1. Lymphoma Lymphoma Non Hodgkin’s lymphoma Hodgkin’s disease

2. Lymphoma Three categories of lymphoma Nodal Extranodal Extralymphatic

3. Extranodal Lymphatic Sites Spleen (C42.2) Thymus Gland (C37.9) Lingual Tonsil (C02.4) Palatine Tonsil (C09.9) Waldeyers’s ring (C14.2) Peyer’s patches (C17.2) Lymphoid nodules of the appen

4. Common Extralymphatic Sites Stomach Small Intestine Uterus Bone Brain Breast Large Intestine Others These sites are designated by an “E” in the stage grou

5. Bilateral Lymph Node Regions Bilateral Cervical cervical, supraclavicular, occipital, preauricular Infraclavicular Axillary Pelvic Inguinal/femoral If both sides are involved, count as two lymph node regions

6. Stage Stage I Single Lymph Node Region

7. Stage Stage II Two or more node regions on the same side of the diaphragm CS Codes

8. Stage III Nodal involvement on both sides of the diagphragm

9. Stage IV Diffuse or disseminated involvement of one or more extralymphatic organs or any involvement of the liver, bone marrow or nodular involvement of the lungs CS Code 80

10. Defining Lymph Node Involvement Clinical enlargement (without other explanation such as infection) Pathologic diagnosis Imaging: nodes larger than 1.5 cm

11. CS Extension codes 11, 21, 31 Presenting in extralymphatic site(s) Stomach, brain, etc.

12. Stage IE: primary parotid lymphoma involving entire gland that undergoes curative surgery Stage IIE: primary lung lymphoma with hilar and mediastinal disease (presenting as 2 masses) Stage IIE: mediastinal lymph nodes with direct extension to lung

13. CS Extension codes 12, 22, 32 Unequivocal palpable splenomegaly Equivocal palpable splenomegaly with radiologic confirmation Radiologic enlargement AND multiple focal defects (not cystic or vascular

14. Determining Stage IV Disease Site of origin Stomach, colon, brain, uterus Most likely extralymphatic Bone, lung Most likely Stage IV Liver, bone marrow, cerebrospinal fluid, pleura ALWAYS stage IV

15. Hodgkin’s disease Hodgkin’s disease *Epidemiology More common in males. Bimodal distribution, with 2 peaks occurring In late twenties and over 45 years. *Etiology Viral infection EBV, HIV ??, high social class, Caucasian > non Caucasian *Pathology DX Reed-Sternberg cells or their variants in the appropriate background of benign reactive cells consisting of lymphocytes,histiocytes, neutrophila, and eosinphils.

16. Good prognostic factors Age below 60 Stage I and II No more than one area of lymphoma outside of nodes

17. Adverse prognostic factors (count 1 point for each factor below) Age 60 and above Stage III and IV More than one area of extra nodal involvement Performance need, a lot of help Elevated LDH

19. Performance status - able to function normally Serum LDH is normal

20. Hodgkin lymphoma Thomas Hodgkin (1798-1866)

21. A possible model of pathogenesis germinal centre B cell transforming event(s) loss of apoptosis RS cell inflammatory response EBV? cytokines

22. classification of HD classification of HD 1- Nodular lymphocyte predominant HL 5% all cases Male predominance Cervical and inguinal involvement Frequent relapse Good prognosis, rarely fetal 2- Classical HD

23. RS cell and variants popcorn celllacunar cellclassic RS cell (mixed cellularity)(nodular sclerosis) (lymphocyte predominance)

24. Reed-Sternberg cell

25. Classical HD A) Nodular sclerosis HD. The most common type, frequently associated with mediastinal mass, and hilar lymphadenopathy, in addition to the neck common in females Good prognosis, most in stage I,II Histology band of fibrosis and lacunar cells

26. Other types B- Lymphocytes Rich Good Prognosis Uncommon, most in stage I, II C-Mixed cellularity : Most common in older people, second most frequent, prognosis fair, most in stage III D- Lymphocytes depleted, Poor prognosis, rare, most stage III, and IV,

28. Reed-Sternberg cells may be found in NHL, benign illnesses, and carcinoma

29. DX Presentation Most of the patients present with superficial lymphadenopathy. Only 4% have limited diseases below the diaphragm. The lymph nodes are usually non tender,firm, rubbery Rarely the patients may present with auto immune thrombocytopenia, and Auto immune hemolytic anemia

30. Constitutional symptoms B symptoms associated with poor prognosis and advanced disease. Fever > 38ºC Drenching night sweats Weight loss more than 10% Other symptoms Purities Alcohol induced pain

31. Contiguous involvement from one group of lymph node to another

32. Abnormalities in T cells Abnormalities in T cells lead to impaired cell mediated immunity is frequent in HD. Because these patients have normal Ig bacterial infection is not common. They may, however present with viral infections, like HZ,Pulmonary fungal infection, cryptococcal meningitis

33. Thromboembolic disease is common in HD as well as NHL.

34. Laboratory tests CBC Anemia, Neutrophilia, eosinphilia lymphocytopenia, thrombocytosis or thrombocytopenia. Lymphocytopenia may due to replacement of lymph node structure with advanced disease or HIV infection. Liver function test may be abnormal, chlestatic pattern, non caseating granuloma or live involvement with HD.LDH may be elevated due to disease activity or organ involvement. ESR, Serum ferritin, and B2 micro globulin are elevated in patients with advanced disease.

35. Radiology CXR *Selected procedures Bone marrow biopsy for patients with anemia, high ESR.B symptoms, Stage IV. Liver biopsy when laparotomy indicated FNA not adequate Laparotomy only irradiation to be used alone

36. Staging Staging is the process to define the extent of the disease, which has direct relationship to the prognosis and treatment. Clinical staging involves history,physical examination, lab, and imaging techniques. Pathological staging refers to the extent of the disease following exploratory laparotomy and splenoctomy. Staging is important before the initiation of the treatment foe 2 reasons : a) HD thought to be spread by contiguous rather than haematogenous dissemination b) The staging of the patient has excellent correlation to survival.

37. Staging Stage IV Diffuse or disseminated involvement of I or more extra lymphatic organs or tissues with or without associated lymph node enlargement, involvement of liver or bone marrow is always considered stage IV A - Absence of B symptoms B - Presence of B symptoms E – Involvement of an extra nodal site by local extension from a nodal site. X – Bulky disease : mediastinal widening greater than one third the diameter of the chest at T6-7, or > 10 cm in any single dimension. CS clinical stage PS Pathological stage ( laparotomy)

38. Staging classification Stage I - Involvement of a single lymph node region (I) or of a single extra lymphatic organ or site (I E ) Stage II – Involvement of 2 or more lymph node regions on the same side of the diaphragm, or localized involvement of the extra lymphatic organ or site and 1 or more lymph node regions on the same side of the diaphragm (II E ). Stage III – Involvement of lymph node regions on both side of the diaphragm III. Which may be accompanied by localized involvement of extra lymphatic organ or organs or site (III E ), or by involvement of the spleen (III S ), or both ( IIISE).

39. Stage IStage IIStage IIIStage IV Staging of lymphoma A: absence of B symptoms B: fever, night sweats, weight loss

40. Bulky disease It is mediastinal widening greater than one third diameter of the chest at the T6-7, or > 10 cm in any single dimension

41. W.P. at presentation

43. Staging procedures 1- History 2- Physical examination: Lymph nodes, spleen, liver 3- Blood studies ESR, CBC, LFT, Serum creatinine. Uric acid, LDH, and Calcium. 4- Imaging studies : CXR, CT Chest, Abdomen, Pelvis. Gallium scan. MRI

44. Treatment Treatment options : Radiotherapy Chemotherapy Combined modality treatment Bone marrow transplantation

45. Radiotherapy Early stage disease stage I, II without B symptoms. Combined modality treatment in patients with early staged disease with some poor prognostic factors. Massive mediastinal involvement needs combine modality treatment. Chemotherapy stage B,and stage IIB-IV

46. Toxicity of treatment # Radiation therapy Acute toxicity includes stomatitis, oral thrush Radiation pneumonitis,and pulmonary fibrosis. Thyroid irradiation hypothyroidism Pelvic irradiation infertility Second malignancies sarcomas, lung cancer ….

47. Treatment and Prognosis StageTreatmentFailure- free survival Overall 5 year survival I,IIABVD x 4 & radiation 70-80%80-90% III,IVABVD x 660-70%70-80%

48. Long term complications of treatment infertility –MOPP > ABVD; males > females –sperm banking should be discussed –premature menopause secondary malignancy –skin, AML, lung, MDS, NHL, thyroid, breast... cardiac disease

49. Mediastinal involvement needs chemotherapy and radiotherapy after finishing radiation. Gallium scan is important to asses the response of treatment in Hodgkin’s lymphoma.

50. W.P. post-chemotherapy