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{{Non-Hodgkin lymphoma}}  
{{Non-Hodgkin lymphoma}}  
{{CMG}} {{shyam}}; {{AE}} {{Preeti}}
{{CMG}} {{shyam}}; {{AE}} {{Preeti}}


==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.<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>
*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 excisional biopsy is needed because it preserves the architecture of the lymph node and allows for precise determination of the type of lymphoma.  
*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.  
*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>  
*[[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 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>
*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 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>
*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>
*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>  
*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.
*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>
*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>  
*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}}

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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