This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology

Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Reem al-mutairi 425201510

Outlines
Introduction of lymphoma Classification of lymphoma Hodgkin's lymphoma: i. Introduction ii. Symptoms iii. Signs iv. Diagnosis v. Staging vi. Management vii. Complication of treatment viii. Prognosis ix. Systemic involved non-hodgkins lymphoma Stem cell transplantation

Introduction of lymphoma
The

lymphomas are malignant tumors of lymphoid tissue ,characterized by the abnormal proliferation B or T cells in lymphoid tissue .

Classification of lymphoma
lymphoma

Hodgkins lymphoma

Non hodgkins lymphoma

Hodgkins lymphoma
Introduction:

- Hodgkin lymphoma (formerly called Hodgkin's disease) is a group of cancers characterized by Reed-Sternberg cells in an appropriate reactive cellular background. An important clinical feature is its tendency to arise within lymph node areas and to spread in an orderly fashion to contiguous areas of lymph nodes . Late in the course of the disease, vascular invasion leads to widespread hematogenous dissemination. -Hodgkin lymphoma has a bimodal age distribution with one peak in the 20s and 30s, and a second peak over the age of 50.

Pathological classification of hodgkins lymphoma

Lymphocyte predominant

Nodular sclerosing

Mixed cellularity (neutrophils, eosinophils, plasma cell)-common

Lymphocyte depleted

Symptoms of hodgkins lymphoma:

General symptoms:
I. Fever II.Weight loss

III.Loss of appetite
IV.Night sweats V.Pruritus

VI.lethargy

 Local symptoms:
I. Enlarged, painless, non-tender, superficial lymph

nodes II.Alcohol-induced pain Rarely, patients with Hodgkins lymphoma complain of severe pain following alcohol ingestion. The pain typically occurs within a few minutes after the ingestion of even a small amount of alcohol. The mechanism is unknown.

 Symptoms related to mass:

Mediastinal mass: retrosternal chest pain, cough, or shortness of breath. 2. Retroperitoneal lymphadenopathy discomfort and pain in the paravertebral or loin regions, particularly in the supine position.
1.

 Signs of HL:
1. 2. 3. 4. 5. 6.

Lymph node enlargement Cachexia Anemia Splenomegaly Hepatomegaly Jundice. rarely

Diagnosis
BLOOD:

(FBC, Film, ESR, LFT, LDH, Urate , Ca.) Lymph node excision biopsy , image guided needle biopsy. Chest X-ray, CT of thorax, abdominal, pelvis and bone marrow biopsystaging of HL

staging
Confined to single lymph node region II. Involvement of two or more nodal areas on the same side of the diaphragm III. Involvement of nodes on both sides of diaphragm. IV. Spread beyond the lymph nodes e.g. liver or bone marrow. each stage is subdivided into A and B
I.

Management
I-A and II-A :

Radiotherapy & short course of chemotherapy ( ABVD: Adriamycin, Bleomycin, Vinblastine and Dacarbazine) II-A with more than 3 areas involved through TO IV-B Radiotherapy & long course of chemotherapy In relapsed disease : high dose of chemotherapy and peripheral stem cell transplantation

Complications of treatment
Due to radiotherapy:

Second malignancies-solid tumors ,IHD, Hypothyroidism and lung fibrosis Due to chemotherapy: Myelosupperssion, nausea, infection, alopecia and AML Due to both of them : NHL & infertility

Prognosis of HL
Depends on stage :

>95% in I-A of HL -5year survival <40% with IV-B of HL -5 year survival

Systemic involved
Skin lesions A variety of skin lesions have
been associated with Hodgkin lymphoma. These include ichthyosis, acrokeratosis (Bazex syndrome), urticaria, erythema multiforme, erythema nodosum, necrotizing lesions, hyperpigmentation, and skin infiltration

ichthyosis

acrokeratosis

urticaria

Erythema nodosum

Hyperpigmentation of skin

necrotizing lesion

 Nephrotic syndrome The nephrotic

syndrome can occur as a paraneoplastic syndrome in patients with early stage Hodgkin lymphoma, possibly due to secretion of a toxic lymphokine, such as IL-13. The usual pathologic pattern is that of minimal change disease but focal glomerulosclerosis, which represent a more severe manifestation of the same pathologic process, also can occur

Hodgkins lymphoma
splenic involvement
Risk factors for splenic involvement CS III-IV disease B symptoms Mixed cellularity or lymphocytic depletion histology, Age greater than or equal to 40 years Two or more supradiaphragmatic sites Male sex

Hodgkins lymphoma
Neurology system :

These include paraneoplastic cerebellar degeneration, chorea, neuromyotonia, limbic encephalitis, subacute sensory neuronopathy, , and subacute lower motor neuronopathy.

Non-hodgkins lymphoma
This is lymphoma without of Reed-Sternberg cell.
B lymphocyte more than T lymphocyte. The extranodal involvement is common,more than

HL. Causes of its congential and acquired immunodeficiency e.g drugs , HIV infection, H.pylori infection

Diffuse lymphocytic non hodgkins lymphoma

 Lymphomas may be grouped by how quickly they are

likely to grow: Indolent (also called low-grade) lymphomas grow slowly. They tend to cause few symptoms. Aggressive (also called intermediate-grade and highgrade) lymphomas grow and spread more quickly. They tend to cause severe symptoms. Over time, many indolent lymphomas become aggressive lymphomas.

Low grade non Hodgkin's lymphomas Small cell lymphocytic Follicular (it is the most common type of lymphoma) Mantle cell Splenic marginal zone lymphoma MALT lymphoma Lymphoplasmacytic NHL

 High grade non Hodgkin's lymphomas

Diffuse large B cell Diffuse mixed cell lymphoma Burkitt's lymphoma Anaplastic large cell lymphoma Diffuse mixed cell lymphoma

Clinical manifestations : as HL Diagnosis :

Blood Lymph node excision biopsy , image guided needle

biopsy. Chest X-ray, CT of thorax, abdominal, pelvis and bone marrow biopsystaging of NHL

Stages of NHL :
Stage I: The lymphoma cells are in one lymph node group or in only

one part of a tissue or organ (such as the lung). Stage II: The lymphoma cells are in at least two lymph node groups on the same side of the. Diaphragm Or, the lymphoma cells are in one part of an organ and the lymph nodes near that organ (on the same side of the diaphragm). Stage III: The lymphoma is in lymph nodes above and below the diaphragm. It also may be found in one part of a tissue or an organ near these lymph node groups. Stage IV: Lymphoma cells are found in several parts of one or more organs or tissues (in addition to the lymph nodes). Or, it is in the liver, blood, or bone marrow each stage is subdivided into A and B

Treatment
Low grade
Without symptoms With symptoms

grade
High grade
Chemotherapy (CHOP) ,biological therapy &Radiotherapy High dose of chemotherapy &stem cell transplanted

Relapse disease

Watchful waiting

localizes

diffuse

Radiotherapy

Radiotherapy chemotherapy & biological therapy

prognosis
Increased age, advanced stage, concomitant disease,

raised LDH and T cell lymphoma are poor prognostic signs 5-years survival for treated patients > 50% for low grade 30% for high grade

Indications for stem cell transplantation

Multiple myeloma Leukemia Lymphoma Sever combined immunodeficiency or congenital neutropenia with defective stem cell. A plastic anemia Sickle cell disease Ewings sarcoma Neuroblastoma Myelodysplastic syndrome

Types of stem cell transplantation

Autologous stem cell transplantation: This type
of transplant uses your own stem cells. Your stem cells are removed before high-dose treatment. The cells may be treated to kill lymphoma cells that may be present. The stem cells are frozen and stored. After you receive high-dose treatment, the stored stem cells are thawed and returned to you.

Allogeneic stem cell transplantation: Sometimes

healthy stem cells from a donor are available. Your brother, sister, or parent may be the donor. Or the stem cells may come from an unrelated donor. Doctors use blood tests to be sure the donor's cells match your cells.

Syngeneic stem cell transplantation: This type of

transplant uses stem cells from a patient's healthy identical twin.

source of stem cell transplantation

Bone marrow
Peripheral blood stem cell Umbilical cord blood

Complications of stem cell transplantation

Infection
Veno-occlusive disease Mucositis Graft-versus-host disease (GVHD)

GVHD is an inflammatory disease that is unique to allogeneic transplantation

General prognosis of stem cell transplantation

widely dependent upon disease type, stage, stem cell

source.

Referances
National cancer institute, www.cancer.go
WWW.UpToDate.COM ,2009

Thank you