it is my power point presentation of lymphoma for final year MBBS students,govt.medical college,kottayam dr irshad ali k m assistant professor,dept.of medicine,govt,medical college,kottayam

1. LYMPHOMA
Dr Irshad Ali

2. Lymphoma
• Clonal malignant disorders that are derived from
lymphoid cells: either precursor or mature T-cell
or B-cell
• Majority are of B- cell origin
• Divided into 2 main types :
1. Hodgkin’s lymphoma
2. Non - Hodgkin’s lymphoma

3. Blood Cell and Lymphocyte
Development
STEM CELLS
Multipotential
myeloid cells
Multipotential
lymphocytic cells
Differentiate & mature into 6
Types of blood cells
red cells basophils
neutrophils monocytes
eosinophils platelets
Differentiate & mature into 3
Types of lymphocytes
T lymphocytes
B lymphocytes
Natural Killer Cells

4. T-Cells and B-Cells
􀂄 Immature lymphocytes that travel to the
thymus differentiate into T-Cells
– “T” is for thymus
􀂄 Immature lymphocytes that travel to the
spleen or lymph nodes differentiate into B
cells
– "B" stands for the bursa of Fabricius, which is
an organ unique to birds, where B cells
mature.

5. ALL MMCLL Lymphomas
Hematopoietic
stem cell
Neutrophils
Eosinophils
Basophils
Monocytes
Platelets
Red cells
Myeloid
progenitor
Myeloproliferative disordersAML
Lymphoid
progenitor T-lymphocytes
Plasma
cells
B-lymphocytes
naïve

6. Lymphoma classification
(2001 WHO)
• B-cell neoplasms
– precursor
– mature
• T-cell & NK-cell neoplasms
– precursor
– mature
• Hodgkin lymphoma
Non-
Hodgkin
Lymphomas

7. A 25 year old lady
1 month of evening rise of temperature, night
sweats and noticed a lump in her neck
On examination pallor, generalized
lymphadenopathy, hepatosplenomegaly

8. Hodgkin lymphoma
Thomas Hodgkin
(1798-1866)

9. Etiology
• ? Infection – EBV
• ? Environmental factors

10. REAL* Classification
• Classic:
– Nodular Sclerosis-MOST COMMON IN WORLD
– Lymhocyte rich
– Mixed Cellularity-MOST COMMON IN INDIA
– Lymhocyte depleted
• Non-Classic
– Nodular Lymphocyte predominant
*REAL – Revised European,American,lymphoma

11. Classical Hodgkin Lymphoma

12. Clinical features
• Bimodal age distribution :
– young adults ( 20-30 yrs) & elderly (> 50yrs) May
occur at any age
• M > F
• Lymphadenopathy:
– most often cervical region
– asymmetrical, discrete
– painless, non-tender
– elastic character on palpation ( rubbery)
– not adherent to skin
– fluctuate in size

13. • Contiguous spread via the lymphatic chain
eg.involvement of abdominal & thoracic LNs
• Extra nodal disease - rare
• Hepatospleenomegaly

14. • Constitutional symptoms ( B symptoms )
–Night sweats,
–sustained fever > 38 degree celsius,
–loss of weight >10% of body weight in 6 mo
• Fever sometimes cyclical (‘Pel-Ebstein fever’)
• Pain at the site of disease after drinking alcohol
• Pallor
• Pruritis
• Symptoms of Bulky (>10 cm) disease

15. Investigations
• CBC : Anemia (normochromic / normocytic),
• eosinophilia, neutrophilia, lymphopenia
• ESR -raised
• LFT- (liver infil / obs at porta hepatis)
• RFT- prior to treatment
• Urate , Ca,
• LDH - adverse prognosis
• CXR- mediastinal mass
• CT thorax / abdomen / pelvis-for staging
• Other: Gallium scan, PET, Lymphangiography ,
Laporotomy

16. • LN FNAC / biopsy :
– Malignant REED-STERNBERG ( RS) Cell: Bi-nucleate cell
with a prominent nucleolus. Derived from B cell, at an
early stage of differentiation
– Reactive background of eosinophils, lymphocytes,
plasma cells
– Fibrous tissue

19. REED-STERNBERG ( RS ) Cell

20. REED-STERNBERG ( RS) Cell

24. Lymphangiography

25. Staging
• Stage I : Involvement of single LN region (I) or extra
lymphatic site (IAE )
• Stage II : Two or more LN regions involved (II) or an extra
lymphatic site and lymph node regions on the same side of
diaphragm
• Stage III : Involvement of lymph node regions on both sides
of diaphragm, with (IIIE) or without (III) localized extra
lymphatic involvement or involvement of the spleen (IIS) or
both (IISE)
• Stage IV : Involvement outside LN areas (Liver, bone
marrow)
A : Absence of ‘B’ symptoms
B : B symptoms present

27. Treatment - Guidelines
• Indications for RT:
– Stage I disease
– Stage II disease with 3 or lesser areas involved
– For Bulky disease
– For pressure problems
• Indications for CT
– All with B symptoms
– Stage II disease with >3 areas involved
– Stage III and IV disease

28. Treatment
• Stage IA , Stage IIA with 3 or < 3 areas involved:
Radiotherapy
• Stage IB, Stage II A with > 3 areas , Stage IIB:
Chemotherapy every 3-4 weeks, 6-8 cycles; either
alone, or in combination with radiotherapy
• Stage III & IV : Chemotherapy +
Radiotherapy ( for bulky disease or palliation of
symptoms)

29. Irradiation fields used in Hodgkin’s Lymphoma

30. Chemotherapy
• MOPP :
Nitrogen Mustard,
Vincristine (Oncovin),
Procarbazine,
Prednisolone
• ABVD:
Adriamycin,
Bleomycin,
Vinblastine,
Dacarbazine
• Higher dose for relapse or younger pts with poor
prognostic features

31. Prognosis
• Overall 10 yr survival – 80%
• In long term survivors there is a risk of
– secondary malignancy: (leukemia , NHL), Solid tumors-
Lung, breast
– Infections
– Cardiac, pulmonary, endocrinal abnormalities

32. International Prognostic Index (IPI)
• Age
• Advanced stage disease
• Performance status
• Elevated LDH
• Presence of Extra nodal disease

33. Non Hodgkin’s lymphoma
• Incidence is increasing
• NHL>HD
• Median age of presentation is 65-70 yrs
• M>F
• More often clinically disseminated at
diagnosis
• B-cell-70% ; T-cell-30%

34. Relative frequencies of different
lymphomas
Hodgkin
lymphoma
NHL
Diffuse large B-cell
Follicular
Other NHL
Non-Hodgkin Lymphomas
~85% of NHL are B-lineage

35. Specific types
• Precursor B cell lymphoblastic
leukemia/lymphoma
Most common cancer in chilhood is B cell ALL

36. Cells are hetrogenous insize and
round/convoluted nuclei,high
nuclear/cytoplasmic ratio and absence of
cytoplasmic granules

37. Mature B cell neoplasm
• B ell chronic lymphoid leukemia/small
lymphocytic lymphoma
Cells expressing CD-5 ANTIGEN
PS-SMUDGE/BASKET CELLS
Autoimmune hemolytic
anemia/thrombocytopenia/hypogamma
globulinemia

39. • Young pt-bone marrow transplatation
• Chlorambucil alone or with cyc,rituximab
• Fludarabine
• CVP-CYC,VINCRISTINE

40. MALT-LYMPHOMA
Extra nodal marginal zone
Associated with H.pylori
CD-5 negative
Can occur in
stomach,orbit,intestine,lung,thyroid,salivary
gland,skin,soft tissue,bladder,kidney,CNS

41. AUTOIMMUNE PROCESS-
• SJOGRENS Syndrome-salivary gland
• Hashimoto’s thyroiditis-thyroid MALT
• C.psittaci conjunctivitis-ocular MALT
• Borrelia skin infection-cutaneous MALT

43. • MANTLE CELL LYMPHOMA
CD-5 POSITIVE

44. irregular nuclear contours of the medium-sized lymphoma cells and the presence of a
pink histiocyte. By immunohistochemistry the lymphoma cells expressed CD20, CD5
and Cyclin D1

45. FOLLICULAR LYMPHOMA

46. • Classic appearance of spleen involved by
follicular lymphoma, namely the presence of
discrete, miliary, small, white "pearly" nodules
throughout the whole parenchyma.

47. T(14,18),BCL-2 POSITIVE

48. DIFFUSE LARGE B CELL LYMPHOMA
• MOST COMMON NHL

51. LARGE CELLS WITH VESICULAR
CHROMATIN AND PROMINENT
NUCLEOLI

52. BURKITT’S LYMPHOMA
• RARE
• T(8;14)
• T(2;8),C-MYC and LAMDA LIGHT CHAIN GENE
• HIV Associated
• Most rapidly progressive human tumour

56. • The "starry sky" appearance seen under low
power is due to scattered tingible body-laden
macrophages (macrophages containing dead
apoptotic tumor cells).

57. Hairy cell leukemia
• B –CELL
• Presents as Pancytopenia
• Hairy projections on light/electron microscopy

58. Hair like projections

59. T –CELL LYMPHOMA/LEUKEMIA
• PRECURSOR T-cell lymphoblastic
leukemia/lymphoma
Presents as ALL
AGGRESSIVE

60. MATURE/PERIPHERAL T cell disorders
• Mycosis fungoides-cutaneous T cell lymphoma
Presents as eczematous skin lesions

61. 52 Yr old male with mycosis fungoides(Alibert-
Bazin syndrome ) - common form of cutaneous
T-cell lymphoma.

62. Sezary syndrome
• Pt with cutaneous T cell leukemia presents
with generalized erythroderma and circulating
tumour cells

65. Adult T cell lymphoma/lekemia
• HTLV-1 retro virus manifestation
• Flower cells

66. • A 22-year-old female presented with 2 weeks
of fever, anemia, generalized
lymphadenopathy, hepatosplenomegaly, and
skin rashes. Her total leukocyte count was 306
× 109/L. Peripheral blood smear showed many
atypical lymphocytes with petal-shaped nuclei
like flowers as seen in the photograph..

67. Flower cells

68. • Peripheral blood immunophenotype noted
negative markers for myeloid and B lymphoid
lineage (CD10, CD19, CD3, CD5, CD7, cyto-
CD3, TCR, CD16, CD56) and strongly positive
for CD4 and CD25, and also CD2, which was
atypical. Bone marrow aspirate and biopsy
revealed involvement by acute leukemia.
Serology for HTLV-1 was positive and serum
calcium was normal

69. Anaplastic large T/null cell lymphoma
• ALK-ANAPLASTIC LYMPHOMA KINASE protein
positive
• t(2;5)
• CD-30 POSITIVE

70. PERIPHERAL T –CELL LYMPHOMA
• AGGRESSIVE
• MATURE T cells

71. NHL-TREATMENT
• R-CHOP-CD-20 POSITIVE
RITUXIMAB,CYCLOPHOSPHAMIDE,ADRIAMYCI
N,VINCRISTINE,PREDNISOLONE
• CHOP

72. Lymphoma like disordes
• Castle man disease-IL-6

73. • A 38-year-old lady was referred for FNAC of
multiple left axillary nodes, one of them in the
axillary tail of left breast, which appeared as a
breast lump in the upper outer quadrant. The
nodes ranged from 1 to 3 cm in size, were well
defined, mobile, firm and non-tender. s

74. • There were no systemic symptoms and no
other organomegaly. Peripheral blood counts
and erythrocyte sedimentation rate (ESR)
were within normal limit

75. Section of lymph node containing
vascularized germinal centres and
eosinophilic material

76. Rosai dorfman disease
• Rosai–Dorfman disease, also known as sinus
histiocytosis with massive lymphadenopathy,
is a rare disorder of unknown cause that is
characterized by abundant histiocytes in the
lymph nodes throughout the body.

78. ONE WORD ANSWER
• FLOWER CELLS SEEN IN-
• BASKET CELLS SEEN IN-
• T(14;18) seen in-
• STARRY SKY PATTERN SEEN IN-
• Mycosis fungoides is ……T/B cell lymphoma
• CD 15 AND CD 30 NOT SEEN IN……HODGKINS
TYPE LYMPHOMA

79. • Thank u