LYMPHOMA

dr. Avit Suchitra,SpB.-KBD

Lymphoma is a cancer in the lymphatic cells of
the immune system.
Typically, lymphomas present as a solid tumor of
lymphoid cells.
Treatment might involve chemotherapy and in some
cases radiotherapy and/or bone marrow
transplantation, and
can be curable depending on the histology, type, and
stage of the disease.
Lymphomas, multiple myeloma
world map - Death - WHO2004

(per 100,000 inhabitants)

 NHL CANCER INCIDENCE 2002
Figure 1.5: Age-standardised incidence and mortality rates for NHL
in males by region of the w orld, 2002 estimates
Northern America
Australia/New Zealand
Western Europe
Northern Europe
Southern Europe
Eastern Africa
Western Asia
South America
Western Africa
South-Eastern Asia
Central America
Southern Africa
Incidence
Eastern Europe
Middle Africa
Northern Africa Mortality
Eastern Asia
South Central Asia

0 5 10 15 20

Rate per 100,000 population

 WHO Classification of Lymphoma
non Hodgkin lymphoma
 What should we do ?
when we meet a patient with suspected
non-Hodgkin’s lymphoma
 PAST HISTORY
• A personal or family history
malignancy,
radiation therapy,
immunosuppressive agents,
chemotherapy,
organ transplantation， etc.

• Relevant infectious illnesses HIV-I,

HTLV-I,
Epstein-Barr virus (EBV),
hepatitis C virus,
Pyothorax-associated
lymphoma.

• Connective tissue diseases, immunodeficiency

disorders etc.
• Agricultural to pesticides and Agent Orange
 CHIEF COMPLAINTS
Systemic complaints
* Fever — temperature >38ºC
* Weight loss >10 percent over the past six months
* Sweats — the presence of drenching night sweats
Lymphadenopathy
* Rapid and progressive or Waxing and waning
* The duration, observed sites, and extent
* Peripheral lymphocytosis
Symptoms in gastrointestinal lymphoma according to involved site
Symptom Stomach n = 277 Small bowel n = 32 Ileocecal n = 26 Multiple sites n = 24
Pain 78 75 77 58
Loss of appetite 47 41 23 58
Weight loss 24 34 15 25
Bleeding 19 6 12 8

Vomiting 18 31 8 21
Night sweats 11 12 19 46
Diarrhea 4 12 19 29
Constipation 3 25 23 12

Fever 2 6 8 4
Perforation 2 9 - -
Ileus - 38 19 4
No symptoms 4 - - -
This table shows the percent of patients with the listed symptom at each of the four major
sites of disease. Data from Koch, P, et al. J Clin Oncol 2001; 19:3861.
 PHYSICAL EXAMINATION
• Waldeyer's ring
• Standard lymph node sites
• Liver and spleen
• Abdominal nodal sites (mesenteric, retroperitoneal)
• Less commonly involved nodal sites (eg, occipital,
preauricular, epitrochlear, popliteal)
PHYSICAL EXAMINATION： Abdomen and Pelvis
Retroperitoneal lymphadenopathy
 Extranodal sites
• Patients with NHL will have primary
extranodal lymphoma at initial Diagnosis
(10~35 %).
• The most common site of primary extranodal
disease is the GI tract, followed by skin.
• Symptoms due to extralymphatic disease are
usually associated with aggressive NHL.
• The skin should be carefully examined for
lesions; all suspicious areas should be
biopsied.
 PHYSICAL EXAMINATION：Extranodal sites

Colonic involvement with lymphoma Lymphoma affecting the kidney

 INITIAL LABORATORY STUDIES
• CBC with differential
• Renal and hepatic function
• Serum calcium, electrolytes, and uric acid
• Serum protein electrophoresis
• the tumor markers beta-2 microglobulin
lactate dehydrogenase
etc
LYMPH NODE AND TISSUE BIOPSY

• Peripheral lymphonodes
• CT-guided core needle biopsies
• Bone marrow examination
• Laparoscopic multiple biopsies
• Surgical operation
 Lymph node selection
• Size:
* Significant enlargement
* Persistence for more than four to six weeks
• Site:
* Supraclavicular nodes — 75 to 90 percent
* Cervical and axillary nodes — 60 to 70 percent
* Inguinal nodes — 30 to 40 percent
 Studies on excised tissue
• An intact lymph node is critical for
histologic, immunologic, molecular biologic
assessment.
• The FNA findings of "lymphoma" requires
to be confirmed.
• Immunologic, cytogenetic, and molecular
studies are useful for making therapeutic
decisions and assessing prognosis.
Reactive lymph node versus follicular lymphoma, and
versus diffuse lymphoma
CLINICAL EVALUATION
Ann Arbor staging classification for Hodgkin's and NHL
 "B" symptoms
• “B” symptoms are more common in aggressive/
highly aggressive histologies (47%) .
• < 25 % with indolent lymphomas have B
symptoms.
 International Prognostic Index
• Age >60
• Serum LDH
• ECOG performance status 2
• Ann Arbor clinical stage III or IV
• Number of involved extranodal disease sites >1
 ECOG Performance Status
Performance Status Definition

0 Fully active; no performance restrictions

1 Strenuos physical activity restricted; fully ambulatory and

able to carry out light work

2 Capable of all selfcare but unable to carry out any work

activities, Up and about 50 percent of waking hours

3 Capable of only limited selfcare; confined to bed or chair,

less than50% of waking hours

4 Completely disabled; cannot carry out any selfcare; totally

confined to bed or chair
 5-yr OS and CR rates according to IPI score

Score Risk group 5-yr OS CR rate

(%) (%)

0 to 1 Low risk 73 87
2 Low-intermediate risk 51 67
3 High-intermediate risk 43 55
4 to 5 High risk 26 44
Treatment
 OS compared between
conventional chemotherapies and R-CHOP

100
CHOP
80 MACOP-B
Overall survival (%)

ProMACE-CytaBOM
60
m-BACOD
40

20

0 5 10 15

Patients over 60 (LNH98-5) 2002

THANKS