1. Lymphoma Brevity in writing is the best insurance for its perusal.
Dr.Usha Dorairajan MS ,FRCSEd
Professor of Surgery
Kilpauk Medical College
Brevity in writing is the best insurance for its perusal.
Rudolf Virchow

3. Lymphoma
A malignant neoplasm of B or T lymphocytes, arising from a monoclonal proliferation of lymphocytes;
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

5. Type
Non Hodgkin’s lymphoma
85%
Hodgkin’s lymphoma
15%

6. Lymphatic Organs
Secondary
lymphoid
organs
Primary lymphoid tissue

7. Incidence of lymphoma in India
GLOBOCAN 2008
INDIA
Male
Female
Both sexes
610618
570793
430.1
518.8
948.9
Population (thousands)
Number of new cancer cases (thousands)
Incidence
69820
3333
35059
36476
7371
23718
Mortality
47653
2412
33564
25690
3587
16243
 Cancer
 Lip, oral cavity
 Nasopharynx
 Stomach
 Colorectum
 Hodgkin lymphoma
 Non-Hodgkin lymphoma
GLOBOCAN 2008 (IARC) Section of Cancer Information

8. Symptoms Painless lymphadenopathy cervical axilla or groin
2. Weight loss
3. Fever
4. drenching sweating at night
5. Pruritis
6. Loss of appetite
7. A feeling of weakness
8. Breathlessness along with edema of the face and neck

9. Risk factors Age Sex Infectious agents Chemicals Genetics
Immunodeficiency states autoimmune
Cancer treatment

10. Infections Human T-lymphotrophic virus type1 adult T lymphoma
Epstein-Barr (EBV) Burkitt’s Hodgkin’s
Helicobacter pylori MALT lymphomas of the stomach;
Human immunodeficiency virus (HIV),
HHV-8 (Human Herpes virus) Primary effusion lymphoma
Hepatitis C virus B-NHL
DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, Eighth Edition

11. Examination
Waldeyer’s ring
Neck
Axilla
Mediastinal widening
Pleural effusion
Epitrochlear nodes
Abdomen liver, spleen,
aortic iliac inguinal
Popliteal node

12. Mediastinal involvement common
in nodular sclerosis Hodgkin’s lymphoma

13. 25 – 50% of NHL have extra nodal presentation
GI tract %
Oropharyngeal %
CNS %

14. Diagnosis Adequate tissue biopsy. Immunohistochemistry Flow cytometry
Accurate diagnosis of lymphoma depends on
Adequate tissue biopsy.
Immunohistochemistry
Flow cytometry
Molecular and Genetic studies
electrophoresis, Southern Blot, microarray PCR
FISH
FNAC?
Immuno phenotyping o

15. Lymph Node Biopsy
Lymphoma

16. Biopsy of easily accessible largest node.
Lymph node biopsy
Biopsy of easily accessible largest node.
A complete node is best. And more than one node
Axilla and groin are avoided.
To be delivered immediately without fixation to path lab.
Cell suspensions of fresh tissue for flow cytometry immunotyping, cell kinetics analysis and molecular analysis.
Touch imprint cytology is for comparing bone marrow and nodal cytology.
A portion is snap frozen for molecular genetics and for
immunohistochemistry.
A portion is fixed and processed for morphological study.

17. Evaluation Diagnosis of NHL lymphoma depends on finding
abnormal numbers of lymphocytes that are destroying
normal architecture of lymphoid tissue
or invading non lymphoid tissue or both.

18. Hodgkin lymphoma –Classification
Nodular lymphocyte-predominant Hodgkin lymphomas
Classic Hodgkin lymphomas Nodular sclerosis Hodgkin lymphoma Lymphocyte-rich classic Hodgkin lymphoma Mixed cellularity Hodgkin lymphoma Lymphocyte depletion Hodgkin

19. Hodgkin’s lymphoma contain one of the characteristic
Reed Sternberg
cell
Hodgkin’s lymphoma contain one of the characteristic
Reed Sternberg cells and mononuclear malignant cells Hodgkin cell) HRS cells
In a background of non neoplastic cells.
HRS cells form only .1% - 1.5% of cellular population

20. Nodular sclerosis Nodular lymphocyte Predominant HL Popcorn cell
Lacunar cell

21. Precursor Lymphoid Neoplasms
B lymphoblastic leukemia / lymphoma NOS B lymphoblastic leukemia / lymphoma with recurrent genetic abnormalities B lymphoblastic leukemia / lymphoma with t(9;22); bcr-abl1 B lymphoblastic leukemia / lymphoma with t(v;11q23); MLL rearranged B lymphoblastic leukemia / lymphoma with t(12:21); TEL-AML1 & ETV6-RUNX1 B lymphoblastic leukemia / lymphoma with hyperploidy B lymphoblastic leukemia / lymphoma with hypodiploidy B lymphoblastic leukemia / lymphoma with t(5;14); IL3-IGH B lymphoblastic leukemia / lymphoma with t(1;19); E2A-PBX1 & TCF3-PBX1 T lymphoblastic leukemia / lymphoma
Mature B-Cell Neoplasms
Chronic lymphocytic leukemia / small lymphocytic lymphoma B-cell prolymphocytic leukemia Splenic marginal zone lymphoma Hairy cell leukemia Lymphoplasmacytic lymphoma / Waldenstrom macroglobulinemia Heavy chain disease Plasma cell myeloma Solitary plasmacytoma of bone Extraosseous plasmacytoma Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type Nodal marginal zone lymphoma Follicular lymphoma Primary cutaneous follicular lymphoma Mantle cell lymphoma Diffuse large B-cell lymphoma, NOS (T-cell / histiocyte-rich type; primary CNS type ; primary leg skin type & EBV+ elderly type) Diffuse large B-cell lymphoma with chronic inflammation Lymphomatoid granulomatosis Primary mediastinal large B-cell lymphoma Intravascular large B-cell lymphoma ALK+ large B-cell lymphoma Plasmablastic lymphoma Large B-cell lymphoma associated with HHV8+ Castleman disease Primary effusion lymphoma Burkitt lymphoma B cell lymphoma, unclassifiable, Burkitt-like B cell lymphoma, unclassifiable, Hodgkin lymphoma-like lymphoma
New
WHO - REAL
Classification of
Lymphoid
Neoplasms
(2008)

22. Mature T-Cell & NK-Cell Neoplasms
T-cell prolymphocytic leukemia T-cell large granular lymphocytic leukemia Chronic lymphoproliferative disorder of NK-cells.
Aggressive NK-cell leukemia Systemic EBV+ T-cell lymphoproliferative disorder of childhood Hydroa vacciniforme-like lymphoma Adult T-cell lymphoma/leukemia Extranodal T-cell/NK-cell lymphoma, nasal type Enteropathy-associated T-cell lymphoma Hepato-splenic T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Mycosis fungoides Sézary syndrome Primary cutaneous CD30+ T-cell lymphoproliferative disorder Primary cutaneous gamma-delta T-cell lymphoma Peripheral T-cell lymphoma, NOS Angioimmunoblastic T-cell lymphoma Anaplastic large cell lymphoma, ALK+ type Anaplastic large cell lymphoma, ALK- type

23. Lymph node structure

24. Immunohistochemistry
The cells are examined to determine what antigens  are expressed on the surface of the cells by using antibodies that bind to those antigens.
Helps determine the type of lymphoma with far greater accuracy than just examining the biopsy under the microscope.
A chart of which antigens are typically positive or negative is on CD chart.( Cluster Differentiation )

25. Flow Cytometry Flow cytometry
Individual cells are separated and examined.
  Flow cytometry
identifies types of lymphoma from FNAC specimens

26. FNAC To diagnose relapse Flow cytometry possible with FNAC
Inaccessible nodes like abdominal and retroperitoneal nodes can be targeted under CT guidance for FNAC

27. Why Immuno phenotyping
To differentiate a lymphoma from poorly differentiated carcinoma
To differentiate a lymphoma from a reactive lesion (monoclonal)
Classification of lymphoma

28. Treatment of lymphoma Treatment Staging work Up Treatment

29. Staging Work Up X-ray chest, CT chest and CT abdomen
Bone marrow biopsy.
PET scan
MRI
CSF analysis

30. Ann Arbor Staging
A/B
A/B
A/B
A/B

31. Cotswold modificationsX
Massive mediastinal disease has been defined by the Cotswold meeting as a thoracic ratio of maximum transverse mass diameter greater than or equal to 33% of the internal transverse thoracic diameter measured at the T5/6 intervertebral disc level on chest radiography .or 10 cm
The number of anatomic regions involved should be indicated by a subscript (eg, II3)
Stage III1
Stage III2
Stage III may be subdivided into: III1, with or without splenic, hilar, celiac, or portal nodes;III2, with para-aortic, iliac, mesenteric nodes
CS \ PS CR
Staging should be identified as clinical stage (CS) or pathologic stage (PS)
A new category of response to therapy, unconfirmed/uncertain complete remission (CR) can be introduced because of the persistent radiologic abnormalities of uncertain significance

32. The treatment and prognosis depends on
stage
patient performance status
the characteristic of lymphoma.

33. International Prognostic Index for Hodgkin’s lymphoma
1- Serum albumin < 4 gm/dl
2- Hemoglobin level below 10.5 gm/dl
3- Male gender
4- Stage IV disease
5- Age ≥ 45 years
6- WBC of ≥ 15,000/mm²7- Lymphocyte count ≤ 600/mm² or ≤ 8% of WBC

34. International Prognostic Index for Non Hodgkin’s lymphoma
Age> 60 years
Performance status>2
LDH> than normal
Ann Arbour stage III or IV
> 2 Extranodal sites

35. Complete haemogram
LFT and RFT patient characteristics
glucose, calcium
Lactate Dehydrogenase (LDH)
Albumin lymphoma characteristic
β2 microglobulin

36. Treatment

37. Hodgkin’s lymphoma usually arises in lymph nodes and spreads to contiguous groups. Extranodal presentation are rare.
Treatment is by
stage of disease
and
prognostic factors

38. Treatment of lymphoma Treatment modality radiotherapy chemotherapy
combination therapy
high dose chemotherapy with bone marrow transplant
monoclonal antibody RITUXIMAB

39. Treatment of Hodgkin’s lymphoma
With appropriate treatment about 85% of patients with Hodgkin disease are cured

40. Treatment of Hodgkin Lymphoma
Radiation therapy alone in special circumstances
Chemoradiotherapy
ABVD for two to four cycles plus involved field radiotherapy(20 Gy or 30 Gy).
Chemotherapy alone
ABVD for four to six to eight cycles. (ABVD: doxorubicin plus bleomycin plus vinblastine plus dacarbazine
BEACOPP (increased dose). (bleomycin plus etoposide plus doxorubicin plus cyclophosphamide plus vincristine plus procarbazine plus prednisone

41. Radiation therapy CURRENT TREND Involved field radiotherapy Neck
Extended field
mantle field
paraaortic field
pelvic field
CURRENT TREND
Involved field radiotherapy
Neck
Mediastinum
Axilla
Paraaortic
inguinal

42. Complications of treatment
Second malignancy
Cardiac dysfunction
Lung fibrosis
sterility
In Hodgkin’s disease current trend is
less aggressive treatment to minimise
complications

43. Cochrane Reviews For early-stage patients chemoradiotherapy
Chemotherapy, radiotherapy and combined modality for Hodgkin's disease, with emphasis on second cancer risk
For early-stage patients chemoradiotherapy
resulted in longer survival and longer HD-free survival than either RT or CT alone
Second malignancy (SM) risk was lower with CRT than with RT
For advanced stages
no difference in survival between CRT and CT alone was established

44. Treatment of non-Hodgkin lymphoma (NHL) depends on the histologic type and stage.

45. Treatment of Non Hodgkin’s lymphoma
Watchful waiting
Chemotherapy with radiation therapy.
Rituximab, an anti-CD20 monoclonal antibody, either alone or in combination with chemotherapy .
R-CHOP (four to eight cycles).
R-CHOP (three to eight cycles) plus IF-XRT.
Autologous BMT or peripheral stem cell transplantation or allogeneic BMT for patients at high risk of relapse is under clinical evaluation

46. Cochrane Summary
improved survival of follicular and in mantle cell lymphoma when treated with R-chemo compared to chemotherapy alone.
no benefit for high-dose chemotherapy with stem cell transplantation as a first line treatment in patients with aggressive NHL.
IFN as maintenance therapy for FL improves progression-free survival. A net benefit for overall survival is less evident

47. HIV associated lymphoma
HIV-associated, non-Hodgkin’s lymphoma occurs in 5-10% of individuals with HIV infection
virtually all of B-cell origin. Most are intermediate- or high-grade lymphomas
Complete response occurs in 33-62% of patients
. Relapse occurs in 25% of complete responders within 6 months.
Median survival is 4-8 months, with about half dying of lymphoma and half of opportunistic infection.

48. Lymphoma is the most common small bowel malignancy in the pediatric age
50-93% of patients have intestinal lymphomas located in the ileocecal region.
a history of nonspecific chronic abdominal pain common
can present acutely as appendicitis or intussusception

49. Oliver Wendell Holmes Jr
Man’s mind once stretched by a new idea never regains it’s original dimensions
Oliver Wendell Holmes Jr

50. Summary
Management of lymphoma needs a multidisciplinary approach with a need to keep abreast of evidence based medicine.
Lymphoma is associated with immuno compromised states
Surgeon ‘s role
in diagnosis of lymphoma.
In treatment of lymphoma in extranodal sites (GI
tract emergencies).

51. Coral gmail.com
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