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 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.

Hodgkin's Lymphoma

WHO Classification Overview

Classifications 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 lymphoma o 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

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 Exam

Follicular 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

Labs

Follicular 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

•

Hydrotherapy 1. 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 cachexia 3. Calendula officinalis: for lymphatic system 4. Echinacea spp.: increases interferon production, purifies blood 5. Galium aparine: specific for enlarged lymph nodes 6. Gentiana lutea: bitter; promotes appetite, improves digestion in chronic debility 7. Iris versicolor (toxic): soft glandular swellings 8. Rumex crispus: to prevent early stages of cancer 9. Taraxacum officinale: loss of appetite, weak digestion 10. 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 o 2.

3.

vitamin C (to bowel tolerance) vitamin E (400 IU TID) o 4.

selenium (200mcg TID)

Treatments

•

Manipulation

o 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