Non-Hodgkin's lymphoma (NHL) Definition Lymphoma is a malignant proliferation of mature lymphocytes that accumulate in lymph nodes ± other tissue, often as a solid tumour. Differs from leukaemia, which arises in the bone marrow and is present in the blood. Non-Hodgkin's lymphomas (NHL) represent 80% of all lymphomas, and are distinguished from Hodgkin's lymphoma by the absence of Reed-Sternberg cells on light microscopy. NHL are a diverse group of conditions, with proliferating cells potentially accumulating in various sites, including lymph nodes, mucosa-associated lymphoid tissue (MALT), CNS, and skin. 90% are B cell proliferations, 10% T cell. Types Low-grade lymphoma: Slow growing, good prognosis, but hard to cure. Follicular lymphoma. CD20 +ve. Marginal zone lymphoma. Various types including MALT, which can occur in stomach, lung, thyroid, or salivary/tear glands. Generally remain localised to original organ so good prognosis. Lymphocytic lymphoma. Similar to CLL. Waldenström's macroglobulinaemia (aka lymphoplasmacytoid lymphoma). ↑IgM production.

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HODGKIN'S
LYMPHOMA
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ALPINE SKI HOUSE
DEFINITION
• Lymphoma is a malignant proliferation of mature lymphocytes that accumulate in lymph nodes ±
other tissue, often as a solid tumour. Differs from leukaemia, which arises in the bone marrow
and is present in the blood.
• Hodgkin's lymphoma represents 20% of all lymphomas, and is characterised by the presence of
'mirror-image' binucleated Reed-Sternberg cells on light microscopy.
• Hodgkin's lymphoma is a B-cell cancer.
• Sub-types
• Common: nodular sclerosis (70%), usually in young patients, and mixed cellularity (25%), usually
in old patients. Both have a good prognosis.
• Rare (5%): lymphocyte-rich (excellent prognosis) or lymphocyte-depleted (bad prognosis).
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EPIDEMIOLOGY
• Lifetime risk: 1/400.
• Occurs any age but peaks at 15-30 and 75-80.
• Commoner in men.
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ALPINE SKI HOUSE
SIGNS AND SYMPTOMS
• Lymphadenopathy:
• Painless, rubbery, nodes, usually cervical (⅔), axillary, or inguinal.
• May be adherent to each other and move together ('matted').
• Increase and decrease spontaneously.
• Painful on alcohol consumption.
• Mediastinal lymph nodes can cause SOB, dry cough, and SVC obstruction.
• B symptoms (present in 25%):
• Weight loss.
• Fever. The classical Pel-Ebstein cyclical fever every 2-4 weeks is rare.
• Night sweats.
• Lethargy
• Pruritus
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SIGNS AND SYMPTOMS
• Other features:
• Anaemia of chronic disease.
• Hepatosplenomegaly in advanced disease.
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RISK FACTORS
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•Family history.
•EBV infection.
•↑Socioeconomic status.

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ALPINE SKI HOUSE
INVESTIGATIONS
• Bloods:
• FBC: pancytopaenia if there is bone marrow infiltration.
• Blood film
• ↑ESR
• LFT, U+E.
• Protein electrophoresis may show paraproteins, though these are commoner in myeloma.
• Biopsy for diagnosis:
• Lymph node excision.
• Bone marrow aspirate and biopsy only if there is altered FBC or B symptoms.
• Analysis: microscopy (Reed-Sternberg cells), immunohistochemistry (CD30 ± CD15 +ve, EBV in
50% of malignant cells), flow cytometry (CD30 ± CD15 +ve), cytogenetics.
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ALPINE SKI HOUSE
INVESTIGATIONS
• Imaging for staging:
• CXR for mediastinal disease (widening).
• Staging: contrast CT head-neck-abdo or PET-CT.
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ALPINE SKI HOUSE
ANN ARBOR STAGING SYSTEM
• Used for both Hodgkin's and non-Hodgkin's. Comprises 2 components.
• By location:
1.1 lymph node (LN) area.
2.≥2 LN areas on 1 side of the diaphragm.
3.LN areas on 2 sides of the diaphragm.
4.Beyond LN e.g. liver, bone marrow.
• By presence of systemic symptoms:
• A: no systemic symptoms, except pruritus.
• B: systemic symptoms.
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MANAGEMENT
• Chemotherapy plus radiotherapy.
• Consider chemo alone if not bulky, or radiotherapy alone for early lymphocyte-rich disease.
• Common chemo regimens: ABVD (doxorubicin
[Adriamycin], Bleomycin, Vinablastine, Dacarbazine), BEACOPP (Bleomycin, Etoposide,
doxorubicin [Adriamycin], Cyclophosphamide, Vinicristine, Procarbazine, Prednisolone).
• Sperm bank pre-chemo for men.
• Autologous stem cell transplantation – in which the patient's bone marrow is removed, chemo
given, then the marrow returned – is used in resistant and relapsed disease.
• Pneumococcal and flu vaccine.
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COMPLICATIONS AND PROGNOSIS
• Treatment complications:
• Radio- or chemo-therapy: AML, NHL, infertility.
• Radiotherapy damage to neighbouring tissue: secondary cancer (especially lung, breast), IHD,
hypothyroidism, pulmonary fibrosis.
• Chemotherapy-specific: all the usual chemo side effects, including immunosuppression, nausea, and hair
loss, plus pulmonary fibrosis from bleomycin.
• Oncological emergencies:
• Infection
• SVC obstruction.
• Prognosis:
• 5 year survival: stage 1-2 90%, stage 3-4 75%.
• Poor prognosis: B symptoms, ↑ESR, lymphocyte-depleted type.
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