Spencer There are various reasons to the causes, effects, and patterns seen with Non-Hodgkin’s Disease.
Most common cancer of the lymphatic system.1
Since 1970, the incidence rates of Non-Hodgkin’s disease have almost doubled. Over 65,000 cases of Non Hodgkin’s Lymphoma are diagnosed annually within the US.1
There are roughly 61 types of Non-Hodgkin’s Lymphoma varying in things ranging from appearance, molecular features, and growth patterns.1
Two main forms of Non-Hodgkin’s Lymphoma Include:1
B-Cell Lymphoma – Stem from B-lymphocytes and account for 85% of all NHL
T-Cell Lymphoma – Stem from abnormal T-lymphocytes and account for 15% of all NHL
Etiology:
Pablo The following factors are associated with Non-Hodgkin lymphoma.
Some inherited immune system disorders, genetic syndromes
Celiac disease
Family history of lymphoma
Psoriasis
HIV/AIDS
Exposure to certain chemicals, and cetain bacterias
Non-random chromosomal translocations
Previous radiation exposure2
Signs & Symptoms:
Becky
Swollen lymph nodes in neck, armpits or groin3
Abdominal pain or swelling
Chest pain, coughing or difficulty breathing
Fatigue
Fever
Night sweats
Weight loss
Diagnostic Procedures:
Adam Diagnostic procedures for NHL include:4
Full physical exam, including evaluation of lymph-node bearing areas such as liver and spleen
Blood cell count
Erythrocyte sedimentation rate
Liver function tests
Lactate dehydrogenase
Imaging tests (CTs of chest, abdomen, pelvis. Head and neck if clinically indicated. PET scans becoming more popular)
Bone marrow biopsy
Histology:
Megan In North America, the most common types of NHL are small cleaved cell lymphoma, 20-30%, and diffuse large cell lymphoma, at 30-40%. The small cleaved cell lymphoma is a low-grade lymphoma and diffuse large cell lymphoma is of intermediate grade. Other types of Non-Hodgkin’s lymphoma include mucosa-associated lymphoma tissue (MALT), mantle cell, and T-cell lymphomas.5
Lymph node drainage:
Kevin6
Metastatic spread:
Erin Since lymph tissue is found throughout the body, non-hodgkins lymphoma can begin in almost any part of the body.7 The cancer can recur (metastasis) in other parts of the lymph system, or in other tissue and organs, such as the liver, lung, bone marrow or spleen. Non-hodgkins lymphoma can spread to lymph nodes far from the primary site or to lymph nodes near an organ that it also has invaded. In staging, an "E" stands of extranodal, which means that cancer is found outside of the lymph nodes in one area or organ. There are many common extranodal sites including gastric, orbital, Waldeyer's ring (tonsil, base of tongue, nasopharynx), salivary glands, thyroid, breast, testicular, CNS, or bone lymphomas.
Grading:
Spencer When dealing with Non-Hodgkin’s disease, the grade is a sign of how likely the cancer will spread.8 There are a few different factors associated with the grading system and how exactly Non-Hodgkin’s Lymphoma is graded. Low Grade Lymphomas include:8
Marginal Zone Lymphoma
Mucosa-Associated Lymphoid tissue (MALT) Lymphoma
Follicular Lymphoma
Mantle Cell Lymphoma
Intermediate Grade include:8
Diffuse Large Cell Lymphoma
Primary Mediastinal Large Cell Lymphoma
Anaplastic Large Cell Lymphoma
High Grade includes:8
Burkitt’s Lymphoma
Lymphoblastic Lymphoma
Staging:
Pablo The staging system used for non Hodgkin lymphoma is the Ann Arbor staging system.9 Stage I Either of the following means the disease is stage I:
The lymphoma is in only 1 lymph node area or lymphoid organ such as the thymus (I).
The cancer is found only in 1 area of a single organ outside of the lymph system (IE).
Stage II Either of the following means the disease is stage II:
The lymphoma is in 2 or more groups of lymph nodes on the same side of (above or below) the diaphragm (the thin band of muscle that separates the chest and abdomen). For example, this might include nodes in the underarm and neck area but not the combination of underarm and groin nodes (II).
The lymphoma extends from a single group of lymph node(s) into a nearby organ (IIE). It may also affect other groups of lymph nodes on the same side of the diaphragm.
Stage III Either of the following means the disease is stage III:
The lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm.
The cancer may also have spread into an area or organ next to the lymph nodes (IIIE), into the spleen (IIIS), or both (IIISE).
Stage IV Either of the following means the disease is stage IV:
The lymphoma has spread outside of the lymph system into an organ that is not right next to an involved node.
The lymphoma has spread to the bone marrow, liver, brain or spinal cord, or the pleura (thin lining of the lungs).
Other modifiers may also be used to describe the lymphoma stage: Bulky disease This term is used to describe tumors in the chest that are at least one-third as wide as the chest, or tumors in other areas that are at least 10 centimeters (about 4 inches) across. It is usually designated by adding the letter X to the stage. Bulky disease may require more intensive treatment. A vs. B Each stage may also be assigned an A or B. The letter B is added (stage IIIB, for example) if a person has any of the B symptoms listed below:
Loss of more than 10% of body weight over the previous 6 months (without dieting)
Unexplained fever of at least 101.5°F
Drenching night sweats
Radiation side effects:
Becky
Depending on the area treated, the side effects of radiation therapy can vary.
If the patient treatment to the head and neck area they may experience side effects such as: dry mouth, altered taste, skin redness, sore throat, difficulty swallowing, loss of appetite, mouth sores or even dry cough. If a patient receives treatment to the abdominal area those side effects may include: nausea, vomiting and possibly fatigue. With treatment to the pelvic area, diarrhea may occur and will be closely monitored.10
Prognosis:
Adam There are a number of prognostic factors that are considered in NHL cases. The following image shows the International Prognostic Index (IPI) for NHL:4
Treatments:
Megan Due to the fact that Non-Hogdkin's Lymphoma encompasses many diseases, there are equally as many treatment options:
Since low-grade lymphomas are more responsive to radiation therapy, the suggested treatment is to provide doses of 20 to 35 Gy delivered in 10 to 20 fractions over 2 to 4 weeks. This results in local control rates of over 95%. Many centers use a dose of approximately 24 to 30 Gy.
For a Small Lymphocytic Lymphoma, radiation may be considered in those rare circumstances of localized disease. Typically, a dose of 30 Gy with generous fields is employed.
With a diagnosis of DLBCL Gastric Lymphoma, radiation doses are 30 to 36 Gy after chemotherapy. The radiation field typically encompasses the entire stomach, celiac axis nodes, and other involved areas with a margin of several centimeters.
When treating Intestinal Lymphoma, typically both diagnosis and treatment are achieved with surgery. Whole-abdominal radiation, with a dose of 20 to 25 Gy in 1.00 to 1.25 Gy fractions, only with incomplete resection.
Waldeyer's Ring Lymphoma (tonsil, base of tongue, nasopharynx) is often treated with chemotherapy and irradiation to the primary tumor and neck nodes.
In Thyroid Lymphoma treated is typically locoregional, moderate-dose irradiation (40 to 45 Gy).
Orbital Lymphoma can be treated using a two-field technique with 4- to 6-MV photons. A corneal shield should be placed in the anterior and lateral fields.
Breast Lymphoma uses radiation therapy to the whole breast (40 to 45 Gy) and to the ipsilateral axillary lymph nodes (40 to 45 Gy) resulting in excellent local control (75% to 78%).
With Testicular Lymphoma, postorchiectomy therapy treats the paraaortic and ipsilateral pelvic lymph nodes. Cure rates of 40% to 50% are associated with stage I and 20% to 30% for stage II disease.
Bone Lymphoma is typically treated with radiation therapy to the whole bone to a minimum dose of 35 Gy.
Primary Central Nervous System Lymphoma utilizes irradiation fields to the whole brain, with extension to the upper cervical spinal cord and typically to the posterior orbits.
With Cutaneous Lymphoma, total-body election irradiation is the preferred treatment modality5
10. Green S. Lymphoreticular system tumors. In: Washington CM, Leaver D, eds. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010: 610-627.
There are various reasons to the causes, effects, and patterns seen with Non-Hodgkin’s Disease.
The following factors are associated with Non-Hodgkin lymphoma.
Diagnostic procedures for NHL include:4
In North America, the most common types of NHL are small cleaved cell lymphoma, 20-30%, and diffuse large cell lymphoma, at 30-40%. The small cleaved cell lymphoma is a low-grade lymphoma and diffuse large cell lymphoma is of intermediate grade. Other types of Non-Hodgkin’s lymphoma include mucosa-associated lymphoma tissue (MALT), mantle cell, and T-cell lymphomas.5
Since lymph tissue is found throughout the body, non-hodgkins lymphoma can begin in almost any part of the body.7 The cancer can recur (metastasis) in other parts of the lymph system, or in other tissue and organs, such as the liver, lung, bone marrow or spleen. Non-hodgkins lymphoma can spread to lymph nodes far from the primary site or to lymph nodes near an organ that it also has invaded. In staging, an "E" stands of extranodal, which means that cancer is found outside of the lymph nodes in one area or organ. There are many common extranodal sites including gastric, orbital, Waldeyer's ring (tonsil, base of tongue, nasopharynx), salivary glands, thyroid, breast, testicular, CNS, or bone lymphomas.
When dealing with Non-Hodgkin’s disease, the grade is a sign of how likely the cancer will spread.8 There are a few different factors associated with the grading system and how exactly Non-Hodgkin’s Lymphoma is graded.
Low Grade Lymphomas include:8
- Marginal Zone Lymphoma
- Mucosa-Associated Lymphoid tissue (MALT) Lymphoma
- Follicular Lymphoma
- Mantle Cell Lymphoma
Intermediate Grade include:8- Diffuse Large Cell Lymphoma
- Primary Mediastinal Large Cell Lymphoma
- Anaplastic Large Cell Lymphoma
High Grade includes:8The staging system used for non Hodgkin lymphoma is the Ann Arbor staging system.9
Stage I
Either of the following means the disease is stage I:
- The lymphoma is in only 1 lymph node area or lymphoid organ such as the thymus (I).
- The cancer is found only in 1 area of a single organ outside of the lymph system (IE).
Stage IIEither of the following means the disease is stage II:
- The lymphoma is in 2 or more groups of lymph nodes on the same side of (above or below) the diaphragm (the thin band of muscle that separates the chest and abdomen). For example, this might include nodes in the underarm and neck area but not the combination of underarm and groin nodes (II).
- The lymphoma extends from a single group of lymph node(s) into a nearby organ (IIE). It may also affect other groups of lymph nodes on the same side of the diaphragm.
Stage IIIEither of the following means the disease is stage III:
- The lymphoma is found in lymph node areas on both sides of (above and below) the diaphragm.
- The cancer may also have spread into an area or organ next to the lymph nodes (IIIE), into the spleen (IIIS), or both (IIISE).
Stage IVEither of the following means the disease is stage IV:
- The lymphoma has spread outside of the lymph system into an organ that is not right next to an involved node.
- The lymphoma has spread to the bone marrow, liver, brain or spinal cord, or the pleura (thin lining of the lungs).
Other modifiers may also be used to describe the lymphoma stage:Bulky disease
This term is used to describe tumors in the chest that are at least one-third as wide as the chest, or tumors in other areas that are at least 10 centimeters (about 4 inches) across. It is usually designated by adding the letter X to the stage. Bulky disease may require more intensive treatment.
A vs. B
Each stage may also be assigned an A or B. The letter B is added (stage IIIB, for example) if a person has any of the B symptoms listed below:
Depending on the area treated, the side effects of radiation therapy can vary.
If the patient treatment to the head and neck area they may experience side effects such as: dry mouth, altered taste, skin redness, sore throat, difficulty swallowing, loss of appetite, mouth sores or even dry cough. If a patient receives treatment to the abdominal area those side effects may include: nausea, vomiting and possibly fatigue. With treatment to the pelvic area, diarrhea may occur and will be closely monitored.10
There are a number of prognostic factors that are considered in NHL cases. The following image shows the International Prognostic Index (IPI) for NHL:4
Due to the fact that Non-Hogdkin's Lymphoma encompasses many diseases, there are equally as many treatment options:
Since low-grade lymphomas are more responsive to radiation therapy, the suggested treatment is to provide doses of 20 to 35 Gy delivered in 10 to 20 fractions over 2 to 4 weeks. This results in local control rates of over 95%. Many centers use a dose of approximately 24 to 30 Gy.
For a Small Lymphocytic Lymphoma, radiation may be considered in those rare circumstances of localized disease. Typically, a dose of 30 Gy with generous fields is employed.
With a diagnosis of DLBCL Gastric Lymphoma, radiation doses are 30 to 36 Gy after chemotherapy. The radiation field typically encompasses the entire stomach, celiac axis nodes, and other involved areas with a margin of several centimeters.
When treating Intestinal Lymphoma, typically both diagnosis and treatment are achieved with surgery. Whole-abdominal radiation, with a dose of 20 to 25 Gy in 1.00 to 1.25 Gy fractions, only with incomplete resection.
Waldeyer's Ring Lymphoma (tonsil, base of tongue, nasopharynx) is often treated with chemotherapy and irradiation to the primary tumor and neck nodes.
In Thyroid Lymphoma treated is typically locoregional, moderate-dose irradiation (40 to 45 Gy).
Orbital Lymphoma can be treated using a two-field technique with 4- to 6-MV photons. A corneal shield should be placed in the anterior and lateral fields.
Breast Lymphoma uses radiation therapy to the whole breast (40 to 45 Gy) and to the ipsilateral axillary lymph nodes (40 to 45 Gy) resulting in excellent local control (75% to 78%).
With Testicular Lymphoma, postorchiectomy therapy treats the paraaortic and ipsilateral pelvic lymph nodes. Cure rates of 40% to 50% are associated with stage I and 20% to 30% for stage II disease.
Bone Lymphoma is typically treated with radiation therapy to the whole bone to a minimum dose of 35 Gy.
Primary Central Nervous System Lymphoma utilizes irradiation fields to the whole brain, with extension to the upper cervical spinal cord and typically to the posterior orbits.
With Cutaneous Lymphoma, total-body election irradiation is the preferred treatment modality5
1. Non-Hodgkin’s Lymphoma. Lymphoma Research Foundation Web Site. http://www.lymphoma.org/site/pp.asp?c=bkLTKaOQLmK8E&b=6296735. Accessed June 25, 2013.
2. WebMD. Web site. http://www.webmd.com/cancer/non-hodgkins-lymphoma/understanding-non-hodgkins-lymphoma-basics. Accessed July 1, 2013.
3. Mayo Clinic staff. Non-Hodgkin’s lymphoma. Mayo Clinic Website. http://www.mayoclinic.com/health/non-hodgkins-lymphoma. January 12, 2012. Accessed June 28, 2013.
4. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
5. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:590.
6. Vann A, Dasher B, Chestnut S, Wiggers N. Portal Design in Radiation Therapy. 2nd ed. Columbia, SC: The R.L. Bryan Company; 2006:85-95.
7. Cleveland Clinic Website. Adult Non-Hodgkin's Lymphoma. http://my.clevelandclinic.org/disorders/non-hodgkins_lymphoma/hic_adult_non-hodgkins_lymphoma.aspx. Accessed July 4, 2013.
8. Non-Hodgkin’s Lymphoma. MD Anderson Cancer Center Web Site. http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/non-hodgkins-lymphoma/index.html. Accessed June 25, 2013.
9. American Cancer Society. Web site. http://www.cancer.org/cancer/non-hodgkinlymphoma/detailedguide/non-hodgkin-lymphoma-staging. Accessed July 1, 2013.
10. Green S. Lymphoreticular system tumors. In: Washington CM, Leaver D, eds. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010: 610-627.