22.9 Lymphomas

NHLs are a heterogeneous group of diseases which are mainly linked by their origin within the lymphoid system and its different cellular components. They are sub classified based on the stage of maturation (immature vs. mature) and cell of origin [B cell, T cell, or natural killer cell (NK) cell].

Diagnostic Criteria

• Peripheral Lymph node enlargement (commonest site-neck)
• Hepatomegally and/or splenomegally in advanced stages
• B-symptoms :Unexplained weight loss, fever, night sweats
• Coughing, trouble breathing, or chest pain in case of Superior vena cava obstruction (SVCO)

Investigations:

• CXR
• Chest and abdominopelvic computed tomography (CT)
• FBC, differential and film
• Bone marrow aspirate and trephine
• Immunohistochemistry
• LDH, urea and electrolyte, creatinine, albumin, aspartate transaminase (AST), bilirubin, alkaline phosphatase, serum calcium, uric acid
• Pregnancy test in females of child–bearing age
• Hepatitis B and C
• HIV status
• Tissue Biopsy for histopathology

Staging: Ann Arbor classification.

Management:

NHL diseases are sensitive to both chemotherapy and radiotherapy

22.9.1.1 Indolent lymphoma

CHOP regimen which include:

S: Cyclophosphamide IV day1 750 mg/m² AND Adriamycin IV 50 mg/m² day AND Vincristine IV 1.4 mg/m² (maximum 2mg) day, AND Prednisolone 100mg (PO) once a day, day 1–5, every 3 weeks for 6–8 cycles.

22.9.1.2 Aggressive lymphoma with CD 20 positive

R–CHOP

S: Rituximab IV 375 mg/m² Day1 AND Cyclophosphamide IV 750 mg/m² Day1 AND Adriamycin IV 50 mg/m² Day1 AND Vincristine IV 1.4 mg/m² (max 2mg) D1 AND Prednisolone 100 mg (PO) Once a day D1–D5, every 3 weeks for 6–8 cycles.

Radiotherapy

• Radiotherapy is directed to genuinely stage IA and IIA Disease
• Mantle or inverted Y: 40Gy/20fr/4weeks with shielding of the critical organs.
• Involved field RT (IFRT): 45Gy/23fr/4.5wks

22.9.2 Hodgkin’s disease (HD)

Classified into two main types:

• Nodular lymphocyte predominant Hodgkin lymphoma–NLPHL
• Classical Hodgkin lymphoma–CHL, which is sub–divided into:
  • Nodular sclerosis classical Hodgkin lymphoma–NSHL
  • Mixed cellularity classical Hodgkin lymphoma–MCHL
  • Lymphocyte–rich classical Hodgkin lymphoma–LRCHL
  • Lymphocyte–depleted classical Hodgkin lymphoma–LDHL

Diagnostic Criteria

• Enlarged painless lymph nodes in the neck or elsewhere
• B symptoms (weight loss, night sweats, and fever), pruritus, alcohol induced pain, general condition, throat, lymph nodes (site, number, size, consistency, mobility, matting), respiratory system, abdomen (liver, spleen, other masses), bone tenderness

Investigations:

• CXR
• CT Scan of neck, chest, abdomen and pelvis
• FBC
• ESR
• Bone marrow aspirate and biopsy (Not required in Stage I or II A)
• Biopsy histological diagnosis
• Liver function profile
• Renal function profile
• LDH

Management:

As it is for NHL, HL diseases are sensitive to both chemotherapy and radiotherapy.

Pharmacological treatment

Chemotherapy aims at cure for any stage of the disease. It is indicated in Stages II–IV. Current standard regimen is ABVD which include combination of the following drugs:

S: Adriamycin IV 25 mg/m²

AND

S: Bleomycin IV 10 IU/m²

AND

S: Vinblastine IV 6 mg/m²

AND

S: Dacarbazine IV 375 mg/m², all given on day 1 & 15, every 4 weeks for 4–8 cycles.

Radiotherapy: can either be; involved field RT or mantle or inverted Y depending on site of disease: 1.8–2Gy/fr for 30–40Gy total dose.