Non Hodgkin's Lymphoma

Questions?

• What is Hodgkin's? • What is a Lymphoma?

 • What does Non-Hodgkin's mean?

Lymphomas and leukemias

  A Leukemia is a tumor that produces abnormal white blood cells in the blood stream. A lymphoma is a tumor of the lymph nodes that causes them to expand, invade other organs and cause the abnormal growth of lymphoid tissue elsewhere.

Leukemias are tumors of the bone marrow, while lymphomas are tumors of the lymphoid organs and lymphatics

Classification of NHLHodgkin's vs. Non Hodgkin's• through microscopy, if the tumor presents with Reed-Sternberg cells,

then the disease is classified as Hodgkin's Lymphoma.  All other forms are classified as non-Hodgkin's.

• The original classification known as the "Working Formula" addressed the NHL into 16 different groups, classified by aggressiveness. There is little correlation between the stages, and thus, the REAL (Revised European-American Lymphoma) and WHO classifications are currently more adapted into medical language.  

• These classifications organize the lymphomas into over 43 distinguishable diseases. 

• They still classifiy Hodgkin's lymphoma, but do not specifically identify NHL. People still use the term, although due to it's broad spectrum, provides little clinical relevance.

Hodgkin's Lymphoma

WHO Classification OverviewClassifications are based on the morphological presentation as opposed to the aggressiveness. B cell Neoplasms• Precursor B cell Neoplasms• Mature B cell Neoplasms (most common)

o Follicular B cell lymphomao Diffuse Large B cell Lymphoma

• B cell proliferations unclassifiedT cell and NK cell Neoplasms• Precursor T and NK cell neoplasms• Mature T and NK cell Neoplasms• T and NK proliferations unclassified

Hodgkin's Lymphoma

Histiocytic Neoplasms

Dendritic cell Neoplasms

Lymphoma classification

B cell Lymphomas  90% of cases are Mature B cell Lymphomas, < 1% are precursor B cell lymphoma

Follicular B cell Lymphoma Mantle Cell Lymphoma Marginal Zone Lymphoma Interfollicular Lymphomas Burkitt Lymphoma Diffuse Large B cell Lymphoma Primary Effusion Lymphoma

 

Diffuse Large B cell Lymphoma

 

Follicular B cell Lymphoma

B cell Developement

Lymphoma Classification continued

T cell Lymphomas  < 12% of cases are T cell and NK cell Lymphomas, although uncommon, they are one of the most aggressive lymphomas.  

Peripheral T cell Lymphoma, unspecified Anaplastic Large Cell Lymphoma Angioimmunoblastic T cell Lymphoma Primary Cutaneous T cell Lymphoma

Lymphoma Classification continued

Rare Lymphomas

Histiocytic tumors•      Similar to Anaplastic Large cell Lymphoma, within the

dermis or gastrointestinal tract. Express a "histiocytic" phenotype, but has no specific markers, thus the diagnosis is that of exclusion.

Dendritic Cell Tumors•     Neoplasms related to accessory cells (DC).  Extremely

rare, and present a significant diagnostic challenge.  Symptoms are unpredictable, showing forms of indolence to lethality.

Risk Factors For          NHL• Systemic Lupus• Rheumatoid arthritis• Celiac Disease• AIDS• Organ Transplant recipients• Congenital Immunodeficiency disorders• Chromosomal abnormalities, specifically with chromosomes

2, 8, 14, and 22 (seen in ~ 60% of cases)  

Typical Patient Signs and Symptoms

• Over the age of 55• Severe night sweats (often times drenching the bed sheets)• Itchiness, generally all over• Fever• Weight Loss• Loss of appetite• Weakness and Fatigue, along with typical signs of anemia• Breathlessness, primarily due to swelling of the face and/or

neck

Physical ExamFollicular B cell Lymphoma Waxing and waning lymphadenopathy often present for long periods prior to diagnosis **This disease progresses slowly  

  

Diffuse Large B cell Lymphoma

Nodal enlargement commonly found in the neck and the abdomen.  Masses can be found outside the lymphatic system: the gastrointestinal tract, testes, thyroid, skin, breast, bone or brain

40% cases present with extranodal extramedullary disease.  **This is an aggressive disease    

LabsFollicular B cell Lymphoma • Normal CBC (may show with

signs of anemia)• Peripheral smear normal• Lymph node biopsy

Diffuse Large B cell Lymphoma • Normal CBC (may show with

signs of anemia)• Peripheral smear normal• Flow cytometry-

Immunophenotype generally includes pan-B-cell antigens such as CD19, CD20, CD22 and CD79a

• Excisional tissue biopsy

Both biopsies require the distinction between: benign vs. malignant lymphoma vs. nonlymphoid malignancies T cell vs. B cell lymphoma HL vs. NHL  subtyping of HL and NHL

Prognosis

• Variable Depends upon:

the amount of dissemination,  the staging of the disease and the type of lymphoma 

  when first diagnosed the disease has spread throughout the

body in 70-90% of patients  although most patients develop progressive disease over 2-

6 years, survival rate is 75% over 5-years  

Treatments

Traditional Treatments:• consists of radiation and/or chemotherapy • and occasional splenectomy

  o remission rates presently 70-90% at 5-years with that

treatment

Treatments

• Naturopathic Treatments: o Nutrition

 o Hydrotherapy

 o Botanicals

 o Supplements

 o Manipulation

 o Homeopathy

Treatments

• Nutrition o Non-Hodgkin's lymphoma:  

1.     decrease intake of fats severely  2.     vitamin C rich foods  3.     apples, celery, collards, guava, kohlrabi

 o Recommendation for all cancers

seaweed, mushrooms (Shiitake), figs, beets, papaya, mung beans, licorice, sea cucumbers, carrot, garlic, walnut, mulberries, asparagus, pumpkin, burdock, dandelion greens, taro roots, pearl barley, grains, fresh fruit and vegetables

Treatments

• Hydrotherapy1. fever treatment 2. constitutional hydrotherapy 3. castor oil packs: over abdominal area and spleen, add phytolacca oil, 2x/week, 1 hour 4. Epsom salt baths: 2x/week, 20-30 min. end with cold friction, dry and stay warm

Treatments

•Botanicals (General cancer/neoplasm): 1.Arctium lappa: alterative for the lymphatic system 2.Berberis aquifolium: dyscrasiae due to cancerous cachexia3.Calendula officinalis: for lymphatic system 4.Echinacea spp.: increases interferon production, purifies blood5.  Galium aparine: specific for enlarged lymph nodes6.Gentiana lutea: bitter; promotes appetite, improves digestion in

chronic debility7. Iris versicolor (toxic): soft glandular swellings8.Rumex crispus: to prevent early stages of cancer9.Taraxacum officinale: loss of appetite, weak digestion10. Trifolium pratense: alterative; purifies blood, cancerous

diathesis; with daily use; patient are slower in developing carcinoma after excision

Treatments

•  Supplements o 1.     beta carotene (150,000 IU QD)o 2.     vitamin C (to bowel tolerance)o 3.     vitamin E (400 IU TID)o 4.     selenium (200mcg TID)

Treatments

• Manipulationo check and align T5, T10-12

Treatments

• Homeopathy 1. Apis: on neck with hectic fever; edema of skin and mucus

membranes 2. Arsenicum album: great exhaustion; burning pains;

lymphoma on neck with hectic fever, with holes as in a sieve 3. Arsenicum iodatum: weakness, night sweats 4. Belladonna: sore throat, swollen face, dry cough 5. Graphites: with fever 6. Phosphorus: with fever, suddenness of symptoms, with

nervous debility; emaciation 7. Pulsatilla: with digestive problems 8. Rhus toxicodendron: restlessness and soreness

Resources

• Clin Lab II Lecture Notes (2009-2010)• Phys Clin II Lecture Notes (2009-2010)• Clinical Hematology and Fundamentals of Hemostasis• www.medscape.com• http://www.ncbi.nlm.nih.gov/sites/entre• http://gemininotcancer.files.wordpress.com• http://www.ethicon.novartis.us • http://www.aurorahealthcare.org