Question: Dr. Chiragbhai, thank you for explaining in last part about Hodgkin Disease Treatment. It really changed my thinking about hematological cancers. This cancer has such a high cure rate, even better than most solid tumors.
What about Non Hodgkin’s Lymphoma? Does it also have a very good prognosis?
Answer: Non Hodgkin’s Lymphoma (NHL) has many different types – over 30. Classification is evolving with more understanding of clinical, histological, molecular patterns. These diseases range from very indolent(slow growing) types which are just observed without therapy, to very aggressive ones like acute leukemia, and in between.
Que: What leads to NHL? What are the causes?
Ans: In most cases, they are not known. But some rare types are associated with viruses such as Hepatitis C or HHV or EBV, or bacteria such as H. pylori. Commonest types do not have a confirmed known etiology. Some are suspected to be associated with exposure to various chemicals such as pesticides. Some are related to chronic immune suppression, such as after kidney transplant.
Que: How do they present?
Ans: Once again, there is a wide variation depending on subtype. However, we will focus our discussion now onwards on common subtypes. NHL can be divided into two main categories: 1. B cell origin 2. T cell and NK cell origin.
They are also divided in three categories based on clinical behavior: many cases have a clinical behavior not matching these categories, for example a follicular lymphoma may occasionally have a rapid progression.
- Low grade: such as follicular, marginal zone etc
- Intermediate : such as DLBCL – diffuse large B cell lymphoma, mantle cell
- High grade: such as Burkitt’s
As the names suggest, low grade have a slow course and high grade have aggressive presentation. Low grade usually present with slow growing lymphadenopathy (sometimes with spontaneous reduction in size), with no other symptoms. High grade have rapidly enlarging lymphadenopathy, fever, weight loss, night sweats, and symptoms related to the organs they commonly infiltrate such as GI tract, lungs etc.
- Blood tests are not diagnostic, and may be entirely normal or may have high ESR, high LDH, anemia, high calcium, increased creatinine etc.
- Similarly USG, CT scan, MRI, PET-CT scans etc also are not diagnostic.
Que: How do we make diagnosis then?
Ans: Only way to diagnose lymphoma is by a BIOPSY. Generally, lymph node biopsy. As far as possible, whole lymph node should be removed for biopsy. For deep seated nodes, such as intra abdominal, a trucut biopsy may be allowed. FNAC (fine needle aspiration) should NOT be done to make a diagnosis of lymphoma or to exclude diagnosis of lymphoma. This is a very common error in clinical practice. Patients coming with a cervical lymph node undergo FNAC, reported as “reactive” or “possible TB” is common and is absolutely dangerous. I have seen several patients misdiagnosed in this manner and later present with advance disease.
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Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com