Dr Rejiv Rajendranath MD DM DNB
Integrated Cancer Care Group
Lymphomas in general are defined as a group of malignant tumours originating from lymph nodes or other lymphatic tissues including tonsil, spleen, bone marrow etc.
Rarely they can disseminate through lymphatics and primarily affect organs like brain,stomach ,lungs and bones.
Basically they are malignant tumours of the immune system. Lymphomas are broadly divided into Hodgkins (HL ) and Non Hodgkins Lymphomas( NHL) and considered as two different entities with unique etiopathogenesis and treatment modalities.
Coming to the the incidence of Lymphomas in our country is 0.84-1.39 /100,000 population and is usually considered as lower than that seen in the west and countries like Japan .
50% of these occur between age 20- 40 years and is considered as a disease affecting the young in our population .Among this NHL constitute at least 90 % .
. But there are some lymphomas like Follicular lymphomas which are particularly seen in elderly more than 60 years and some like Burkits Lymphomas and Lymhoblastic Lymphomas are seen predominantly in children. Interestingly Hodgkins lymphomas have a bimodal peak seen in very young as well as the elderly .
As far as causative factors of lymphomas are considered it is multifactorial including some of the viruses and immunodeficiency states.
Typically Epstein Barr virus is considered to be associated with burkits lymphoma and hodgkins lymphoma .
Some Bacteriae like H pylori infections are usually associated with MALT lymphomas affecting the stomach.
Immunodeficiency states of the patient are also an important factor. For eg Primary CNS lymphoma is seen mostly in patients with HIV infections
Lymphomas are classified as per the 2016 revision of WHO classification of lymphoid neoplasms. Hence lymphomas may be classified based on cell size,(largev/small) nodal architecture( follicular v/s diffuse) aggressive v/s indolent etc .
Most common NHL diagnosis include Diffuse Large B cell Lymphoma (DLBCL), follicular lymphomas, Mantle cell lymphomas etc .
hodgkins lymphoma classification include Classical HD and Nodular Lymphocyte Predominant HD . To ascertain and exact subtype of lymphoma is of paramount importance in further staging work up and treatment planning .
Lymphomas present with variable signs and symptoms based on the site involved and extent od the disease. This include Lymph node swelling,Back ache,unexplained fever,night sweats and unexplained weight loss .
Diagnostic and Staging investigations include an intact lymph node biopsy with special lab studies called Immuno histochemistry studies (IHC) and most of the cases Bone marrow aspiration and biopsy study .
Whole body PET CT scan has become the standard staging investigation in majority of the lymphomas.
Staging of lymphomas help in ascertain stages I to IV based on the involvement of lymph nodes above and below the Diaphragm and presence or absence of involvement of bone marrow and other organs like liver and lung .
Accurate staging is again mandatory for planning the right type and duration of treatment. Risk stratification scoring using few prognostic factors like age sex are also important.
This also helps in prognosticating to low risk group whose Curative rates are as high as 90 % to high risk subset where we need aggressive treatment modalities and results shall be around 40 % .
Treatment modalities include Conventional Combination cytotoxic chemotherapy which will kill cacer cells as well as normal cells and newer targeted therapy like Monoclonal Antibodies against CD 20 Antigen called as Rituximab which will target only the cancer cells .
Rituximab in combination with CHOP based Chemotherapy is standard of care in DLBCL. Treatment agent and duration depend on Age, stage, comorbid conditions of the patient like Diabetes,Hypertension etc.
Aggressive lymphomas are treated with intensive combination Chemotherapy and targeted therapy and usually milder therapies for indolent Lymphomas.
Majority of the lymphomas are curable with current treatment stratergies and usual an end of treatment Whole body PET scan is done to document complete disappearance of the disease .
Other novel treatment strategies like Stem cell transplantation, Novel Agents Antibody Drug Conjugates like Brentuximab , immunotherapy like anti PD 1 monoclonal Antibodies like Nivolumab are approved for use in relapsed and refractory lymphomas and still we can cure a significant subset of patients whose disease has come back after standard treatment stratergies.
In summary recent Advances in Diagnostic and treatment strategies in the field of Lymphomas has made it one of the highly curable malignancies and a new hope for our patients.
