1. Lymphoma Rob Jones

2. Aim and learning outcomes Aim ◦ To revise the key points of lymphoma Learning outcomes ◦ Revise the basics of haemopoiesis ◦ Understand what a lymphoma is ◦ Know the difference between lymphoma and leukaemia ◦ Know the difference between Hodgkin and non- Hodgkin lymphoma ◦ Know some key facts about Hodgkin and non- Hodgkin lymphoma

3. Haemopoiesis

4. What’s a lymphoma?! Lymphomas are clonal malignant disorders that derive from lymphoid cells (either precursor or mature T-cells or B-cells)

5. Lymphoma vs. leukaemia LymphomaLeukaemia CellsLymphoid cellsLymphoid and myeloid cells Solid/liquidSolid (lumps)Liquid (malignant cells spill into the peripheral blood)

6. Hodgkin vs. non-Hodgkin lymphoma Histological division Hodgkin: Reed-Sternberg cells Non-Hodgkin: no Reed-Sternberg cells

7. Key facts about Hodgkin and non-Hodgkin lymphoma

8. Aetiology Unknown Infections may cause certain types of lymphoma ◦ EBV: HL, Burkitt lymphoma (a type of NHL) ◦ H. pylori: gastric MALT lymphomas (a type of NHL) ◦ HTLV-1: adult T-cell lymphoma (a type of NHL) Risk factors ◦ Age ◦ Family history ◦ Immunosuppression

9. Epidemiology Incidence ◦ Uncommon, but not rare! Age ◦ Hodgkin: incidence peaks in 30s ◦ Non-Hodgkin: older people Gender ◦ Males > females Location ◦ Certain subtypes more common in certain areas e.g. Burkitt lymphoma more common in Africa

10. Clinical features Lymphoid Nodal (75%) ◦ Lymphadenopathy  Cervical, axillary, inguinal, mediastinal ◦ Alcohol-induced pain virtually diagnostic of Hodgkin lymphoma Extra-nodal (25%) ◦ Lymphoid tissue in other organs  Oropharynx, skin, bone, gut, CNS, lung Systemic Fever Weight loss Night sweats Itch Fatigue

11. Differential diagnosis Other haematological malignancy: leukaemia, myeloma TB HIV/AIDS Other systemic causes of itch…

12. Investigations Bloods ◦ FBC ◦ Blood film ◦ ESR ◦ LFT ◦ LDH Diagnosis ◦ Biopsy and histology of lymph node/affected tissue Staging ◦ CT chest/abdomen/pelvis

13. Diagnosis: classification of HL SubgroupCharacteristicsCases (%)Surviving 5yrs (%) Lymphocyte richInfiltrate consists largely of small lymphocytes 1570 Nodular sclerosingNode divided by broad bands of connective tissue into nodules containing a mixture of cells 4060 Mixed cellularitySame as above, but there are no broad bands of connective tissue 30 Lymphocyte depletedFew lymphocytes, many Hodgkin’s and Reed- Sternberg cells 1520

14. Diagnosis: classification of NHL B-cell Follicular lymphoma Diffuse large B-cell lymphoma Waldenström’s macroglobulinaemia Mantle cell lymphoma Hairy cell leukaemia Burkitt lymphoma T-cell Peripheral T-cell lymphomas Anaplastic large cell lymphoma Angioimmunoblastic T-cell lymphoma Follicular lymphoma and diffuse large B-cell lymphoma account for 2/3 of NHL

15. Staging: Ann Arbor system StagesCharacteristics IInvolvement of one lymph node area IIInvolvement of two or more lymph node areas on the same side of the diaphragm IIIInvolvement of lymph nodes on both sides of the diaphragm ± splenic involvement IVInvolvement of ≥1 extra-nodal site (e.g. liver, bone marrow, lung) AWithout systemic symptoms BWith systemic symptoms (night sweats, fever, weight loss)

16. Management Chemotherapy ◦ HL: ABVD  Adriamycin  Bleomycin  Vinblastine  Dacarbazine ◦ Diffuse large B-cell lymphoma (subtype of NHL): R-CHOP  Rituximab  Cyclophosphamide  Hydroxydaunorubicin  Oncovin  Prednisolone Radiotherapy Bone marrow transplantation

17. Prognosis Depends on histological subtype and stage, but there are some independent prognostic markers: ◦ Extra-nodal disease ◦ Bloods:  Hb,  ESR,  LDH ◦ Older age ◦ Poor WHO performance status

18. The end