NHL

Slight male predominace1 In the U.S., white males have a higher incidence1 Median age is 65 y.o.1 Peak in the 80-84 age group || Risk factor for NHL include:1 - Epstien-Barr virus - patients who have undergone an organ transplant - congenital or acquired immunosuppression ( EBV, HIV) - Chromosomal aberrations - Patients previously treated for Hodgkin's disease with chemo and radiation. - people exposed to agricultural herbicides || Enlarged lymph nodes, fever, night sweats, fatigue, itching, and weight loss. Unlike Hodgkin's, however, NHL may arise in a wide variety of sites1 Most commonly in the lymph nodes, GI tract, and Waldeyer's ring. Abdominal pain or a change in bowel habits may indicate pelvic disease. 1 Symptoms of brain involvement may include headaches, vision problems, and seizures.1 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Systemic symptoms are rare, occuring in only 10 to 15% of the patients at the time of presentation.1 || __ B-cell Neoplasms __ Precursor B-cell neoplasm Precursor B-lymphoblastic leukemia/lymphoma precursor B-cell acute lymphoblastic leukemia) Mature (peripheral) B-cell neoplasms  -B-cell chronic lymphocytic leukemia/ samll lymphocytic lymphoma  -B-cell prolymphocytic leukemia  -Lymphoplasmacytic lymphoma  -Splenic marginal zone B-cell lymphoma (+ villous lymphocytes)  -Hairy cell leukemia  -Plasma cell myeloma/ plasmacytoma  -Extranodal marginal zone B-cell lymphoma of MALT type  -Nodal marginal zone B-cell lymphoma (+ monocytoid B cells)  -Follicular lymphoma  -Mantle-cell lymphoma  -Diffuse large B-cell lymphoma  --Mediastinal large B-cell lymphoma  --Primary effusion lymphoma  -Burkitt's lymphoma/Burkitt cell leukemia __ T-cell and NK-cell neoplasms __ Precursor T-cell neoplasm  -Precursor T-lymphoblastic lymphoma/leukemia  --(precursor T-cell acute lymphoblastic leukemia)  Mature (peripheral) T-cell neoplasms  -T-cell prolymphocytic leukemia  -T-cell granular lymphocytic leukemia -Aggresive NK-cell leukemia -Adult T-cell lymphoma/ leukemia (HTLV-1+) -Extranodal NK/T-cell lymphoma, nasal type -Enteropathy-type T-cell lymphoma -Hepatosplenic gamma-delta T-cell lymphoma -Subcutaneous panniculitis-like T-cell lymphoma -Mycosis fungoides/ Sezary syndrome -Anaplastic large-cell lymphoma, T/null cell, primary cutaneous type -Peripheral T-cell lymphoma, not otherwise characterized -Angioimmunoblastic T-cell lymphoma -Anaplastic large-cell lymphoma, T/null cell, primary systemic type || Lymph nodes areas. Tumors may arise in any area of lymphoid aggression, such as lymph nodes, spleen, waldeyer's ring, bone marrow, Gastrointestinal tract, and other areas where lymphoid tissue circulate.2 || <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Follicular Lymphoma (FL) (grades 1-2) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Small lymphocytic lymphoma (SLL) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Marginal zone lymphoma (MZL): Extranodal (MALT lymphoma) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Nodal <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Splenic <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Mycosis fungoides (T-cell lymphoma of skin) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Diffuse large B-cell (including immunoblastic, and mediastinal B-cell) lymphoma (DLBCL) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Follicular lymphoma (grade III) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Mantle cell lymphoma (MCL) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">T-cell lymphomas: Peripheral T-cell lymphoma (PCTL) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Angiocentric <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Angioimmunoblastic <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">NK lymphoma <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Anaplastic large cell lymphoma (ALCL) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Lymphoblastic lymphoma <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Burkitt’s lymphoma <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">High-grade B-cell, Burkitt’s-like || <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">I - Involvement of a single lymph node region or lymphoid structure (e.g., spleen, thymus, Waldeyer's ring) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">II - Involvement of two or more lymph node regions on the same side of the diaphragm <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">III - Involvement of lymph regions or structures on both sides of the diaphragm <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">IV - Involvement of extranodal site(s) beyond that designated E <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">A - No symptoms <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">B - Fever (>38°C), drenching sweats, weight loss (10% body weight over 6 months) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">E - Involvement of a single extranodal site contiguous or proximal to known nodal site <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">(i) - Suffix X to designate bulky disease as more than one third widening of the mediastinum or >10-cm maximum dimension of nodal mass <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">(ii) - The number of anatomic regions involved should be indicated by a subscript (e.g., II3) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">(iii) - Stage III may be subdivided into: <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">III1 - with or without splenic, hilar, celiac, or portal nodes <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">III2 - with para-aortic, iliac, mesenteric nodes <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">(iv) - Staging should be identified as clinical stage or pathologic stage <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">(v) - A new category of response to therapy, unconfirmed/uncertain complete remission should be introduced because of the persistent radiologic abnormalities of uncertain significance || || Small Lymphocytic Lymphoma DLBCL Gastric Lymphoma Intestinal Lymphoma Waldeyer's Ring Lymphoma (tonsil, base of tongue, nasopharynx) Thyroid Lymphoma Orbital Lymphoma Breast Lymphoma Testicular Lymphoma Bone Lymphoma Primary Central Nervous System Lymphoma Cutaneous Lymphoma ||
 * **Epidemiolgy:** || <span style="color: blue; font-family: Arial,sans-serif; font-size: 10pt;">Incidence has increased by 65% since the 1970’s1
 * **Etiology:** || <span style="color: blue; font-family: Arial,sans-serif; font-size: 10pt;">Exact causes are unknown <span style="color: blue; font-family: Arial,sans-serif;">1 <span style="color: blue; font-family: Arial,sans-serif; font-size: 10pt;">Researchers have discovered that lymphomas are genetic alterations of the B or T lymphocyte cells.1
 * **Signs & Symptoms:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">S&S’s are similar to those of Hodgkin’s lymphoma1
 * **Diagnostic Procedures:** || * The history and physical examination are the first standard steps along with the cytological evaluations.Blood tests: complete blood count (CBC), HIV test, blood chemistry, urinalysis, serum lactate dehydrogenase (LDH), liver function tests, and serum alkaline phosphatase.A bone marrow biopsy is necessary because bone marrow involvement is common in many lymphomasMRI is more sensitive than a biopsy, so it can also identify CNS involvement.Chest radiograph;CT of the abdomen, pelvis, neck and chest (CT scan of the brain may be recommended if previous tests or symptoms indicate possible disease at these sites)
 * Bone scan
 * PET scans
 * Further diagnostic tests may include a gallium whole-body scan and upper GI or small bowel series. A lymphangiogram of the pelvis and abdomen are done if the CT scan shows abnormal results. The initial diagnosis of NHL usually requires an excisional lymph node biopsy for precise classification. 2 ||
 * **Histology:** || WHO classification of non-­Hodgkin’s lymphomas:3
 * **Lymph node drainage:** || [[image:uwlmedicaldosimetry2012/nhl.jpg]]
 * **Metastatic spread:** || <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">The metastatic spread of Non-Hodgkins’s lymphoma (NHL) varies depending on classification (low grade, intermediate grade, or high grade). Most low grade types involve extranodal sites. Intermediate and high grade types can involve any number of extranodal and visceral sites. It is also not uncommon for low grade NHLs to transform histologically into a more aggressive type. 4 ||
 * **Grading:** || **<span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Abridged version of the WHO Lymphoma Classification Organized by Clinical Groups ** 4
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Low Grade (Indolent) **
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Intermediate grade (Aggressive) **
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">High Grade (Highly Aggressive) **
 * **Staging:** || **<span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Ann Arbor Staging Classification and the Cotswold Modifications ** 5
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Stage Features **
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">FOR ALL STAGES **
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">FOR STAGES I TO III **
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">COTSWOLD MODIFICATIONS **
 * **Radiation side effects:** || Side effects are dependant on treatment location and may include:
 * **Prognosis:** || Prognosis For Non-Hodgkins lymphoma can be good, but it has a very broad prognosis due to its dependance on factors such as stage location and the tumors response to radiation. ||
 * **Treatments:** || Follicular Lymphoma: Stage I ad II 2
 * Low-grade lymphomas are more responsive to radiation therapy: Doses of 20 to 35 Gy delivered in 10 to 20 fractions over 2 to 4 weeks result in local control rates of over 95%. Many centers use a dose of approximately 24 to 30 Gy.
 * Radiation may be considered in those rare circumstances of localized disease. Typically, a dose of 30 Gy with generous fields is employed.
 * Radiation doses are 30 to 36 Gy after chemotherapy
 * The radiation portal typically encompasses the entire stomach, celiac axis nodes, and other involved areas with a margin of several centimeters.
 * Typically, 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, if surgical resection is incomplete.
 * Chemotherapy and irradiation to the primary tumor and neck nodes results
 * With locoregional, moderate-dose irradiation (40 to 45 Gy)
 * A two-field technique can be used (4- to 6-MV photons), with a corneal shield plaved in the anterior and lateral fields.
 * Radiation therapy to the whole breast (40 to 45 Gy) and to the ipsilateral axillary lymph nodes (40 to 45 Gy) results in excellent local control (75% to 78%).
 * Historically, postorchiectomy therapy involved radiation therapy to the paraaortid and ipsilateral pelvic lymph nodes, with cure rates of 40% to 50% for stage I and 20% to 30% for stage II disease.
 * Radiation therapy to the whole bone to a minimum dose of 35 Gy
 * Irradiation fields are usually to the whole brain, with extension to the upper cervical spinal cord and typically to the posterior orbits.
 * Total-body election irradiation is the preferred treatment modality. ||
 * **TD 5/5:** || Due to the nature of both Non Hodgkins and Hogkins lymphoma to be located and spread anywhere lymph travles I have encluded a table that is sued at my clinical site that refrences RTOG Trials for current dose tolerances
 * **References:** || # <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Green S. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MI: Mosby. 2010: 619-620.
 * 1) Chao KC, Perez CA, Brady LW. // Radiation Oncology Management Decisions // . 2nd ed. Philadelphia, PA; Lippincott Williams & Wilkins. 2011: 589-600.
 * 2) American Cancer Society. Non-Hodgkin Lymphoma. Available at: []. Accessed June 26, 2012.
 * 3) <span style="color: purple; font-family: 'Arial','sans-serif'; font-size: 13px;">Hoppe RT, Phillips TL, Mack III M. //Leibel and Phillips Textbook of Radiation Oncology//. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010
 * 4) <span style="color: purple; font-family: 'Arial','sans-serif'; font-size: 13px;">Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG. //Abeloff's Clinical Oncology//. 4th ed. Philadelphia, PA: Churchill Livingstone; 2008. ||

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