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
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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
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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
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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
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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
Diffuse Large B cell Lymphoma
Waxing and waning
lymphadenopathy often present
for long periods prior to diagnosis
Nodal enlargement commonly
found in the neck and the
abdomen.
**This disease progresses slowly
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 cytometryImmunophenotype 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 26 years, survival rate is 75% over 5-years
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
Treatments
• Naturopathic Treatments:
o 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
Treatments
• Nutrition
o 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
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 2.
vitamin C (to bowel tolerance)
o 3.
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
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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