Non- Hodgkin's Lymphoma

Question 1

Which cells does NHL affect

Answer 1

B cells or T cells and can be classified as low grade or high grade

Question 2

Risk factors for NHL

Answer 2

Elderly
Caucasians
History of viral infection (specifically Epstein-Barr virus)
Family history
Certain chemical agents (pesticides, solvents)
History of chemotherapy or radiotherapy
Immunodeficiency (transplant, HIV, diabetes mellitus)
Autoimmune disease (SLE, Sjogren’s, coeliac disease)

Question 3

Symptoms of NHL

Answer 3

Painless lymphadenopathy (non-tender, rubbery, asymmetrical)
Constitutional/B symptoms (fever, weight loss, night sweats, lethargy)
Extranodal Disease - gastric (dyspepsia, dysphagia, weight loss, abdominal pain), bone marrow (pancytopenia, bone pain), lungs, skin, central nervous system (nerve palsies)

Question 4

Do “B” symptoms in Non- Hodgkin’s occur earlier rather than later

Answer 4

Later than Hodgkin’s

Extra nodal disease more common

Question 5

Investigations for Non-Hodgkins

Answer 5

Excisional node biopsy is the diagnostic investigation of choice (certain subtypes will have a classical appearance on biopsy such as Burkitt’s lymphoma having a ‘starry sky’ appearance)
CT chest, abdomen and pelvis (to assess staging)
HIV test (often performed as this is a risk factor for non-Hodgkin’s lymphoma)
FBC and blood film (patient may have a normocytic anaemia and can help rule out other haematological malignancy such as leukaemia)
ESR (useful as a prognostic indicator)
LDH (a marker of cell turnover, useful as a prognostic indicator)
Other investigations can be ordered as the clinical picture indicates (LFT’s if liver metastasis suspected, PET CT or bone marrow biopsy to look for bone involvement, LP if neurological symptoms)

Question 6

Staging for Non-Hodgkins

Answer 6

Stage 1 - One node affected
Stage 2 - More than one node affected on the same side of the diaphragm
Stage 3 - Nodes affected on both sides of the diaphragm
Stage 4 - Extra-nodal involvement e.g. Spleen, bone marrow or CNS

Question 7

Management for NHL

Answer 7

Management is dependent on the specific sub-type of non-Hodgkin’s lymphoma and will typically take the form of watchful waiting, chemotherapy or radiotherapy.
All patients will receive flu/pneumococcal vaccines
Patients with neutropenia may require antibiotic prophylaxis

Question 8

Complications of NHL

Answer 8

Bone marrow infiltration causing anaemia, neutropenia or thrombocytopenia
Superior vena cava obstruction
Metastasis
Spinal cord compression
Complications related to treatment e.g. Side effects of chemotherapy

Question 9

Prognosis of NHL

Answer 9

Low-grade non-Hodgkin’s lymphoma has a better prognosis

High-grade non-Hodgkin’s lymphoma has a worse prognosis but a higher cure rate

Question 10

Management of Haematological malignancy in young people - what to do

Answer 10

Very urgent full blood count within 48 hours to investigate for leukaemia

• Pallor
• Persistent Fatigue
• Unexplained fever
• Unexplained persistent infections
• Generalised lymphadenopathy
• Persistent/ unexplained bone pain
• Unexplained bone pain
• Unexplained bruising
• Unexplained bleeding