Lymphomas

Question 1

Give an example of a high grade and a low grade non-Hodgkin’s lymphoma.

Answer 1

• high grade: DLBCL (most common type), Burkitt’s

- low grade: follicular

Question 2

Suggest risk factors for the development of NHL.

Answer 2

• EBV, HCV, HTLV-1, HIV
• pesticides, herbicides + fertilisers
• chronic antigenic stimulation e.g. H. pylori infection in MALT lymphoma
• FHx

Question 3

How is Hodgkin’s lymphoma different to NHL?

Answer 3

Arises from Reed-Sternberg cells (giant B cell with bilobed nucleus + prominent eosinophilic inclusion-like nucleoli)

Question 4

What are the risk factors for HL?

Answer 4

• EBV
• HIV
• immunosuppression

Question 5

How do NHL and HL usually present?

Answer 5

NHL

• painless DISSEMINATED lymphadenopathy
• B symptoms
• extranodal involvement: spenomegaly, hepatomegaly, BM symptoms

HL

• painless CERVICAL lymphadenopathy (alcohol-induced pain in <10%)
• B symptoms

Question 6

Which Ix would you perform to confirm a diagnosis of NHL?

Answer 6

1. bloods
   - FCB: normocytic anaemia +/- lymphopaenia/lymphocytosis
   - peripheral blood film: lymphocytosis
   - LDH + B2-microglobulin: poorer prognosis if raised
   - screen for EBV, HBV, HCV, HIV
2. LN or other tissue biopsy
3. CT neck/chest/abdo/pelvis

Question 7

Which Ix would you perform to stage a NHL?

Answer 7

• if low grade NHL confirmed: BM biopsy

- if high grade NHL confirmed: PET scan

Question 8

Which Ix would you perform to confirm a diagnosis of HL?

Answer 8

1. Bloods
   - FBC: normocytic anaemia
   - ESR: unfavourable prognosis if >70
   - LDH: raised
2. LN biopsy
3. CT chest/abdo/pelvis

Question 9

Which Ix would you perform to stage a HL?

Answer 9

PET-CT scan (BM biopsy often unnecessary)

Question 10

Which system is used to stage lymphoma?

Answer 10

Ann-Arbor Classification:

• stage I: single region (usually 1 LN)
• stage II: two separate LN regions on same side of diaphragm
• stage III: both sides of diaphragm +/- spleen
• stage IV: disseminated extra-nodal disease

A: no systemic Sx
B: systemic Sx

Question 11

How would you treat a patient with HL? What is the prognosis?

Answer 11

combination chemo +/- RT

both localised and advanced disease can be cured in 80-90%

Question 12

How would you treat a patient with low-grade NHL? What is the prognosis?

Answer 12

• watch and wait or RT if localised non-bulky disease without BM involvement or B symptoms OR
• chemo (R-CHOP)

relatively good prognosis with 10yr medial survival, although usually not curable in advanced stage

Question 13

How would you treat a patient with high-grade lymphoma?

Answer 13

• chemo (R-CHOP) or RT - often curative
• SCT for relapse or refractory disease

significant cure rate with intensive Tx