Non-Hodgkin's Lymphoma
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Introduction
Commonest lymphoma involving H&N= diffuse large B cell lymphoma (non-Hodgkins).
Typical presentation: cervical lymphadenopathy ± “B” symptoms. May also get unilateral
enlargement of Waldeyer’s ring (adenoid, palatine tonsil, tongue base tonsil)
incidence increases with age
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Pathophysiology
Malignant cell is typically a B lymphocyte, but may be T lymphocyte or NK cell.
B cell: precursor
mature
- CLL/SLL
- marginal zone NHL
- mantle cell NHL
- follicular lymphoma
- indolent, incurable in most, though possible success with allgenic BMT or very early disease
- diffuse large B cell
- aggressive lymphoma, curable with R-CHOP plus anti-CD20
- Burkitt's lymphoma
T cell
precursor
mature:
- mycosis fungoides/Sezary syndrome
- peripheral T cell lymphoma
- angioimmunoblastic T cell lymphoma
Signs and Symptoms
non-Hodgkin's lymphoma typically resents with painless lymphadenopathy
Nodal involvment may not follow orderly anatomic progression.
- history
- physical exam
History
Physical Exam
Examination for lymphadenopathy should be done as follows:
- location and number
- size and shape
- mobility: freely mobile, or tethered
- consistency: hard or soft
- tenderness
- warmth (infection?)
Lymph nodes chains exist as follows:
HEENT: occipital, posterior auricular, pre-auricular, tonsillar, submandibular, sub-mental, anterior/posterior cervical, supra- or infraclavicular
Axillary: pectoral, medial/posterior axillary, lateral
Hepato/splenomegaly
Inguinal: horizontal/vertical chains
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Histology important in predicting progression and response to treatment.
FNA may point in right direction, but require LN architecture for staging, so
do excisional LN biopsy (send fresh for “lymphoma protocol”) or core needle biopsy.
Diagnostic Imaging
Staging CT: H&N, chest, abdo, pelvis
Hematology may do bone marrow bx, gallium scan or serum protein electrophoresis
Differential Diagnosis
The differential includes:
- reactive adenitis
- cat scratch fever
- atypical TB
- HIV
- connective tissue disorder
Staging
The Ann Arbor staging is one of the more popular methods.
Stage I: cancer is in one region, with one lymph node and surrounding area. B symptoms may or may not be present.
Stage II: cancer is in two regions, both on the same side of the diaphragm.
Stage III: cancer is on both sides of the diaphragm.
Stage IV: cancer is disseminated, involving one or more extra-lymphatic organs (liver, bone marrow, or liver)
Treatments
Watch and wait for many folks
oral or IV chemo, radiation
anti-CD20 may be used; can be coupled to radioisotope
Consequences and Course
Prognostic points include:
- age over 60
- stage III or IV
- extra-nodal at more than 1 site
- performance impaired
- LDH abnormal
5 year survival:
0-1: 73%
2: 51%
3: 43%
4-5: 26%
Natural history:
indolent: years
aggressive: months
leukemia-like: weeks
Resources and References
Topic Development
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