om verma

1. Lymphoma
RELIANCE INSTITUTE OF NURSING
DHAMTARI
MR . OM VERMA

2. DEFINITION
It is a defined as lymphoma is a cancer of .
lymph node
lymphoma is a type of cancer that begins
in immune system cells called
lymphocytes .production of one or more
abnormal cells in one or more of the
lymph nodes.

3. Abnormal lymphocytes collect in one or more
lymph node or in lymph tissues such as
spleen ,tonsils and eventually they from mass of
cells called tumor.
Cancer that forms in the germ-fighting
lymphatic system is called lymphoma.
Lymphoma: A tumor of the lymphoid tissue. The
major types of lymphoma are Hodgkin's disease
and non-Hodgkin's lymphoma

4. IMMUNE SYSTEM PROBLEM
•This may be because their immune system is
weakened by another medical condition, such as:
•being on drugs to prevent rejection of an organ or
bone marrow transplant (immunosuppressive drugs)
– lymphomas that develop in this situation are
sometimes called post-transplant lymph proliferative
disorders

5. INFECTION
•Infections
•Certain lymphomas are linked to particular infections.
A few viruses cause lymphomas directly – the virus
lives in the lymphoma cells and makes them grow and
divide. Other viruses and bacteria cause lymphomas
indirectly – the infection stimulates the immune
system chronically (over a long time), which makes
lymphoma more likely to develop.

6. Con…….
•Epstein–Barr virus
•human T-lymphotropic virus 1
human herpes virus
hepatitis C virus
Helicobacter pylori,
Chlamydia psittaci,

7. ABNORMAL B CELL
•B cells develop large abnormal cells
,these abnormal cancerous cells are
called Reed-sternberg cells . Instend of
undergoing the normal cell cycle of life
and death,
•Reed-sternberg cells don't die and they
continue to produce abnormal B cells in
a malignant process . These cells also
attract other normal immune cells that
cause the tumor ..

8. •Previous cancer treatments
•Chemotherapy and radiotherapy treatment given for a
previous cancer can increase the risk of someone
developing lymphoma. This is thought to be due to
damage caused by these treatments
to genes of the lymphocytes

9. •Older age
•Many lymphomas, like other cancers, are more
common in older people. This is because as time goes
on more changes happen in the genes and the body is
less able to repair these.

10. •Lifestyle
•Smoking Many cancers are caused by
smoking but there is much less evidence
that it leads to lymphoma. Smokers may
have a slightly increased risk of follicular
lymphoma

11. Lymphoma
Main types:
1) Hodgkin lymphoma
2) Non Hodgkin lymphoma
# B-cell lymphoma
# T-cell lymphoma

12. •B lymphocytes (B cells): B cells make
proteins called antibodies to help protect the
body from germs (bacteria and viruses).
•T lymphocytes (T cells): There are several
types of T cells. Some T cells destroy germs or
abnormal cells in the body. Other T cells help
boost or slow the activity of other immune
system cells.

13. HODGKIN LYMPHOMA
•Lymphoma is the most common blood cancer. The two main forms of
lymphoma are Hodgkin lymphoma (HL) and non-Hodgkin lymphoma
(NHL). Lymphoma occurs when cells of the immune system called
lymphocytes, a type of white blood cell, grow and multiply
uncontrollably. Cancerous lymphocytes can travel to many parts of the
body, including the lymph nodes, spleen, bone marrow, blood, or other
organs, and form a mass called a tumor. The body has two main types of
lymphocytes that can develop into lymphomas: B-lymphocytes (B-cells
and T-lymphocytes (T-cells).
•.

14. Hodgkin lymphoma progresses it compromises body's ability
to fight infection .common beginning
Lymph nodes located in upper part of body ….

15. TYPES OF H L
•Nodular Sclerosis HL is the most common
subtype of HL, accounting for 60 to 80 percent
of all HL cases. In nodular sclerosis CHL, the
involved lymph nodes contain RS cells
(Reed/Sternberg ) mixed with normal white
blood cells. The lymph nodes often contain a
lot of scar tissue, which is where the name
nodular sclerosis (scarring) originates.

16. Epstein-Barr virus infection: Having been
infected with EBV might lead to mutation(s) in
the B-lymphocytes, causing the abnormal Reed-
Sternberg cells to develop
•HIV infection and AIDS: This subtype is more
commonly associated with HIV infection
MIXED CELLLULARTY HODGKIN DISEASE

17. Lymphocyte-Depletion
•. Involvement of lymph node by HIV-
associated classic Hodgkin
lymphoma of the lymphocyte
depletion subtype. Large Hodgkin
Reed-Sternberg (HRS) cells with
multiple nuclei and prominent
nucleoli are present. HRS cells
express the typical phenotype with
intense staining

18. The Revised European American Lymphoma
Classification (REAL)
I. Precursor B-cell neoplasm:
# Precursor B-lymphoblastic leukemia/lymphoma
II. Mature (peripheral) B-cell neoplasms
# B-cell chronic lymphocytic leukemia / small lymphocytic lymphoma
# Lymphoma of mucosa-associated lymphoid tissue type (MALT)
# Follicular lymphoma
# Mantle cell lymphoma
# Diffuse large cell B-cell lymphoma
# Burkett's lymphoma

19. The Revised European American
Lymphoma Classification (REAL)
I. Precursor T cell neoplasm:
# Precursor T-lymphoblastic lymphoma/leukemia
II. Mature (peripheral) T cell and NK-cell neoplasms
# Adult T cell lymphoma/leukemia (HTLV1+)
# Mycosis fungoides/Sézary's syndrome
# Peripheral T cell lymphoma, not otherwise characterized
# Anaplastic large cell lymphoma, T/null cell, primary systemic type
T-Cell and Natural Killer Cell Neoplasms

20. Hodgkin lymphoma
1) Nodular lymphocyte predominance
Hodgkin's lymphoma
2) Classical Hodgkin's lymphoma
Nodular sclerosis Hodgkin's lymphoma
Lymphocyte-rich classical Hodgkin's lymphoma
Mixed cellularity Hodgkin's lymphoma
Lymphocyte depletion Hodgkin's lymphoma

21. Epidemiology

22. Hodgkin lymphoma
 Definition:
A neoplastic transformation of lymphocytes particularly in lymph
nodes.
Characterized by:
1) the presence of Reed-Sternberg cells on histology
2) spreading in an orderly fashion to contagious lymph nodes
( For example, Hodgkin lymphoma that starts in the cervical lymph nodes may
spread first to the supraclavicular nodes then to the axillary nodes )

23. Red-Sternberg cells
# Cells with mirror image nuclei and prominent, eosinophilic, inclusion-
like nuclei.

24. Etiology
Hodgkin disease has bimodal age distribution--
one peak in the 20s and 60s.
Doctors seldom know why one person develops
Hodgkin lymphoma and another does not. But
research shows that certain risk factors increase the
chance that a person will develop this disease.
Having one or more risk factors does not mean that a
person will develop Hodgkin lymphoma. Most people
who have risk factors never develop cancer.

25. Risk factors
1) Certain viruses:
Epstein-Barr virus (EBV)
Human immunodeficiency virus (HIV)
2) Weakened immune system:
inherited condition
 certain drugs used after an organ transplant
3) Age:
Hodgkin lymphoma is most common among teens and adults aged 15 to
35 years and adults aged 55 years and older.
4) Family history:
Family members, especially brothers and sisters, of a person with
Hodgkin lymphoma or other lymphomas may have an increased chance of
developing this disease.

26. Clinical presentation
 Enlarged, painless, rubbery, non- erythematous, nontender lymph nodes
are the hallmark of the disease.
 May become painful after drinking alcohol
 Patients may develop ‘’B’’ symptoms which are:
# Drenching night sweats.
# 10% weight loss
# Fever
 25% have ''B'' symptoms
 Although pruritus is common in the disease it is not one of the ‘’B’’
symptoms.
 Cervical, supraclavicular and axillary lymphadenopathy are the most
common initial signs of the disease.

27. Clinical presentation
Extralymphatic sites may be involved such as:
# Spleen
# Liver
# Bone marrow
# Lung
# CNS
Extralymphatic involvement is more common with non-
hodgkin lymphoma.

28. Clinical presentation
Emergency presentation:
Infections
SVC obstruction ( facial edema, increased JVP and
Dyspnea)

29. Staging
The doctor considers the following to determine the
stage of Hodgkin lymphoma:
The number of lymph nodes affected.
Whether these lymph nodes are on one or both sides of the
diaphragm.
Whether the disease has spread to the bone marrow,
spleen, liver, or lung.
Each stage is divided into A or B symptoms according to the
presence of systemic symptoms.

30. Staging

31. Diagnosis
An excisional lymph node biopsy is the essential first step in
diagnosis.
A biopsy is the only sure way to diagnose Hodgkin lymphoma. The
biopsy can be:
1) Excisional biopsy
2) Incisional biopsy
3) Fine needle aspiration usually cannot remove a large enough
sample for the pathologist to diagnose Hodgkin lymphoma.
After that the most important step is to determine the extent
of the disease because the stage will determine the nature of
the therapy, that is, radiation vs. chemotherapy

32. Investigations used for staging
 Chest x-ray : X-ray pictures may show swollen lymph nodes or other signs of
disease in the chest .
 CT: Chest, abdomen and pelvis ( CT is sensitive enough to detect any
abnormal nodes)
 MRI
 PET scan
 LP for CSF cytology if any CNS signs
 Lymphangiography and laparotomy are no longer used for staging.
 A bone marrow biopsy is used when :
1) B symptoms
2) Stage3 or 4

33. Abnormal lab tests ( don’t alter the stage of
the disease)
CBC: anemia and high WBC ( Eosinophilia is common)
LDH: high ( poor prognostic factor)
ESR: high ( poor prognostic factor)
LFTs: help determine the need for liver biopsy

34. After lymphoma is diagnosed, a variety of tests may be carried out
to look for specific features characteristic of different types of
lymphoma. These include:
1) Immunophenotyping
2) Flow cytometry
3) FISH testing.
The classification of lymphoma can affect treatment and prognosis.
Classification systems generally classify lymphoma according to:
1) Whether or not it is a Hodgkin lymphoma.
2) Whether the cell that is replicating is a T cell or B cell.
3) The site that the cell arises from.

35. Histology
Hodgkin has several histological subtypes.
Lymphocyte-predominant has the Best
prognosis.
Lymphocyte-depleted has the Worst prognosis.

36. Treatment
Therapy is entirely based on the stage.
Localized disease ( stage IA and IIA ) is managed
predominantly with radiation.
All patients with evidence of ‘’B’’ symptoms as well as
stage III and IV are managed with chemotherapy.
The most effective combination chemotherapeutic regimen
for Hodgkin lymphoma is ABVD ( adriamycin, bleomycin,
vinblastin and dacarbazine).

37. Treatment
 ABVD is superior to MOP (meclorethamine,
vincristin(oncovin) , prednisolone and procarbazine)
because ABVD has fewer side effects such as:
1) Permanent sterility
2) Secondary cancer formation
3) Aplastic anemia
4) Peripheral neuropathy

38. International Prognostic Index
The International Prognostic Index (IPI) was first developed
to help doctors determine the prognosis for people with fast-
growing lymphomas. The index depends on 5 factors:
1) The patient’s age
2) The stage of the lymphoma
3) Whether or not the lymphoma is in organs outside the
lymph system
4) Performance status (PS) – how well a person can
complete normal daily activities
5) The blood (serum) level of (LDH)

40. Follicular Lymphoma International
Prognostic Index
The IPI is useful for most lymphomas, but it’s not as
helpful for follicular lymphomas, which tend to be
slower growing.

41. Non-Hodgkin lymphoma (NHL)
Definition:
The neoplastic transformation of either B or T cell
lineages of lymphatic cells.
NHL causes the accumulation of neoplastic cells in
both the lymph nodes as well as more often diffusely
in extralymphatic organs and the bloodstream.
Absent reed-Sternberg cells.

42. Risk factors
INFECTIONS:
Human immunodeficiency virus (HIV)
 Epstein-Barr virus (EBV): linked to Burkitt lymphoma.
Helicobacter pylori: Extranodal tissues generating lymphoma
include MALT ( Mucosa associated lymphoid tissue)
Human T-cell leukemia/lymphoma virus( HTLV-1)
Hepatitis C virus
Age:
Most people with non-Hodgkin lymphoma are older than 60.

43. Clinical Presentation
Clinical presentation is the same as for Hodgkin lymphoma.
The difference is that Hodgkin is localized to cervical
and supraclavicular nodes 80%-90% of the time.
Whereas NHL is localized 10-20% of the time.
CNS involvement is more common with NHL.
HIV positive patients often have CNS involvement.

44. Staging and diagnosis
Staging and Diagnosis are the same as for Hodgkin lymphoma.
Differences:
Bone marrow biopsy is more central in the initial staging of
NHL
Because the presence of bone marrow involvement means the
patient has stage IV disaese and therefore needs combination
chemotherapy, further invasive testing such as laparotomy is
not required.

45. Grades
NHL divided into Low or high grade
A high grade lymphoma has cells which look quite different
from normal cells.
They tend to grow fast (aggressive).usually look follicular.
Incurable. Wider dissemination at presentation.
Low grade lymphomas have cells which look much like
normal cells and multiply slowly(indolent).usually look
diffuse. Long term treatment maybe achievable.

46. Low-grade lymphomas
Many low-grade lymphomas remain indolent for many
years.
Treatment of the non-symptomatic patient is often
Avoided.
 In this case watchful waiting is often the initial course of
action. This is carried out because the harms and risks of
treatment outweigh the benefits.
If a low-grade lymphoma is becoming symptomatic,
radiotherapy or chemotherapy are the treatments of choice.
They don’t cure the lymphoma, they can alleviate the
symptoms.
Patients with these types of lymphoma can live near-normal
lifespans, but the disease is Incurable.

47. High-grade lymphomas
Treatment of the aggressive, forms of lymphoma can
result in a cure in the majority of cases.
However, the prognosis for patients with a poor response
to therapy is worse.
Treatment for these types of lymphoma typically consists
of aggressive chemotherapy, including the CHOP or R-
CHOP regimen.

48. Treatment
Same principles of treating Hodgkin Lymphoma.
The initial chemotherapeutic regimen is CHOP
 ( cyclophosmamide, hydroxy-adriamycine, oncovin and
prednisolone).
CNS lymphoma is often treated with radiation in addition to
CHOP.
Relapses can be controlled with BM transplantation.
Some pts express CD-20 antigen in greater amount. In this
case, monoclonal antibody Rituximab should be used.
Rituximab is an anti-CD20 antibody that has limited toxicity
and add survival benefit to the use of CHOP.