1. NON-HODGKIN’S LYMPHOMA
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2. Definition:
The neoplastic transformation of either B or T cell lineages of lymphatic cells.
NHL causes the accumulation of neoplastic cells in both the lymph nodes as well as more often diffusely in extralymphatic organs and the bloodstream.
Absent reed-Sternberg cells.
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3. EPIDEMIOLOGY 60% of all lymphomas in children
8-10% of all malignancies in children between 5-19 yrs of age
Secondary causes of NHL include;
Inherited / acquired immune deficiencies
Viruses
HIV
EBV
Genetic Syndromes
Ataxia Telangiectasia
Bloom syndrome
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4. Risk factors INFECTIONS: Human immunodeficiency virus (HIV)
Epstein-Barr virus (EBV): linked to Burkitt lymphoma.
Helicobacter pylori: Extranodal tissues generating lymphoma include MALT ( Mucosa associated lymphoid tissue)
Human T-cell leukemia/lymphoma virus( HTLV-1)
Hepatitis C virus
Age:
Most people with non-Hodgkin lymphoma are older than 60.
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5. PATHOLOGICAL SUB TYPES OF NHL
Burkitt Lymphoma
40% of NHL
B Cell Origin
Lymphoblastic Lymphoma
30% of NHL
80% T Cell Origin & 20% B Cell Origin
Diffuse Large B Cell Lymphoma
20% of NHL
Anaplastic Large Cell Lymphoma
10% of NHL
70% T Cell Origin
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6. Burkitt Lymphoma

7. Clinical Presentation
Clinical presentation is the same as for Hodgkin lymphoma.
The difference is that Hodgkin is localized to cervical and supraclavicular nodes 80%-90% of the time. Whereas NHL is localized 10-20% of the time.
CNS involvement is more common with NHL.
HIV positive patients often have CNS involvement.
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8. Clinical Presentation
Burkitt Lymphoma
Abdominal Tumor
Head & Neck Disease
Involvement of bone marrow & CNS
Lymphoblastic Lymphoma
Intrathoracic / mediastinal supradiaphragmatic mass
Diffuse Large B Cell Lymphoma
Abdominal Mass
Mediastinal Mass
Anaplastic Large Cell Lymphoma
Primary cutaneous manifestation
Systemic disease ( fever , weight loss)
Dissemination to liver , spleen , lung , mediastinum & skin
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9. Clinical Presentation
Other clinical features include;
Lymphadenopathy
Superior vena cava syndrome
Dyspnea
Abdominal Mass
Intestinal obstruction / intussusception
Ascites
Nasal Stuffiness
Earache
Tonsil enlargement
Localised bone involvement
Acute paraplegia secondary to CNS / spinal cord compression
Tumor Lysis Syndrome
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10. Staging system for Non-Hodgkin lymphoma
Stage Description I A single tumor (extranodal) or single anatomic area (nodal) with the exclusion of mediastinum or abdomen
II A single tumor (extranodal) with regional node involvement two or more nodes areas on the same side of diaphragm Two single (extranodal) tumors with or without the regional node involvement on same side of diaphragm A primary gastrointestinal tract tumor usually in the ileocecal area, with or without involvement of associated mesenteric nodes, which may must bemgrossly ( > 90%) resected
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11. Stage III. Two single tumors (extranodal) on opposite
Stage III Two single tumors (extranodal) on opposite side of the diaphragm Two more nodal areas above and below the diaphragm Any primary intarthoracic tumor (mediastinal, pleural, or thymic) Any extensive primary intra – abdominal disease IV Any of the above, with initial involvement of central nervous system or bone marrow t time of diagnosis
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12. DIFFERENTIAL DIAGNOSIS
Hodgkin Disease
Leukemia
Germ Cell Tumor
Wilms Tumor
Neuroblastoma
Rhabdomyosarcoma
Reactive lymphadenitis
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13. Diagnosis Tissue biopsy for; Flow cytometry Karyotyping
Bone marrow biopsy is more central in the initial staging of NHL
Complete Blood Count
Serum Electrolytes, Calcium , Phosphorus , Uric acid
LFT’s & RFT’s
Bone Marrow Aspiration & Biopsy
CSF Examination
Chest X Ray
CT Scan
Head & Neck
Chest
Abdomen & Pelvis
PET Scan & Bone Scan
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14. Grades NHL divided into Low and high grade
A high grade lymphoma has cells which look quite different from normal cells.
They tend to grow fast (aggressive).usually look follicular. Incurable. Wider dissemination at presentation.
Low grade lymphomas have cells which look much like normal cells and multiply slowly(indolent).usually look diffuse. Long term treatment maybe achievable.
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15. Low-grade lymphomas
Many low-grade lymphomas remain indolent for many years.
Treatment of the non-symptomatic patient is often Avoided.
In this case watchful waiting is often the initial course of action. This is carried out because the harms and risks of treatment outweigh the benefits.
If a low-grade lymphoma is becoming symptomatic, radiotherapy or chemotherapy are the treatments of choice.
They don’t cure the lymphoma, they can alleviate the symptoms.
Patients with these types of lymphoma can live near-normal lifespans, but the disease is Incurable.
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16. High-grade lymphomas
Treatment of the aggressive, forms of lymphoma can result in a cure in the majority of cases.
However, the prognosis for patients with a poor response to therapy is worse.
Treatment for these types of lymphoma typically consists of aggressive chemotherapy, including the CHOP or R-CHOP regimen.
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17. Treatment The initial chemotherapeutic regimen is CHOP
( cyclophosmamide, hydroxy-adriamycine, oncovin and prednisolone).
CNS lymphoma is often treated with radiation in addition to CHOP.
Relapses can be controlled with BM transplantation.
Some pts express CD-20 antigen in greater amount. In this case, monoclonal antibody Rituximab should be used.
Rituximab is an anti-CD20 antibody that has limited toxicity and add survival benefit to the use of CHOP.
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18. Duration of Treatment
Burkitt Lymphoma & Diffuse Large B Cell Lymphoma ………. 6 weeks to 6 months
Lymphoblastic Lymphoma …..24 months
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19. COMPLICATIONS Infections Mucositis Pancytopenia Electrolyte imbalance
Poor nutrition
Growth retardation
Cardiac Toxicity
Gonadal Toxicity with Infertility
Secondary malignancies
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20. Thank you
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