20Lymphadenopathy Painless, Rubbery Usually at neck and supraclavicular areas10% sub-diaphragmatic
21Sites of LN involvment in HL Peripheral LNCervical, supraclavicular and axillary LN (70%)Generalized lymphadenopathy is not typical in HLThoraxAnterior mediastinum in NS HLOthers, Rare:LungPleural effusionPericardial effusionSVC obstructionAbdomenHepatosplenomegaly.Retroperitoneal LN.
22Differential Diagnosis of Lymph-adenopathy InfectionsAutoimmune disordersHaematologicalLymphomasLeukemiasAIDSMetastasesBenign
23Hepatosplenomegaly Could be because of: Disease infiltration. Reactive ( no infiltration).
24Spread to other LN groups CONTIGUOUS SPREADFrom one LN to the next.
33Complete blood count ESR, may be raised May be Normal Normochromic, normocytic anaemiaLymphopenia ( A bad sign)EosinophiliaNeutrophiliaESR, may be raised
34Renal function tests, need to be normal before Rx. Liver function testsMay be NormalAbnormalWith infiltraion or without infiltraionObstructive pattern enlarged LN at porta hepatis.Renal function tests, need to be normal before Rx.Serum LDHReflect level of tumor bulk and turnoverNot of great significance in HL
40Bone Marrow biopsy Indications 1- Hodgkin Lymphoma when bone marrow involvement is suspectedabnormal full blood countadvanced stage of the disease.2-ALL cases of Non Hodgkin Lymphoma.
41Staging of lymphoma Ann Arbor classification Stage IStage IIStage IIIStage IV
42Bulky Disease Mediastinal mass >⅓ of the maximum transverse diameter of the chestPresence of nodal mass with a maximal dimension > 10cm
43LYMPHOMA STAGING “B” symptoms Stage A No B symptoms Unexplained Fever > 38oCUnexplained Weight loss > 10% body weight within the preceding 6 months.Drenching night sweetsStage A No B symptomsStage B any one of the B symptoms
65Specially in T-Cell Lymphoma Extranodal DiseaseExtranodal Disease:Bone Marrow: Low Grade> High GradeGutThyroidLungTestisBrainSkinBone , rareMore Common in nhlSpecially in T-Cell Lymphoma
66Compression Syndromes Intestinal ObstrucionAscitesSVC obstrucionSpinal Cord CompressionMore Common in NHL
67NHL vs. HL Clinical Features Extent at presentationLocalizedDisseminatedSpread to LNContingousSkippyExtra-nodal DiseaseRareMore commonObstruction SyndromesLess Common
68Staging of lymphoma Cotswolds Staging classification Stage IStage IIStage IIIStage IV
69LYMPHOMA STAGING “B” symptoms Stage A No B symptoms Unexplained Fever > 38oCUnexplained Weight loss > 10% body weight within the preceding 6 months.Drenching night sweetsStage A No B symptomsStage B any one of the B symptoms
71As in Hodgkin Lymphoma Hematological examinatons: Complete blood countLiver function testsRenal function testsSerum LDHReflect level of tumor bulk and turnoverParticularly of relevance in aggressive NHLRadiological examinatons
723-Bone Marrow biopsy Indications of bone marrow biopsy: 1- Hodgkin Lymphoma when bone marrow involvement is suspectedabnormal full blood countadvanced stage of the disease.2-ALL cases of Non Hodgkin Lymphoma.
73As in Hodgkin Lymphoma PLUS Immunophenotyping of surface antigens:B-Cell or T-CellImmunoglobulin Levels, some NHL cause raised IgG or IgM levels.Serum Uric AcidRaised in high grade NHL renal failure if not treated.HIV testing, If relevant to clinical condition..
74Non Hodgkin lymphoma Treatment depends on: Grade ( Low or High) Clinical Stage
75Treatment of Low Grade NHL Indications for treatmentSystemic SymptomsRapid nodal growthBone Marrow involvment.Compression SyndromesObservation and Follow upActive TreatmentStage I-IIRadiotherapyPalliative Radiotherapy for:SVC obstructionSpinal Cord CompressionPainStage III-IVChemotherapySingle agent (Chlarambucil, Fludarabine)Or; Combination chemotherapy (CVP)Rituximab (Monoclonal Antibody) for CD-20 positive follicular lymphoma
76Treatment of high Grade NHL Chemotherapy (CHOP) 3 cycles Stage I-II – Non BulkyChemotherapy (CHOP) 3 cyclesAND RadiotherapyStage I-II – BulkyStage III-IVChemotherapy (CHOP) 6-8 cyclesChemotherapy (CHOP) + RituximabFor CD20 + Diffuse large B Cell lymphomaRadiotherapy to area of bulky diseaseRelapsed DiseaseAutologus Stem Cell Transplantation
77Repeat cycle every 3 weeks CHOPCCYCLOPHOSPHAMIDEHDOXORUBICINOVINCRISTINE (Oncovin)PPREDNISOLONERepeat cycle every 3 weeks
78Rituximab Monoclonal Antibody Against CD20 antigen. Can be combined with other chemotherapyUsed forDiffuse Large B cell LymphomaFollicular Lymphoma that is CD20 positive
79Gastric MALToma Low grade histology Related to H.pylori infection Surgery is not routinely performed.Treatment:Treat H.pylori infectionChemotherapy if;Large cell componentDeeply penetratingMetastaticRelapsing
82Classification of NHL The working formulation (1982) Clinical behaviour + histopathological featuresNot incorporated the origin of the cell ( B or T)Missing a large variaty of new clinicopathological entities.The WHO/REAL classification (1993)Incorporates immunophenotypesDifferentiate between cells of T or B originRecognizes seversal less common entities
83The International Prognostic Index (IPI) for NHL Five independent prognostic factors1- age older than 60 years2- higher stage (III or IV)3- More than one extranodal site involvement4- lower performance status ( ECOG>1)5- elevated serum LDH0-1 5 yr survival is 73%4-5 5 yr survival is 26%
84A practical way to think of lymphoma HLNHLIncidence4: /yr12: /yrReed-Sternberg cellsPresentAbsentCell TypeB-cellB-cell(70%), T-cell(30%)SexMales>FemalesMedial Age31 yrs65-70 yrsLN enlragementUsually supradiaphragmaticAny whereSpread patternContiguousSkippedExtranodal involvementLess commonMore commonDeterminants of treatmentStage (I,II,III,IV)B symptomsGrade (Low/High)Stage(I,II,III,IV)
85A practical way to think of lymphoma CategorySurvival of untreated patientsCurabilityTo treat or not to treatNon-Hodgkin lymphomaIndolentLow GradeYearsGenerally not curableGenerally defer Rx if asymptomaticAggressiveHigh GradeWeeks MonthsCurable in someTreatHodgkin lymphomaAll typesVariable – months to yearsCurable in most
86Modes of Spread of Lymphoma Hodgkin LymphomaAlmost always originate in a LNContiguous spreadExtranodal disease to bone, brain or skin is rare.Non Hodgkin LymphomaUsually widespread at presentationSkippy spreadExtranodal involvement is more common than in HLBone marrow, GIT, Thyroid, Lung, Skin , testis, Brain and Bone.