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  • • The diagnosis of non-Hodgkin lymphoma encompasses a wide spectrum of lymphoid-derived tumors

    • More than 10 distinct tumor subtypes with variable biologic behavior

    • Non-Hodgkin lymphoma may originate from B cells, T cells, or histiocytes

    • In contrast to Hodgkin lymphoma, lymph node tumor involvement is more likely to spread in a noncontinous fashion in non-Hodgkin lymphoma

    • Prognosis and treatment is more dependent on the grade and type of malignancy in contrast to the importance of clinical stage in Hodgkin lymphoma

    • Functionally separated into low-grade and high-grade groups

    • 33% of cases arise outside of the lymph nodes: oropharynx, paranasal sinuses, thyroid, GI tract, liver, testicles, skin, bone marrow, and CNS

    • Most common extranodal site is the stomach, accounting for 50% of all GI lymphomas

    • Most accepted classification system is the Revised European-American Lymphoma (REAL) classification

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Epidemiology

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  • • Risk factors for the development of lymphoma:

    • Ataxia-telangiectasia

    • Wiscott-Aldrich syndrome

    • Celiac disease

    • Prior chemotherapy

    • History of radiation therapy

    • Immunosuppressive therapy

    • HIV

    • Human T-cell lymphotropic virus type 1 infection

    • Sjögren syndrome

    • Extranodal lymphoma risk factors:

    • -Gastric lymphoma: Helicobacter pylori infection

      -Thyroid lymphoma: Hashimoto thyroiditis

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Symptoms and Signs

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  • • Nontender enlargement of lymph nodes

    • Constitutional symptoms:

    • -Fever

      -Drenching night sweats

      -Weight loss

    • Gastric lymphoma symptoms and signs include epigastric pain, weight loss, and frequently a palpable epigastric mass

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Laboratory Findings

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  • • No distinctive basic laboratory findings present, although lymphomas tend to be associated with an elevated lactic dehydrogenase

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Imaging Findings

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  • • Imaging findings are specific to the location and type of lymphoma

    Chest film: May demonstrate mediastinal adenopathy

    CT scan: Main staging tool used to demonstrate areas of adenopathy

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  • • Hodgkin lymphoma

    • Non-Hodgkin lymphoma

    • Reactive lymphadenopathy

    • -Infectious mononucleosis

      -Cat-scratch disease

      -HIV

      -Drug reactions (eg, phenytoin)

    • Tumor metastases

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Rule Out

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  • • Reactive lymphadenopathy

    • Metastatic disease to the lymph nodes

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  • • Detailed history of risk factors and presence of constitutional symptoms

    • Thorough physical exam assessing all lymph node beds

    • Routine laboratory testing

    • Excisional biopsy of enlarged lymph node

    • Bone marrow biopsy

    • CT scans of the neck, chest, abdomen, and pelvis

    • Gastric lymphoma work-up also includes esophagogastroduodenscopy with biopsy and brush cytology

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When to Admit

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  • • Most patients with lymphadenopathy that is suspicious for lymphoma are worked-up urgently as an outpatient or admitted to expedite the process

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When to Refer

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  • • Following histologic diagnosis, patients are referred to medical and radiation oncologists for definitive treatment

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  • • Treatment depends on grade and stage of the lymphoma:

    • -Low-grade localized: Radiation with or without adjuvant chemotherapy

      -Low-grade systemic: "Watch and wait" approach; when more aggressive disease develops, single agent palliative chemotherapy ...

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