1. LYMPHOMAS By
DR : Ramy A. Samy

2. INTRODUCTION Neoplastic lymphoid proliferation
Two types – Hodgkins & Non-Hodgkins.
Fever, lymphadenopathy,
Immunodeficiency / autoimmune syndrome
Viral, genetic, unknown etiology.
Lack of programmed cell death - Apoptosis

3. Lymphomas are a cancer of the lymphatic system
Lymphatic vessels
Lymph nodes (underarms, groin, neck, spleen, tonsils and bone marrow)

4. The Lymphatic system is our bodies main fight against infection
Lymphocytes (B-cell and T-cell)
Carried through our lymphatic system and help our bodies fight infection
Lymphocytes are carried through the lymph vessels as well as the blood stream, so cancer can start in nodes and spread anywhere throughout the body.

6. Lymphoma
Row of enlarged lymph nodes

7. Lymphoma - Gross

8. Lymphoma Intestine

9. Lymphoma Intestine

10. Mediastinal Lymphnodes-NHL

11. NON-HODGKIN LYMPHOMAS
Essentials of Diagnosis
Often presents with painless lymphadenopathy.
Pathologic diagnosis of lymphoma is made by pathologic examination of tissue.

12. General Considerations
The non-Hodgkin lymphomas are a heterogeneous group of cancers of lymphocytes.
The disorders vary in clinical presentation and course from indolent to rapidly progressive.

13. Associated with Non-H lymphoma
SLE
Celiac Disease
AIDS
Organ transplant patients
Rheumatoid Arthritis

14. Classification of the lymphomas is a controversial area still undergoing evolution
Eighty-five percent (85 %)of non-Hodgkin lymphomas are B-cell, 15% are T-cell.
These lymphomas are either indolent (low grade) and incurable or aggressive (intermediate and high grade) and potentially curable.

15. Classification
Usually classified by how the cells look under a microscope and how quickly they grow and spread
Aggressive lymphomas (high-grade lymphomas)
Indolent Lymphomas (low-grade lymphomas)

16. Classification of Malignant Lymphomas
Low Grade: small lymphoid cells, nodular growth
Intermediate Grade: large cells, follicular and diffuse patterns
High Grade: immunoblastic, lymphoblastic, Burkitt’s disease
T-cell lymphomas: peripheral, cutaneous

17. World Health Organization proposed classification of non-Hodgkin lymphomas.
Precursor B   
B cell lymphoblastic lymphoma
Mature B   
Diffuse large B cell lymphoma   
Mediastinal large B cell lymphoma  
Follicular center cell lymphoma   
Small lymphocytic lymphoma   
Lymphoplasmacytic lymphoma   
Mantle cell lymphoma   Burkitt lymphoma   
Marginal zone lymphoma     
MALT type     
Nodal type     
Splenic type

18. Diffuse - & - Follicular
NHL- Histologic types
Diffuse - & - Follicular

19. Small – Intermed. – Large
NHL- Histologic types
Small – Intermed. – Large

20. Precursor T   
T cell lymphoblastic lymphoma
Mature T (and NK cell)   
Anaplastic T cell lymphoma   
Peripheral T cell lymphoma   
Cutaneous T-cell lymphoma (mycosis fungoides)

21. Lymphoma spread to Spleen

22. Clinical Findings Symptoms and Signs
Patients with indolent lymphomas usually present with :
painless lymphadenopathy, which may be isolated or widespread.
lymph nodes may be peripherally or centrally
The indolent lymphomas are usually disseminated at the time of diagnosis, and bone marrow involvement is frequent.
constitutional symptoms such as fever, drenching night sweats, and weight loss (referred to as "B" symptoms).

23. On examination,
lymphadenopathy may be isolated, or extranodal sites of disease (skin, gastrointestinal tract, liver) may be found.
Patients with Burkitt lymphoma are noted to have abdominal pain or abdominal fullness because of the predilection of the disease for the abdomen.

24. Laboratory Findings
The peripheral blood is usually normal even with extensive bone marrow involvement by lymphoma.
Circulating lymphoma cells in the blood is uncommon.

25. Bone marrow involvement is manifested as paratrabecular monoclonal lymphoid aggregates
In some high-grade lymphomas, the meninges are involved and malignant cells are found with cerebrospinal fluid cytology.
The chest radiograph may show a mediastinal mass in some lymphomas.
The serum LDH has been shown to be a useful prognostic marker and is now incorporated in risk stratification of treatment.

27. The diagnosis of lymphoma is made by tissue biopsy.

28. Treatment
The treatment of indolent lymphoma depends on the stage of disease and the clinical status of the patient.
A small number of patients have limited disease with only one abnormal lymph node group and may be treated with localized irradiation with curative intent.

29. Most patients with indolent lymphoma have disseminated disease at the time of diagnosis and are not curable.
When the disease is not bulky and the patient not symptomatic, no initial therapy is required.
Some patients will have spontaneous remissions.

30. Treatment with the anti-CD20 monoclonal antibody rituximab (intravenous) is a commonly used treatment because of its very low toxicity and avoidance of chemotherapy.
Combinations of rituximab with chemotherapy may also be used.
Common chemotherapy regimens include fludarabine; the combination of cyclophosphamide, vincristine, and prednisone (R-CVP); and cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP).

31. Prognosis
The median survival of patients with indolent lymphomas is 10–15 years..

32. HODGKIN DISEASE Essentials of Diagnosis : Painless lymphadenopathy.
Constitutional symptoms may or may not be present.
Pathologic diagnosis by lymph node biopsy.

33. General Considerations
Hodgkin disease is a group of cancers characterized by Reed–Sternberg cells in an appropriate reactive cellular background
The malignant cell is derived from B lymphocytes of germinal center origin.

34. Reed-Sternberg Cell

35. Hodgkins lymphoma

36. Hodgkins lymphoma cells

37. Clinical Findings There is a bimodal age distribution,
with one peak in the 20s and a second over age 50 years.
painless mass, commonly in the neck.
constitutional symptoms such as fever, weight loss, or drenching night sweats, or generalized pruritus.
An unusual symptom of Hodgkin disease is pain in an involved lymph node following alcohol ingestion.

38. An important feature of Hodgkin disease is its tendency to arise within single lymph node areas and spread in an orderly fashion to contiguous areas of lymph nodes.
Only late in the course of the disease will vascular invasion lead to widespread hematogenous dissemination.

39. Hodgkin disease is divided into several subtypes:
classic Hodgkin (nodular sclerosis, mixed cellularity, and lymphocyte depleted) and
non-classic Hodgkin (lymphocyte predominant).
Hodgkin disease should be distinguished pathologically from other malignant lymphomas and may occasionally be confused with reactive lymph nodes seen in infectious mononucleosis, cat-scratch disease, or drug reactions (eg, phenytoin).

40. STAGING The staging nomenclature (Ann Arbor) is as follows:
stage I, one lymph node region involved;
stage II, involvement of two or more lymph node regions on one side of the diaphragm;
stage III, lymph node regions involved on both sides of the diaphragm; and
stage IV, disseminated disease with extranodal involvement.
In addition, patients’ stages are qualified as "A" if they lack constitutional symptoms or as "B" if 10% weight loss over 6 months, fever, or drenching night sweats are present.

41. Staging of Lymphoma

42. THANK YOU