone marrow biopsy to look for bone involvement

Question 6

Staging of non-H lymphoma?

Answer 6

Ann Arbor
I - one node
II - 2+ nodes same sid eof diaphragm
III - nodes on both either of diaphragm
IV - extranodal invovlemnt - spleen, marrow, CNS

A - no systemic symptoms
B - B symptoms present

Question 7

Mx of non-H lymphoma?

Answer 7

Low grade - often incurable and widely disseminated
E.g. Follicualr
MALT
MX - none if symptomless
Radiotherapy in localised disease
Interferon alfa or rituximab to maintain remission

High grade - aggressive but curable E.g. Burkitt’s lymphoma (childhood disease with jaw lymphadenopathy), diffuse large B-cell lymphoma

RCHOP chemotherapy
GCSF to help neutropenia

Question 8

Complications of Non-H lymphoma?

Answer 8

Bone marrow infiltration leading to pancytopenia:
Anaemia, infection, bleeding
SVCO
Mets
Spinal cord compression

Question 9

What are worse prognosis features?

Answer 9

Age>60
Systemic symptoms
Bulky disease
Raised LDH
Disseminated disease

Question 10

How does rituximab work?

Answer 10

Kills CD20+ cells by antibody directed cytotoxicity

Sensitises to CHOP chemo