Non Hodgkins lymphoma

Rakesh Biswas
MD, Professor, Department of Medicine,
People's College of Medical Sciences,
Bhanpur, Bhopal, India

Staging
Stage

I : Involvement of single LN region (I) or extra

lymphatic site (IAE )
Stage II : Two or more LN regions involved (II) or an
extra lymphatic site and lymph node regions on the
same side of diaphragm
Stage III : Involvement of lymph node regions on both
sides of diaphragm, with (IIIE) or without (III) localized
extra lymphatic involvement or involvement of the
spleen (IIS) or both (IISE)
Stage IV : Involvement outside LN areas (Liver, bone
marrow)
A : Absence of B symptoms
B : B symptoms present

Non Hodgkins lymphoma

Incidence

is increasing

NHL>HD
Median

age of presentation is 65-70 yrs

M>F
More

often clinically disseminated at

diagnosis
B-cell-70% ; T-cell-30%

Clinical features
Widely disseminated
Nodal

at presentation

involvement:
Painless lymphadenopathy, often cervical region is
the most common presentation
Hepatospleenomegaly
Extranodal :
Intestinal
lymphoma ( abdominal pain, anemia, dysphagia);
CNS
( headache, cranial nerve palsies, spinal cord
compression) ;
Skin, Testis; Thyroid; Lung
Bone marrow (low grade): Pancytopenia

Clinical features contd

Systemic symptoms
Sweating,

weight loss, itching

Metabolic complications:
hyperuricemia,
hypercalcemia,
renal failure

Compression syndrome:
Gut

obstruction
Ascites
SVC obstruction
S/C Compression

Classification
REAL
Clinical
Low

/ Working Formulation

grade
Intermediate grade
High grade

Classification

Proliferation:
Course:
Symptoms:
Treatment:

Low grade

High grade

Low
Indolent
-ve
Not curable

High
Rapid, fatal(un-Rx)
+ve
Potentially Curable

Etiology
Cannot

be attributed a single cause

Chromosomal translocations:

t (14, 18)

Infection:
Virus:EBV, HTLV,HHV-8,

HIV
Bacteria: H.Pylori - Gastric lymphoma
Immunology:
Congenital

immunodeficiency,
Immunocompromised patients - HIV, organ transplantation

Management
Low grade:
Asymptomatic : No treatment ;
Radiotherapy

for localised disease (Stage 1);

Chemotherapy: mainstay is
Chlorambucil; Initial response good , but repeated
relapses, median survival 6-10 yrs;
Newer:

Fludarabine, 2-CdA (Chlorodeoxyadenosine)

Monoclonal
SCT/BMT

antibody: Rituximab

Aggressive ( high / intermediate grade):

Chemotherapy:

mainstay
CHOP
-every 3 weeks, at least

6 cycles
Cyclophosphamide,
Doxorubicin Hydrochloride,
Vincristine,
Prednisolone

 High

risk cases with poor prognostic

factors or relapse :
High dose chemotherapy
combined with autologous BMT / SCT

Monoclonal
With

antibody

CNS involvement / leukemic relapse :

Similar to ALL

Prognosis
Low

grade : Median survival 10 yrs

High Grade:
Increasing

age, advanced stage, concomitant

disease, raised LDH,T- cell phenotype : Poor
prognosis