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{{Non-Hodgkin lymphoma}}  
{{Non-Hodgkin lymphoma}}  
{{CMG}} {{shyam}}; {{AE}} {{AS}}
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==Overview==
==Overview==
The diagnostic study of choice for non-Hodgkin lymphoma is excisional lymph node biopsy. A bone marrow biopsy is an alternative to a lymph node biopsy.  
The diagnostic study of choice for non-Hodgkin lymphoma is excisional lymph node biopsy. A bone marrow biopsy is an alternative to a lymph node biopsy. According to the Ann Arbor system with Cotswald modifications, there are four stages of non-Hodgkin lymphoma based on the number of nodes and extra nodal involvement.
 
==Diagnostic study of choice==
==Diagnostic study of choice==
*The diagnostic study of choice for non-Hodgkin's lymphoma is excisional lymph node biopsy. An excisional biopsy is needed because it preserves the architecture of the lymph node and allows for precise determination of the type of lymphoma. Fine needle aspiration biopsy is insufficient. In addition to light microscopy evaluation of the excisional biopsy samples, the immunophenotypic analysis with immunohistochemistry helps to determine non-Hodgkin's lymphoma subtypes and distinguish non-Hodgkin's lymphoma from T cell rich large B cell lymphoma and anaplastic large cell lymphoma. The presence of CD20 positive clonal B cells defines non-Hodgkin lymphoma. Flow cytometry is an effective method in differentiating between Hodgkin's lymphoma and non-Hodgkin lymphoma, as well as subtypes of non-Hodgkin lymphoma.
*The diagnostic study of choice for non-Hodgkin's lymphoma is excisional [[lymph node biopsy]].<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
 
*An [[Biopsy|excisional biopsy]] is needed because it preserves the architecture of the [[lymph node]] and allows for precise determination of the type of lymphoma.  
*A bone marrow biopsy can also be done to diagnose non-Hodgkin lymphoma if there is sufficient evidence of marrow involvement (i.e. presence of cytopenias). Non-Hodgkin lymphoma cells originate in the bone marrow, which is the site of B cell production and maturation. A length of 2cm of the core biopsy is generally needed for diagnosis, which is in contrast to diagnostic requirements for leukemias. A bone marrow is not the diagnostic study of choice for Hodgkin lymphoma if a lymph node can be biopsied.
*[[Fine needle aspiration|Fine needle aspiration biopsy]] is usually insufficient.<ref name="pmid28332735">{{cite journal| author=Intragumtornchai T, Bunworasate U, Wudhikarn K, Lekhakula A, Julamanee J, Chansung K et al.| title=Non-Hodgkin lymphoma in South East Asia: An analysis of the histopathology, clinical features, and survival from Thailand. | journal=Hematol Oncol | year= 2018 | volume= 36 | issue= 1 | pages= 28-36 | pmid=28332735 | doi=10.1002/hon.2392 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28332735  }} </ref>
*In addition to light microscopy evaluation of the [[Biopsy|excisional biopsy]] samples, the immunophenotypic analysis with immunohistochemistry helps to determine non-Hodgkin's lymphoma subtypes and distinguish non-Hodgkin's lymphoma from T cell rich large B cell lymphoma and anaplastic large cell lymphoma.<ref name="pmid28332735">{{cite journal| author=Intragumtornchai T, Bunworasate U, Wudhikarn K, Lekhakula A, Julamanee J, Chansung K et al.| title=Non-Hodgkin lymphoma in South East Asia: An analysis of the histopathology, clinical features, and survival from Thailand. | journal=Hematol Oncol | year= 2018 | volume= 36 | issue= 1 | pages= 28-36 | pmid=28332735 | doi=10.1002/hon.2392 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28332735  }} </ref>
*The presence of [[CD20|CD20 positive]] clonal B cells defines non-Hodgkin lymphoma.<ref name="pmid25499449">{{cite journal| author=Casulo C, Burack WR, Friedberg JW| title=Transformed follicular non-Hodgkin lymphoma. | journal=Blood | year= 2015 | volume= 125 | issue= 1 | pages= 40-7 | pmid=25499449 | doi=10.1182/blood-2014-04-516815 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25499449  }} </ref>
*In about 40% of adult patients with non Hodgkin lymphoma, the extranodal sites are the primary presenting sites with the most common site being the Gastrointestinal tract.<ref name="pmid25499449">{{cite journal| author=Casulo C, Burack WR, Friedberg JW| title=Transformed follicular non-Hodgkin lymphoma. | journal=Blood | year= 2015 | volume= 125 | issue= 1 | pages= 40-7 | pmid=25499449 | doi=10.1182/blood-2014-04-516815 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25499449  }} </ref>
*A bone marrow (BM) [[biopsy]] can also be done to diagnose non-Hodgkin lymphoma if there is sufficient evidence of marrow involvement such as presence of cytopenias.<ref name="pmid25499449">{{cite journal| author=Casulo C, Burack WR, Friedberg JW| title=Transformed follicular non-Hodgkin lymphoma. | journal=Blood | year= 2015 | volume= 125 | issue= 1 | pages= 40-7 | pmid=25499449 | doi=10.1182/blood-2014-04-516815 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25499449  }} </ref>
*Non-Hodgkin lymphoma cells originate in the [[bone marrow]], which is the site of B cell production and maturation.
*Bilateral BM biopsy has been recommended with trephine biopsy being preferred to marrow aspiration for detecting marrow infiltration.<ref>Bartl R, Frisch B, Burkhardt R, Jδger K, Pappenberger R, Hoffmann-Fezer G. Lymphoproliferations in bone marrow: i0 dentification and evaluation, classification and staging. J Clin Pathol 1984;37:233-54.</ref><ref>Bain BJ, Clark DM, Lampert IA, Wilkins BS, editors. Bone marrow pathology. 3 rd ed. UK: Blackwell Science Ltd; 2001. </ref>
*BM biopsies, performed under [[local anesthesia]], were obtained using the conventional technique with a Jamshidi needle from the posterior superior iliac spines, fixed in 10% formalin solution and decalcified using 10% formal - formic acid for 4 - 6 h followed by routine processing and paraffin embedding.<ref>Culling CF, Allison RT, Barr WT. Connective tissue. In: Cellular Pathology Techniques. 4 th ed. London: Butterworth and Co. ltd; 1985. p. 172-3. </ref>


==Staging==
According to the Ann Arbor staging system with Cotswald modifications, there are four stages of non-Hodgkin lymphoma based on the number of nodes and extra nodal involvement. Staging for non-Hodgkin lymphoma is provided in the following table:<ref name="pmid28287948">{{cite journal| author=Bligh MP, Borgaonkar JN, Burrell SC, MacDonald DA, Manos D| title=Spectrum of CT Findings in Thoracic Extranodal Non-Hodgkin Lymphoma. | journal=Radiographics | year= 2017 | volume= 37 | issue= 2 | pages= 439-461 | pmid=28287948 | doi=10.1148/rg.2017160077 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28287948  }} </ref><ref name="pmid28378140">{{cite journal| author=Thacker N, Bakhshi S, Chinnaswamy G, Vora T, Prasad M, Bansal D et al.| title=Management of Non-Hodgkin Lymphoma: ICMR Consensus Document. | journal=Indian J Pediatr | year= 2017 | volume= 84 | issue= 5 | pages= 382-392 | pmid=28378140 | doi=10.1007/s12098-017-2318-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28378140  }} </ref>


{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+ '''Ann Arbor staging system'''
! style="background: #4479BA; color:#FFF;" | Stage
! style="background: #4479BA; color:#FFF;" | Involvement
|-
| colspan="3" style="padding: 5px 5px; background: #DCDCDC;" | '''stage I'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" | I
| style="padding: 5px 5px; background: #F5F5F5;" | One nodal group or lymphoid organ (e.g. spleen or thymus)
|-
| style="padding: 5px 5px; background: #F5F5F5;" | IE
| style="padding: 5px 5px; background: #F5F5F5;" | One extra nodal site
|-
| colspan="3" style="padding: 5px 5px; background: #DCDCDC;" | '''stage II'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" | II
| style="padding: 5px 5px; background: #F5F5F5;" | Two or more nodal groups, same side of diaphragm
|-
| style="padding: 5px 5px; background: #F5F5F5;" | II E
| style="padding: 5px 5px; background: #F5F5F5;" | Localized extra nodal site with stage II criteria, both on the same side of the [[Diaphragm (anatomy)|diaphragm]]
|-
| colspan="3" style="padding: 5px 5px; background: #DCDCDC;" | '''stage III'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" | III
| style="padding: 5px 5px; background: #F5F5F5;" | Nodal groups on both sides of the diaphragm
|-
| style="padding: 5px 5px; background: #F5F5F5;" | III S (1)
| style="padding: 5px 5px; background: #F5F5F5;" | With [[Spleen|splenic]] involvement
|-
| style="padding: 5px 5px; background: #F5F5F5;" | III E (2)
| style="padding: 5px 5px; background: #F5F5F5;" | With localized extra nodal site
|-
| style="padding: 5px 5px; background: #F5F5F5;" | III SE
| style="padding: 5px 5px; background: #F5F5F5;" | Both
|-
| colspan="3" style="padding: 5px 5px; background: #DCDCDC;" | '''stage IV'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" | IV
| style="padding: 5px 5px; background: #F5F5F5;" | Disseminated involvement of one or more extra lymphatic organ (e.g. lung, bone) +/- any nodal involvement
|-
| colspan="3" style="padding: 5px 5px; background: #DCDCDC;" | '''Additional staging variables'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" | X
| style="padding: 5px 5px; background: #F5F5F5;" | Bulky nodal disease: largest tumor is 10 cm or larger
|-
| style="padding: 5px 5px; background: #F5F5F5;" | A
| style="padding: 5px 5px; background: #F5F5F5;" | Asymptomatic
|-
| style="padding: 5px 5px; background: #F5F5F5;" | B
| style="padding: 5px 5px; background: #F5F5F5;" | Presence of B symptoms ([[fever]], [[night sweats]] and [[weight loss]])
|-
| style="padding: 5px 5px; background: #F5F5F5;" | E
| style="padding: 5px 5px; background: #F5F5F5;" | Extra nodal: other than the lymph nodes or spread to tissues beyond, but nearby, the lymphatic tissues
|-
| style="padding: 5px 5px; background: #F5F5F5;" | S
| style="padding: 5px 5px; background: #F5F5F5;" | Spleen
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Limited disease 
| style="padding: 5px 5px; background: #F5F5F5;" |
* Stage I or II<BR>
* No B symptoms<BR>
* Non-bulky tumor
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Advanced disease 
| style="padding: 5px 5px; background: #F5F5F5;" |
* Stage III or IV<BR>
* B symptoms<BR>
* Bulky tumor
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}


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Latest revision as of 20:50, 21 January 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]; Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[3]

Overview

The diagnostic study of choice for non-Hodgkin lymphoma is excisional lymph node biopsy. A bone marrow biopsy is an alternative to a lymph node biopsy. According to the Ann Arbor system with Cotswald modifications, there are four stages of non-Hodgkin lymphoma based on the number of nodes and extra nodal involvement.

Diagnostic study of choice

  • The diagnostic study of choice for non-Hodgkin's lymphoma is excisional lymph node biopsy.[1]
  • An excisional biopsy is needed because it preserves the architecture of the lymph node and allows for precise determination of the type of lymphoma.
  • Fine needle aspiration biopsy is usually insufficient.[2]
  • In addition to light microscopy evaluation of the excisional biopsy samples, the immunophenotypic analysis with immunohistochemistry helps to determine non-Hodgkin's lymphoma subtypes and distinguish non-Hodgkin's lymphoma from T cell rich large B cell lymphoma and anaplastic large cell lymphoma.[2]
  • The presence of CD20 positive clonal B cells defines non-Hodgkin lymphoma.[3]
  • In about 40% of adult patients with non Hodgkin lymphoma, the extranodal sites are the primary presenting sites with the most common site being the Gastrointestinal tract.[3]
  • A bone marrow (BM) biopsy can also be done to diagnose non-Hodgkin lymphoma if there is sufficient evidence of marrow involvement such as presence of cytopenias.[3]
  • Non-Hodgkin lymphoma cells originate in the bone marrow, which is the site of B cell production and maturation.
  • Bilateral BM biopsy has been recommended with trephine biopsy being preferred to marrow aspiration for detecting marrow infiltration.[4][5]
  • BM biopsies, performed under local anesthesia, were obtained using the conventional technique with a Jamshidi needle from the posterior superior iliac spines, fixed in 10% formalin solution and decalcified using 10% formal - formic acid for 4 - 6 h followed by routine processing and paraffin embedding.[6]

Staging

According to the Ann Arbor staging system with Cotswald modifications, there are four stages of non-Hodgkin lymphoma based on the number of nodes and extra nodal involvement. Staging for non-Hodgkin lymphoma is provided in the following table:[7][8]

Ann Arbor staging system
Stage Involvement
stage I
I One nodal group or lymphoid organ (e.g. spleen or thymus)
IE One extra nodal site
stage II
II Two or more nodal groups, same side of diaphragm
II E Localized extra nodal site with stage II criteria, both on the same side of the diaphragm
stage III
III Nodal groups on both sides of the diaphragm
III S (1) With splenic involvement
III E (2) With localized extra nodal site
III SE Both
stage IV
IV Disseminated involvement of one or more extra lymphatic organ (e.g. lung, bone) +/- any nodal involvement
Additional staging variables
X Bulky nodal disease: largest tumor is 10 cm or larger
A Asymptomatic
B Presence of B symptoms (fever, night sweats and weight loss)
E Extra nodal: other than the lymph nodes or spread to tissues beyond, but nearby, the lymphatic tissues
S Spleen
Limited disease
  • Stage I or II
  • No B symptoms
  • Non-bulky tumor
Advanced disease
  • Stage III or IV
  • B symptoms
  • Bulky tumor

References

  1. ↑ Jiang M, Bennani NN, Feldman AL (2017). "Lymphoma classification update: B-cell non-Hodgkin lymphomas". Expert Rev Hematol. 10 (5): 405–415. doi:10.1080/17474086.2017.1318053. PMID 28395545.
  2. ↑ 2.0 2.1 Intragumtornchai T, Bunworasate U, Wudhikarn K, Lekhakula A, Julamanee J, Chansung K; et al. (2018). "Non-Hodgkin lymphoma in South East Asia: An analysis of the histopathology, clinical features, and survival from Thailand". Hematol Oncol. 36 (1): 28–36. doi:10.1002/hon.2392. PMID 28332735.
  3. ↑ 3.0 3.1 3.2 Casulo C, Burack WR, Friedberg JW (2015). "Transformed follicular non-Hodgkin lymphoma". Blood. 125 (1): 40–7. doi:10.1182/blood-2014-04-516815. PMID 25499449.
  4. ↑ Bartl R, Frisch B, Burkhardt R, Jδger K, Pappenberger R, Hoffmann-Fezer G. Lymphoproliferations in bone marrow: i0 dentification and evaluation, classification and staging. J Clin Pathol 1984;37:233-54.
  5. ↑ Bain BJ, Clark DM, Lampert IA, Wilkins BS, editors. Bone marrow pathology. 3 rd ed. UK: Blackwell Science Ltd; 2001.
  6. ↑ Culling CF, Allison RT, Barr WT. Connective tissue. In: Cellular Pathology Techniques. 4 th ed. London: Butterworth and Co. ltd; 1985. p. 172-3.
  7. ↑ Bligh MP, Borgaonkar JN, Burrell SC, MacDonald DA, Manos D (2017). "Spectrum of CT Findings in Thoracic Extranodal Non-Hodgkin Lymphoma". Radiographics. 37 (2): 439–461. doi:10.1148/rg.2017160077. PMID 28287948.
  8. ↑ Thacker N, Bakhshi S, Chinnaswamy G, Vora T, Prasad M, Bansal D; et al. (2017). "Management of Non-Hodgkin Lymphoma: ICMR Consensus Document". Indian J Pediatr. 84 (5): 382–392. doi:10.1007/s12098-017-2318-0. PMID 28378140.
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