Non-Hodgkin Lymphoma

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

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

Imaging Findings

• • 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

• • Hodgkin lymphoma

  • Non-Hodgkin lymphoma

  • Reactive lymphadenopathy

  • -Infectious mononucleosis

    -Cat-scratch disease

    -HIV

    -Drug reactions (eg, phenytoin)

  • Tumor metastases

Rule Out

• • Reactive lymphadenopathy

  • Metastatic disease to the lymph nodes

• • 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

When to Admit

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

When to Refer

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

• • 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 ...