Lymphoma

Lymphoma

1. Anatomyhistology of lymph nodes

   • Kidney shaped encapsulated bodies
   • Located along the lymphatic vessels
   • Histologic parts
     • Cortex
       • Contains lymphoid follicles
       • B cells
       • Receive lymph from afferent vessels
     • Medulla
       • Plasma cells
       • Medullary sinuses
         • Drain lymph into efferent vessels
         • Macrophages
     • Parasortex
       • T cells

2. Risk factors/Causes

   • Viruses
     • EBV
     • HIV
     • HHV-8
   • Weakened immune system
     • Genetic condition
     • Immunosuppressants
       • Cyclosporine
   • Age
     • Young adults (15-25 yrs)
     • Elderly >55 yrs
   • Family history
     • Genetic mutations/chromosomal abnormalities
   • Exposure to radiation

3. Investigations

   • CBC
     • Anemia, thrombocytopenia, leukopenia, lymphocytosis
   • Peripheral blood smear
     • Atypical cells
   • Chemistry panel
     • Exclude
       • Tumor lysis syndrome
       • Ureteral obstruction by retroperitoneal lymphadenopathy
   • Serology for infectious disease
     • HBV, HIV, etc.
   • ANA antibody
     • +SLE is associated with increased risk of death
   • Hemoccult bleeding
     • Exclude GI bleeding and anemia
   • Chest X-ray
     • Hilar or mediastinal adenopathy
   • Immunohistochemistry and flow cytometry
     • Check for immunophenotype expression
   • CT scan
     • Evaluate enlarged lymph nodes
   • Bone marrow aspiration
   • LDH and B2-microglobulin
     • Prognostic factors
     • Elevated LDH
       • High tumor burden

4. Classification

   • Hodgkin's lymphoma
     • Classical
       • Nodular sclerosis
         • CD15+/CD30+
         • Fibrous bands that divide areas into nodules
         • Lacunar cells
           • Variant of RS cells
           • Cells contained within a lacuna
       • Mixed cellularity
       • Lymphocyte-rich
       • Lymphocyte-depleted
     • Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)
       • CD15-/CD30-
       • L&H cells (Popcorn cells)
         • Multilobulated nucleus
     • Histologic features of affected lymph nodes
       • Reed Sternberg cells (RS cells)
         • Large multinucleated lymphocytes
         • Owl eye appearance
       • Polymorphous cellular background
   • Non-hogkin's lymphoma
     • Aggressive (high grade)
       • Diffuse large B-cell lymphoma
         • Genetic cause
           • Translocation or mutation in BCL6 gene
             • Chromosome 3
           • t(14;18) with rearrangement of BCL2 (10%)
           • MYC oncogene activation (5%)
         • Environmental exposure
           • Infectiouns (EBV/HIV/HHV-8)
       • Anaplastic large-cell lymphoma
       • Burkitt lymphoma
       • Mantle cell lymphoma
     • Indolent (low grade)
       • Follicular lymphoma
       • Cutaneous T-cell lymphoma
       • Lymphoplasmacytic lymphoma
       • Marginal zone B-cell lymphoma

5. Staging

   • Grade I
     • Only one group of lymph nodes affected anywhere in the body
   • Grade II
     • Two or more groups of lymph nodes affected, all on the same side of the diaphragm (either above or below)
   • Grade III
     • Lymph nodes affected on both sides of the diaphragm
   • Grade IV
     • Spread to at least one body organ outside the lymphatic system

6. Management

   • Chemotherapy
     • ABVD
       • Doxorubicin (Adriamycin)
       • Bleomycin
       • Vinblastine
       • Dacarbazine
     • Stanford V
       • Doxorubicin + Vinblastine + Mechlorethamine + Etoposide + Vincristine + Bleomycin+ Prednisone
     • BEACOPP
       • Bleomycin + Etoposide + Adriamycin + Cyclophosphamide + Vincristine (Oncovin) + Procarbazine + Prednisone
   • Radiation therapy
     • Total nodal
     • Regional nodal
     • Involved field
     • Involved site

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