Non Hodgkin's Lymphoma

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Non Hodgkin's Lymphoma
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Questions?

• What is Hodgkin's?
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• What is a Lymphoma?
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• What does Non-Hodgkin's mean?

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Lymphomas and leukemias

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• 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

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Classification of NHL

• Hodgkin'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.

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Hodgkin's Lymphoma
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WHO Classification Overview

• Classifications are based on the morphological
  presentation as opposed to the aggressiveness.
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• B cell Neoplasms
• Precursor B cell Neoplasms
• Mature B cell Neoplasms (most common)
• Follicular B cell lymphoma
• Diffuse Large B cell Lymphoma
• B cell proliferations unclassified
• T 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

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Lymphoma classification

• B cell Lymphomas
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• 90 of cases are Mature B cell Lymphomas, lt 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
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Diffuse Large B cell Lymphoma

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Follicular B cell Lymphoma
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B cell Developement
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Lymphoma Classification continued

• T cell Lymphomas
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• lt 12 of cases are T cell and NK cell Lymphomas,
  although uncommon, they are one of the most
  aggressive lymphomas. 
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• Peripheral T cell Lymphoma, unspecified
• Anaplastic Large Cell Lymphoma
• Angioimmunoblastic T cell Lymphoma
• Primary Cutaneous T cell Lymphoma

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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.

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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)
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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

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Physical Exam

• Diffuse Large B cell Lymphoma
• Nodal enlargement commonly found in the neck and
  the abdomen. 
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• 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.
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• This is an aggressive disease
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• Follicular B cell Lymphoma
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• Waxing and waning lymphadenopathy often present
  for long periods prior to diagnosis
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• This disease progresses slowly
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Labs

• Diffuse Large B cell Lymphoma
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• 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

• Follicular B cell Lymphoma
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• Normal CBC (may show with signs of anemia)
• Peripheral smear normal
• Lymph node 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

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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
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• although most patients develop progressive
  disease over 2-6 years, survival rate is 75 over
  5-years
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Treatments

• Traditional Treatments
• consists of radiation and/or chemotherapy 
• and occasional splenectomy
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• remission rates presently 70-90 at 5-years with
  that treatment

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Treatments

• Naturopathic Treatments
• Nutrition
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• Hydrotherapy
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• Botanicals
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• Supplements
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• Manipulation
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• Homeopathy

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Treatments

• Nutrition
• Non-Hodgkin's lymphoma  
• 1.     decrease intake of fats severely 
• 2.     vitamin C rich foods 
• 3.     apples, celery, collards, guava, kohlrabi
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• 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

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Treatments

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

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Treatments

• Botanicals (General cancer/neoplasm) 
• Arctium lappa alterative for the lymphatic
  system 
• Berberis aquifolium dyscrasiae due to cancerous
  cachexia
• Calendula officinalis for lymphatic system 
• Echinacea spp. increases interferon production,
  purifies blood
•  Galium aparine specific for enlarged lymph
  nodes
• Gentiana lutea bitter promotes appetite,
  improves digestion in chronic debility
• Iris versicolor (toxic) soft glandular swellings
• Rumex crispus to prevent early stages of cancer
• Taraxacum officinale loss of appetite, weak
  digestion
•  Trifolium pratense alterative purifies blood,
  cancerous diathesis with daily use patient are
  slower in developing carcinoma after excision

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Treatments

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

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Treatments

• Manipulation
• check and align T5, T10-12

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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

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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