Non-Hodgkin lymphoma (NHL) is a malignant proliferation of lymphocytes (B and T cells). Like Hodgkin lymphoma, NHL often presents with constitutional signs; however, NHL is associated with painless lymphadenopathy. B cell NHL’s include Burkitt lymphoma, diffuse large B cell lymphoma, mantle cell lymphoma, and marginal zone lymphoma. T cell NHL’s include adult T cell lymphoma and mycosis fungoides. Management is primarily through chemotherapy.

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Image: “Micrograph of a diffuse large B cell lymphoma, abbreviated DLBCL. Lymph node FNA specimen. Field stain.” By Nephron. License: CC BY-SA 3.0 DE


Epidemiology and Etiology

Background

Lymphoma is a neoplastic proliferation of lymphoid cells. 

  • Non-Hodgkin lymphoma (60%)
  • Hodgkin lymphoma (40%)

Epidemiology

Non-Hodgkin lymphoma

  • Accounts for 4% of all cancers
    • Most common hematopoietic cancer
  • Occurs in both children and adults
  • Risk of developing NHL increases with age
    • > 50% of cases are in those > 65 years old

Etiology

  • Malignant proliferation of mature or progenitor B cell, T cells, and (rarely) natural killer cells. 
  • Associated with:
    • Genetic translocations that result in the overexpression of transcription factors
      • t(14;18) causes ↑ Bcl-2
      • t(8;14) causes ↑ c-myc
      • t(11;14) causes ↑ Cyclin D1
    • Infections
      • Epstein-Barr virus (EBV)
      • Human T cell leukemia virus (HTLV)
      • H. pylori 
    • Chronic inflammatory conditions
      • Hashimoto thyroiditis
      • Sjögren syndrome
      • Chronic gastritis

Video

Non-Hodgkin Lymphomas – Lymphoma by Paul Moss, PhD
Lymphoma in Children by Brian Alverson, MD

Clinical Presentation and Types of NHL

The clinical presentation varies depending on the type of lymphoma. The hallmark symptom of Non-Hodgkin lymphoma is painless lymphadenopathy

Indolent lymphomas:

  • Insidious onset of 
    • Lymphadenopathy 
    • Hepato or splenomegaly
    • Cytopenias
      • Anemia
      • Neutropenia
      • Thrombocytopenia

Aggressive lymphomas:

  • Constitutional, “B” symptoms
    • Low-grade fever
    • Night sweats
    • Weight loss
  • Rapidly growing mass
    • May result in SVC obstruction
      • Facial swelling and congestion
      • Venous distension in the upper limbs/neck 
      • Pleural effusion
  • Elevated LDH and uric acid

Common Non-Hodgkin lymphomas

Type Risk Factors and Genetics Notes
B cell origin

(85-90%)

Follicular lymphoma Driven by

  •  t(14;18)
  • Overexpression of Bcl-2
Population: late adulthood
Classic presentation:

  • Indolent onset/course
  • Painless lymphadenopathy

Complications: progression to diffuse large B cell lymphoma

Diffuse large  B cell lymphoma
(most common NHL)
Arrises sporadically or from transformation of low-grade lymphoma (Ex: follicular lymphoma) Population: late adulthood
Classic presentation:

  • Enlarging lymph node or extranodal mass
  • Extremely aggressive
Burkitt’s lymphoma Associated with

  • EBV

Driven by 

  • t(8;14)
  • Overexpression of c-myc
Population: adolescents or young adults
Classic presentation: extranodal mass

  • African form: jaw mass
  • Sporadic form: abdominal mass
  • Aggressive

Histology: “Starry sky” appearance

Mantle cell lymphoma Driven by

  • t(11;14) 
  • Overexpression of Cyclin D1
Population: late adulthood, males
Classic presentation:

  • Painless lymphadenopathy 
  • Highly aggressive, often presents in late-stage disease
Marginal zone lymphoma  Associated with

Hashimoto thyroiditis

Sjögren syndrome

  • H. pylori
Population: adults with chronic inflammatory conditions
Clinical presentation:

  • Indolent onset
  • Painless lymphadenopathy

MALToma: marginal zone lymphoma of mucosal sites

  • Symptoms may mimic gastritis
  • Gastric MALToma may regress with treatment of H. pylori
T cell origin

(10-15%)

Adult T cell lymphoma Associated with

  • HTLV
Population: adults
Geographic location: Japan, West Africa, Caribbean
Clinical presentation:

  • Cutaneous lesions
  • Lytic bone lesions
  • Hypercalcemia
Mycosis fungicides Associated with 

  • Staphylococcus aureus
  • Borrelia species
Population: adults
Clinical presentation:

  • Skin patches/plaques

Histology: atypical CD4+ cells with cerebriform nuclei
Complications: progression to T cell leukemia

Picture of a mouth of a patient with Burkitt lymphoma showing disruption of teeth and partial obstruction of airway

Image: “Picture of a mouth of a patient with Burkitt lymphoma showing disruption of teeth and partial obstruction of airway.” By Mike Blyth – Own work. License: CC BY-SA 2.5

burkitt lymphoma histopathology

Image: “Malignant B cell lymphocytes seen in Burkitt lymphoma, stained with hematoxylin and eosin (H&E) stain.” License: Public Domain

Video

Lymphadenopathy: Non-Hodgkin Lymphoma (NHL) – White Blood Cell Pathology by Carlo Raj, MD
Lymphadenopathy: Diffuse Large B-Cell Lymphoma – White Blood Cell Pathology by Carlo Raj, MD
Lymphadenopathy: Follicular Lymphoma and Lymphoid Hyperplasia – White Blood Cell Pathology by Carlo Raj, MD
Lymphadenopathy: Burkitt Lymphoma – White Blood Cell Pathology by Carlo Raj, MD

Diagnostics and Staging

Diagnostics

  • Excisional lymph node biopsy
    • Can be excised or core-needle
    • Histology is key.
  • Initial laboratory work-up:
    • CBC with white cell differential and platelet count
    • Electrolytes, BUN, and Cr
    • LFTs
    • LDH
    • Uric acid
  • Imaging:
    • CT and PET
      • Staging 
      • Guided biopsy
      • Measuring response to therapy
  • Unique circumstances:
    • Endoscopy/gastroscopy
      • If suspected MALToma
    • Lumbar Puncture 
      • If CNS symptoms
    • Thoraco or paracentesis
      • If suspected pleural effusion or ascites
    • Bone Marrow biopsy 
      • If aggressive lymphoma suspected

Staging

  • Limited importance for treatment of NHL
  • More important for targeting therapies for Hodgkin lymphoma

Staging for NHL

Stage Features Subclasses
I Involvement of 1 lymph node group E: extranodal extension
II Involvement of 2 lymph node groups on the same side of the diaphragm
III Involvement of lymph node groups on both sides of the diaphragm 
IV Disseminated, widespread disease

Image: Hodgkin disease saging. By Lecturio.

Treatment

Treatment is based on many factors including histological subtype, stage, and patient comorbidities.

  • For localized disease (stage I or II)
    • Local radiation
    • Small course of chemotherapy
  • For advanced disease (stage III, IV, or “B” symptoms)
    • Rituximab and CHOP
      • C – cyclophosphamide
      • H – adriamycin (hydroxydaunorubicin)
      • O – vincristine (oncovin)
      • P – prednisone
  • Before beginning treatment, patients may need a baseline evaluation of their
    • Cardiac function
    • Pulmonary function
    • Fertility goals (if childbearing age)

Prognosis

  • International prognostic index (IPI) for NHL assigns 1 point for each of the following:
    • Age > 60 years
    • Stage III or IV disease
    • Elevated serum LDH
    • Performance status
    • More than 1 extranodal site

IPI Scoring

Risk Points 5-year survival
Low 0—1 73 %
Low-intermediate 2 51 %
High-intermediate 3 43 %
High 4—5 26 %

Clinical Relevance

Hodgkin Lymphoma: Neoplastic proliferation of Reed-Sternberg cells (B cells) within the lymph nodes that classically presents with “B” symptoms. Histology is positive for CD15 and CD30. 

Multiple Myeloma: The most common primary tumor of the bone in people aged 40-50 years old; occurs secondary to monoclonal plasma cell proliferation. Associated with monoclonal M protein spike, hypercalcemia, lytic bone lesions/back pain, renal involvement, and blood smear showing rouleaux formation.

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