lymphoma

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      • Hodgkin’s lymphoma
        • Follicular B cells undergo a transformation to malignant cells. (MCQ)
        • Four subtypes based on histology of lymph node and cell type: (MCQ)
          • Lymphocyte predominant
          • Nodular sclerosing:
            • Most common type(MCQ)
            • typically presents as cervical lymph node enlargement or mediastinal mass
          • Mixed cellularity
          • Lymphocyte depleted:
            • Rare, worst prognosis (MCQ)
            • Disease with bimodal distribution having peaks in 30s and 70s
            • May have an association with Epstein–Barr virus (EBV) (MCQ)
        • Clinical
          • Presents with asymptomatic lymph node enlargement or CXR showing mediastinal mass(MCQ)
          • “B” symptoms (MCQ)
            • occur in patients with more widespread disease.
            • These include fever, night sweats, weight loss, and shortness of breath.
        • Diagnosis
          • Lymph node biopsy
          • Presence of Reed–Sternberg cells is required for diagnosis. (MCQ)
        • Treatment
          • Curable depending on stage.
          • Based on staging and pathology, both chemotherapy and radiotherapy are utilized(MCQ)
          • prognosis is dependent on extension of disease.
          • Generally, if the lesion is small and only on one side of the diaphragm, radiation is used alone. (MCQ)
          • Otherwise, add chemotherapy. (MCQ)
      • Non-hodgkin’s lymphoma
        • Most originate from B cells.
        • B cell lymphomas are further classified based on the tissue type origination from lymph node: germinal center, mantle zone, or marginal zone
        • The working classification is most widely used
          • It categorizes lymphoma by low, intermediate, and high grade based on median survival.
        • Signs and symptoms/treatment
          • Lymphadenopathy
          • Fatigue, weight loss, fever, and night sweats are common symptoms.
          • Involvement of mesenteric nodes and extranodal disease is more common. (MCQ)
          • Hepatosplenomegaly
        • Follicular NHL
          • A common presentation of the low-grade follicular lymphomas is asymptomatic, painless, diffuse, long-standing lymphadenopathy in a middle-aged individual. (MCQ)
          • Bone marrow involvement is present in the majority of patients. (MCQ)
          • Treatment includes alkylating agent (cyclophosphamide) and prednisone. (MCQ)
          • Least aggressive (MCQ)
          • median survival is 6 years.
        • Diffuse Large Cell Lymphoma type NHL
          • Most common intermediate-grade lymphoma
          • Diffuse large cell lymphoma may present in a variety of extranodal sites,
          • particularly the gastrointestinal tract and the head and neck. (MCQ)
          • Patients treated with chemotherapy—CHOP (MCQ)
            • Cyclophosphamide
            • doxorubicin
            • vincristine [Oncovin]
            • prednisone
        • Lymphoblastic Lymphoma type NHL
          • High grade lymphomas derived from thymic T-cells(MCQ)
          • Often seen in children
          • Associated with a large mediastinal mass (MCQ)
          • Shows testicular, CNS, and marrow involvement(MCQ)
        • Burkitt’s Lymphoma type NHL
          • High-grade lymphoma
          • more common in children than adults(MCQ)
          • High incidence of bone marrow involvement
          • African type has higher association with EBV and jaw involvement than American type.
          • Marrow with “starry-sky” appearance(MCQ)
          • Treatment includes high-dose cyclophosphamide, methotrexate, and cytarabine and intensive CNS prophylaxis. (MCQ)
          • Unlike Hodgkin’s disease, histology of the nodes is a major predictor of prognosis in NHL. (MCQ)
        • Prognosis
          • Depends on histology of malignancy, not spread of disease.
          • Generally, prognosis is better if histology is nodular or follicular and cell size is small. (MCQ)
          • Prognosis is worse if histology is diffuse and cell size is large. (MCQ)
      • Clinical Pearls
          • Non Hodgkins Lymphoma :
            • Often presents with painless lymphadenopathy(MCQ)
            • Burkitt lymphoma
              • characteristic cytogenetic abnormality of translocation between the long arms of chromosomes 8 and 14 has been identified. (MCQ)
              • The protooncogene c-myc is translocated from its normal position on chromosome 8 to the heavy chain locus on chromosome 14(MCQ)
              • Cells committed to B cell differentiation are likely to have enhanced expression of this heavy chain locus
              • overexpression of c-myc (in its new anomalous position) is related to malignant transformation.
          • Follicular lymphomas
            • the t(14,18) translocation is characteristic (MCQ)
            • results in overexpression of bcl-2, resulting in protection against apoptosis (MCQ)
          • Bone marrow involvement is manifested as paratrabecular lymphoid aggregates
          • In some high-grade lymphomas, the meninges are involved and malignant cells are found with cerebrospinal fluid cytology.
          • The chest radiograph may show a mediastinal mass in lymphoblastic lymphoma. (MCQ)
          • The serum LDH has been shown to be a useful prognostic marker and is now incorporated in risk stratification of treatment
          • Treatment with the anti-CD20 antibody rituximab is a commonly used treatment because of its very low toxicity and avoidance of chemotherapy. (MCQ)
          • Common chemotherapy regimens include
            • fludarabine
            • the combination of cyclophosphamide, vincristine, and prednisone (R-CVP) (MCQ)
            • cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP). (MCQ)
          • Radioimmunoconjugates – yttrium-90 ibritumomab tiuxetan(MCQ)
            • fuse anti-B cell antibodies with radiation
            • produce improved results
          • Some patients with clinically aggressive low-grade lymphomas may be appropriate candidates for allogeneic transplantation.
          • Those with lymphoblastic lymphoma receive regimens similar to those used for T cell ALL.
          • Mantle cell lymphoma
            • not effectively treated with standard chemotherapy regimens.
            • Intensive initial therapy including autologous stem cell transplantation has been shown to improve outcomes and is now the standard of care.
            • Reduced-intensity allogeneic stem cell transplantation offers curative potential.
          • Patients with mucosal associated lymphoid tumors (MALT lymphomas) of the stomach
            • treated with combination antibiotics directed against Helicobacter pylori (MCQ)
            • require frequent endoscopic monitoring.
          • Factors that confer adverse prognosis are
            • age over 60 years
            • elevated serum LDH(MCQ)
            • stage III or stage IV disease
            • poor performance status
        • Hodgkin disease
          • The malignant cell is derived from B lymphocytes of germinal center origin.
          • An important feature of Hodgkin disease is its tendency to arise within single lymph node areas and spread in an orderly fashion to contiguous areas of lymph nodes. (MCQ)
          • Only late in the course of the disease will vascular invasion lead to widespread hematogenous dissemination
          • The staging nomenclature (Ann Arbor) is as follows: (MCQ)
            • Stage I, one lymph node region involved
            • Stage II, involvement of two lymph node areas on one side of the diaphragm
            • Stage III, lymph node regions involved on both sides of the diaphragm
            • Stage IV, disseminated disease with bone marrow or liver involvement
            • stage A if they lack constitutional symptoms
            • stage B if 10% weight loss over 6 months, fever, or night sweats are present.
          • Treatment of Hodgkin disease (MCQ)
            • Radiation therapy used as initial treatment only for patients with low-risk stage IA and IIA disease.
              • addition of limited chemotherapy for some patients treated with radiation appears promising.
            • Most patients with Hodgkin disease (including all with stage IIIB and IV disease) are best treated with combination chemotherapy using doxorubicin (Adriamycin), bleomycin, vincristine, and dacarbazine (ABVD)


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Everything happens for a reason, and something good always comes out of something bad, just got to keep searching for the light at the end of all this suffering