LYMPHOMAS

Presented by Dr. Mohamed Talaat

Professor of Internal Medicine and Clinical Hematology
Cairo University
INTRODUCTION

• The term lymphoma identifies a heterogeneous group of biologically and clinically

distinct neoplasms that originate from cells in the lymphoid tissue.

• They have been historically divided into 2 distinct categories : Hodgkin’s and Non-
Hodgkin’s Lymphoma.

• 85% of lymphomas originate from mature B cells

• 10% to 15% derive from the T-cell lineage.

ANATOMY OF THE LYMPHOID SYSTEM

Lymphoid Tissues can be divided into 2 major categories :

1) CENTRAL or PRIMARY LYMPHOID TISSUES:

• These are tissues in which the lymphoid precursor cells mature to a stage at which
they are capable of performing their function in response to an antigen
• Includes Bone Marrow and Thymus

2) PERIPHERAL or SECONDARY LYMPHOIDTISSUE

• These are tissues in which antigen specific reactions occur
• Includes Lymph Nodes, Spleen and Mucosa Associated Lymphoid Tissue
A) CENTRAL LYMPHOID ORGANS
BONE MARROW
• It is the site of generation of all circulating blood cells in an adult.
• Gives rise to all cells of the immune system by a process called hematopoiesis.

It is of 2 types :

1. Red marrow
▪ Contains hematopoietic tissue
▪ Found in flat bones like skull, scapula, pelvic bone, vertebrae, ribs
▪ Also found in epiphyseal and metaphyseal ends of long bones.

2. Yellow marrow
▪ Contains mainly fatty tissue
▪ Present in diaphysis of long bones
▪ As a person’s age advances, red marrow is converted into yellow marrow.
▪ Process can be reversed if there is a need for hematopoiesis.
B) THYMUS
• Bi-lobed gland situated in the thorax above the heart.
• It increases progressively in size up to adolescence
following which it atrophies.
• Divided into a cortex and medulla

FUNCTION:

• Site at which immature T cells, which migrate from the

bone marrow undergo maturation and selection to naive
T cells
PERIPHERAL OR SECONDARY LYMPHOID TISSUE

Lymph Nodes
• Bean shaped structures strategically positioned
at various sites throughout the body
• They have afferent vessels entering at the periphery and
efferent vessels emerging at the hilus.
• Arranged in groups, along the blood vessels or
the flexural side of a joint

Function
• To process antigens, present in lymph fluid drained
from tissues and organs via the afferent lymphatics.
Spleen
• Location
▪ Left epigastric region
▪ Between 9th to 11th rib
▪ In line of 10 th rib

• Largest lymphatic organ in the body.

• Can vary considerably in size and weight

Functions of Spleen

• Important role in haematopoiesis during fetal development.

•Mechanical filtration of pathogens located within cells or circulating in
the plasma.
• Recognizes and removes old, damaged or malformed RBCs.
HISTOLOGY

• Divided into a capsule, cortex, medulla and sinuses.

• Sinuses are present at three sites : Subcapsular,
cortical and medullary.
• Sinuses contain numerous macrophages which filter
the lymph fluid, identify and process antigens and
present them to lymphocytes.
• Cortex contains B cell follicles
• Paracortex contains high endothelial venules and T
cell zones.
• Medulla contains medullary cords and sinuses.
SCHEMATIC REPRESENTATION OF A LYMPHOID FOLLICLE
HODGKINS LYMPHOMA

• Hodgkin lymphoma encompasses a distinctive group of neoplasms that are

characterized by the presence of a Reed-Sternberg cell.

• Arise in a single lymph node or chain of lymph nodes and typically spread in a
stepwise fashion to anatomically contiguous nodes.

• Two major sub-types are now recognized :

a) Classic Hodgkins Lymphoma

b) Nodular Lymphocyte predominant Hodgkins lymphoma
HODGKINS LYMPHOMA: CLINICAL FEATURES
• Hodgkins Lymphoma patients present with peripheral lymphadenopathy.

• Involved nodes are non tender with no overlying skin changes, discrete and freely
movable.

• Characteristic clinical presentation is enlarged superficial lymph nodes in young

adults.

• Commonly involved lymph nodes are cervical and supraclavicular(60-80%),

followed by axillary lymph nodes. Inguinal and femoral lymph node groups are less
commonly involved.

• Central lymphadenopathy is seen in some sub-types.

B SYMPTOMS
A. FEVER (25-50%)
B. DRENCHING NIGHT SWEATS
C. WEIGHT LOSS
D. OTHER NON-SPECIFIC SYMPTOMS (pruritus, fatigue and pain after drinking alcohol)

SYMPTOMS OF EXTRA NODAL MANIFESTATION:

A. Involvement of Liver

1) Abdominal swelling secondary to hepatomegaly or hepatosplenomegaly

2) Jaundice and ascites

B. Signs of mediastinal involvement

1) Retrosternal Chest pain

2) Cough and shortness of breath
3) Pleural and pericardial effusion
INVESTIGATIONS
A. DETAILED HISTORY WITH ATTENTION TO PRESENCE OR ABSENCE OF CLINICAL
SYMPTOMS

B. CAREFUL PHYSICAL EXAMINATION EMPHASIZING NODE CHAINS , WALDEYERS

RING AND SIZE OF LIVER AND SPLEEN

C. ROUTINE LABORATORY TESTS

• Complete Blood Cell Count
• Erythrocyte Sedimentation Rate
• Liver Function Test

D. CHEST RADIOGRAPH
• Low cost method for diagnosis and surveillance in Hodgkins Lymphoma
• Useful for detecting mediastinal disease
INVESTIGATIONS (Cont.)
E. CT SCAN
• Standard thoracic examination for patients with HL
• Useful for determination of sites on initial involvement
as well as extent of disease
• Helps in classification of early stage patients into
favorable or unfavorable prognosis.

F. ADEQUATE SURGICAL BIOPSY OF AFFECTED LYMPH NODES

G. STAGING LAPAROTOMY (to determine involvement of abdominal lymph nodes)

(Staging laparotomy was extensively used when radiation therapy was preferred treatment for early stage
Hodgkin's lymphoma. It was mandatory to define the extent of abdominal involvement to determine
whether there was an indication for chemotherapy. Nowadays, with availability of better imaging techniques
and with routine use of chemotherapy for early stage disease, staging laparotomy is not indicated as a
routine procedure)
REED STERNBERG CELL

• The sine qua non of Hodgkin lymphoma is the Reed Sternberg (RS) cell

• These are different kinds of giant cells.

• Usually derived from Blymphocytes.

• Enormous bilobed or multilobate nucleus,

exceptionally prominent nucleoli and abundant,
usually slightly eosinophilic cytoplasm.

• Particularly characteristic are cells with two mirror-

image nuclei , each containing a large acidophilic
nucleolus surrounded by a clear zone, features that
impart an “owl- eye” Appearance.
CLASSIC HODGKINS LYMPHOMA

• Monoclonal Lymphoid Neoplasm, composed of mononuclear Hodgkins cells and

multi- nucleated Reed Sternberg cells in an infiltrate containing a mixture of
eosinophils, small lymphocytes , neutrophils and histiocytes.

• Subtypes of Classic Hodgkins Lymphoma( cHL):

a) Nodular Sclerosis type

b) Mixed cellularity
c) Lymphocyte Rich
d) Lymphocyte Depleted
STAGING OF HODGKINS LYMPHOMA
TREATMENT METHODS

1. RADIOTHERAPY

2. CHEMOTHERAPY

3. COMBINED TREATMENT MODALITY

RADIOTHERAPY
Radiation therapy is the most effective single therapeutic agent for treating early
stage Hodgkins lymphoma.

INVOLVED FIELD RADIOTHERAPY

• Most commonly used technique
• The main objective is to treat the involved site and immediately adjacent
continuous sites.
• The involved field is limited to the site of clinically involved lymph node groups.
• Different involved fields include
a) Neck
b) Mediastinum
c) Axilla
d) Para aortic
e) Inguinal
CHEMOTHERAPY
TREATMENT RELATED SIDE EFFECTS
A) PULMONARY COMPLICATIONS
• Radiation pneumonitis typically occurs 1-6 months after completion of
radiotherapy.
• 10-15% of patients with large mediastinal tumours who receive a combination
of chemotherapy and mantle field radiation therapy develop radiation
pneumonitis.

CLINICAL FEATURES
• Mild, non-productive cough
• Low grade fever
• Dyspnoea on exertion

RADIOLOGIC FEATURES
• Formation of infiltrates confined to the original radiation fields.
TREATMENT RELATED SIDE EFFECTS (Cont.)
B) CARDIAC COMPLICATIONS
1) Chemotherapy associated Cardiac Complications
• Caused by anthracyclines
• Presents as ECG changes, arrythmias or cardiomyopathy leading to
congestive heart failure
• Caused by direct damage to the cardiac myoepitheliem
• Cardiotoxicity caused by doses greater than 500mg/m2 of body surface
area

2) Radiotherapy associated Cardiac Complications

• Wide spectrum of cardiac diseases such as coronary artery disease,
myocardial dysfunction, valvular heart disease.
• Radiation associated heart diseases usually present 10-15 years after
exposure.
TREATMENT RELATED SIDE EFFECTS (Cont.)
C) SECONDARY NEOPLASIA
• Radiotherapy and certain chemotherapeutic agents such as nitrogen
mustards, procarbazine, cyclophosphamide and etoposide are known to
induce secondary malignancies.
• Acute leukemias are the commonest secondary malignancies, usually
occurring within the first 10 years of initial treatment.
• Secondary Non-Hodgkins Lymphomas after Hodgkins Lymphoma.
• Incidence of secondary solid organ tumors increases with time.
• Solid organs most at risk of developing a secondary malignancy are lung and
breast.
• Other secondary cancers that occur after successful completion of treatment
include sarcomas, melanomas and bone tumors.
GONADAL DYSFUNCTON
MALES FEMALES

• Post treatment gonadal damage • Gonadal damage in females and –

premature ovarian failure
• Cryoconservation of sperm • Anti-Mullerian hormone is the most
sensitive indicator of gonadal function
and can be used for post- treatment
assessment of ovarian reserve.
TREATMENT FAILURES
DIVIDED INTO 3 CATEGORIES:

A) PRIMARY PROGRESSIVE DISEASE :

→ Patients who never achieved a complete remission or relapse within 3 months
after end of first line of treatment

B) EARLY RELAPSE:
→ Relapse occurs 3 to 12 months after the end of 1st treatment

C) LATE RELAPSE
→ Relapse after a complete remission lasting at least 12 months
NON HODGKINS LYMPHOMA
INTRODUCTION

• Non-Hodgkin’s lymphomas (NHL) are neoplastic transformations of mature B, T,

and natural killer (NK) cells.

• In children diffuse large B-cell lymphoma (DLBCL), Burkitt’s lymphoma (BL), and
lymphoblastic lymphoma are most common.

• DLBCL is also the most common histologic subtype in adults.

• Poorer prognosis as compared to Hodgkins Lymphoma as complete cure achieved

in less than 50% of patients(compared to over 80% in Hodgkins).
ETIOLOGY
CLINICAL FEATURES
NHLs have been divided into groups based on clinical behavior

A) LOW-GRADE LYMPHOMAS
• Peripheral adenopathy that is painless and slowly progressive.
• Spontaneous regression of enlarged nodes may occur (waxing and waning
LN’s)
• Primary extra-nodal involvement and B symptoms are not common in patients
with low grade disease.
CLINICAL FEATURES (Cont.)
B) INTERMEDIATE OR HIGH GRADE
• Peripheral lymphadenopathy
• More than one third of patients present with extranidal involvement; the most
common sites are the gastrointestinal tract , skin, bone marrow, sinuses,
genitourinary tract, thyroid, and central nervous system .
• Involvement of retroperitoneal, mesenteric, and pelvic nodes is common in
most histologic subtypes of NHL.
• Primary lymphomas of bone are very rare(5%)Most common sites are femur,
pelvis and vertebrae.
• Primary GI lymphomas often present with hemorrhage, pain, or obstruction
CLINICAL FEATURES (Cont.)
B) INTERMEDIATE OR HIGH GRADE (Cont.)
• Most common site is the stomach. Common histological subtypes presenting are
Diffuse Large B Cell Lymphoma, Mantle Cell Lymphoma and MALT
Lymphoms.
• B-symptoms are more common( 30-40% of patients)
• Lymphoblastic lymphoma, a high-grade lymphoma, often manifests with an
anterior superior mediastinal mass, superior vena cava (SVC) syndrome, and
leptomeningeal disease with cranial nerve palsies.
• Primary CNS lymphomas are high-grade neoplasms of B-cell origin. Most
lymphomas originating in the CNS are large cell lymphomas or
immunoblastomas, and they account for 1% of all intracranial neoplasms.
• Symptoms of primary NHL of the CNS include headache, lethargy, focal
neurologic symptoms, seizures, and paralysis.
INVESTIGATIONS
A) BIOPSY
• INDICATION : lymph node larger than 1.5 × 1.5 cm that is not associated with a
documented infection and that persists longer than 4 weeks should be
considered for a biopsy.
• A biopsy should be performed immediately for patients with other findings
suggesting malignancy

B) LABORATORY INVESTIGATIONS

• Complete Blood Count

• Liver Function tests
• Serum Protein Electrophoresis
• LDH and b-2 microglobulin
INVESTIGATIONS (Cont.)
C) IMAGING
1. CT SCAN
• Chest, abdominal and pelvic CT scans are done routinely.
• Essential for accurate staging of the disease.
2. PET SCAN
• 18F-Fluorodeoxyglucose PET scan is highly sensitive for detecting both nodal
and extra-nodal disease.
• Particularly useful for histologically aggressive lymphomas
• PET scanning detects an actively metabolizing tumor in residual masses
following or during chemotherapy, and persistent abnormal uptake predicts
for early relapse and/or reduced survival.
3. MRI SCAN
• Useful in detecting bone, bone marrow, and CNS diseases in the brain and
spinal cord.
• Concept of staging has less impact in NHL than in HL

• Prognosis is more dependent on histology and clinical parameters than the stage at
presentation.

• Staging in NHLs, therefore, is done to identify the minority of patients who can be
treated with local therapy or combined modality treatment.
DIFFUSE LARGE B CELL LYMPHOMA

• DLBCL constitutes 31% of all NHLs, and is the most common histologic subtype

• DLBCLs consist of a diffuse proliferation of large cells that have a high mitotic rate.

• Cell of origin is usually Germinal Center and Post germinal center activated B cells.

• Can prove to be rapidly fatal if left untreated.

MARGINAL ZONE LYMPHOMAS

MZLs are indolent NHLs that include three diseases arising from post-GC marginal
zone B cells:

A)Nodal Marginal Zone Lymphomas

B) Splenic Marginal Zone Lymphoma

C) Extranodal Marginal Zone Lymphoma

NODAL MARGINAL ZONE LYMPHOMA (MZL)
• Constitute less than 1% of all lymphomas
• Disease process restricted to Lymph Nodes

PATHOLOGY
• Within lymph nodes, there are collections of B cells in a parafollicular, perivascular, and
perisinusoidal distribution.
• These cells may surround reactive-appearing GCs and mantle zones

CLINICAL FEATURES
• Majority of patients present with Stage III/IV disease
• Asymptomatic
• The 5-year survival for patients with nodal MZL is 55% to 79%.

TREATMENT
• Patients are frequently treated with chemoimmunotherapy
• Regimens include either alkylating agents or purine analogs plus rituximab.
EXTRANODAL MARGINAL ZONE LYMPHOMA

• Also known as MALT Lymphoma or Mucosa Associated Lymphoid Tissue

Lymphoma

• The most common site is the stomach.

• Associated with various chronic inflammatory and infectious conditions infections

like H. Pylori, Borrelia, Chlamydia, and Hepatitis C Virus

• MALT lymphoma behaves indolently.

• Associated with auto-immune conditions like Sjogren’s syndrome and autoimmune

thyroiditis.
MANTLE CELL LYMPHOMA

• MCL is a malignancy of small- to medium-sized B cells in the mantle zone

REFERENCES

• Devita, Hellman’s Concepts and Principles of Oncology

• Robbins Basic Pathology

• Sabiston’s Textbook of Surgery