Lymphoma

Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy).

There are two main categories of lymphoma: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Hodgkin’s lymphoma is a specific disease and non-Hodgkins lymphoma encompasses all the other lymphomas. Hodgkin’s lymphoma is the most likely specific lymphoma to appear in your exams.

 

Hodgkin’s Lymphoma

Overall 1 in 5 lymphomas are Hodgkin’s lymphoma. It is caused by proliferation of lymphocytes. There is a bimodal age distribution with peaks around aged 20 and 75 years.

 

Risk factors

  • HIV
  • Epstein-Barr Virus
  • Autoimmune conditions such as rheumatoid arthritis and sarcoidosis
  • Family history

 

Presentation

Lymphadenopathy is the key presenting symptom. The enlarged lymph node or nodes might be in the neck, axilla (armpit) or inguinal (groin) region. They are characteristically non-tender and feel “rubbery”. Some patients will experience pain in the lymph nodes when they drink with alcohol.

 

B symptoms are the systemic symptoms of lymphoma:

  • Fever
  • Weight loss
  • Night sweats

 

Other symptoms can include:

  • Fatigue
  • Itching
  • Cough
  • Shortness of breath
  • Abdominal pain
  • Recurrent infections

 

Investigations

Lactate dehydrogenase (LDH) is a blood test that is often raised in Hodgkin’s lymphoma but is not specific and can be raised in other cancers and many non-cancerous diseases.

Lymph node biopsy is the key diagnostic test.

The Reed-Sternberg cell is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma. They are abnormally large B cells that have multiple nuclei that have nucleoli inside them. This can give them the appearance of the face of an owl with large eyes. The Reed-Sternberg cell is a popular feature in medical exams.

CT, MRI and PET scans can be used for diagnosing and staging lymphoma and other tumours.

 

Ann Arbor Staging

The Ann Arbor staging system is used for both Hodgkins and non-Hodgkins lymphoma. The system puts importance on whether the affected nodes are above or below the diaphragm. A simplified version is:

  • Stage 1: Confined to one region of lymph nodes.
  • Stage 2: In more than one region but on the same side of the diaphragm (either above or below).
  • Stage 3: Affects lymph nodes both above and below the diaphragm.
  • Stage 4: Widespread involvement including non-lymphatic organs such as the lungs or liver.

 

Management

The key treatments are chemotherapy and radiotherapy. The aim of treatment is to cure the condition. This is usually successful however there is a risk of relapse, other haematological cancers and side effects of medications.

Chemotherapy creates a risk of leukaemia and infertility.

Radiotherapy creates a risk of cancer, damage to tissues and hypothyroidism.

 

Non-Hodgkin Lymphoma

Non-Hodgkins lymphoma is a group of lymphomas. There are almost endless types of lymphoma. A few notable ones are:

  • Burkitt lymphoma is associated with Epstein-Barr virus, malaria and HIV.
  • MALT lymphoma affects the mucosa-associated lymphoid tissue, usually around the stomach. It is associated with H. pylori infection.
  • Diffuse large B cell lymphoma often presents as a rapidly growing painless mass in patients over 65 years.

 

Risk factors for non-Hodgkin’s lymphoma include:

  • HIV
  • Epstein-Barr Virus
  • H. pylori (MALT lymphoma)
  • Hepatitis B or C infection
  • Exposure to pesticides and a specific chemical called trichloroethylene used in several industrial processes
  • Family history

 

The presentation is similar to Hodgkin’s lymphoma and often they can only be differentiated when the lymph node is biopsied.

 

Management involves a combination of treatments depending on the type and staging of the lymphoma:

  • Watchful waiting
  • Chemotherapy
  • Monoclonal antibodies such as rituximab
  • Radiotherapy
  • Stem cell transplantation

 

Last updated April 2019
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