Lymphomas can start almost anywhere in the body, but with modern advances in diagnosis, imaging studies and availability of targeted drugs, the outlook for patients has improved tremendously
Lymphomas are cancers originating from the lymphatic cells of the immune system, typically seen as solid tumours. The lymphatic system is part of the body’s immune system and helps fight infections and other diseases. Because lymphatic tissue is found in many parts of the body, lymphomas can start almost anywhere. In 1832, Thomas Hodgkin, a British pathologist published the first description of lymphoma, a specific form which is named after him as ‘Hodgkin Lymphoma’.
Since then many other forms of lymphoma have been described, all grouped under a single label ‘non-Hodgkin lymphoma’.However, the latest lymphoma classification by the WHO (2008) considers the ancient arrangement obsolete because the different lymphomas grouped under NHL have very little in common with each other. Hence the NHL label is slowly being abandoned considering its minimal relevance.
Causes and risk factors
The cause of this cancer is unknown for most patients. However, lymphomas may develop in people with a weakened immune system such as in organ transplant patients on immunosuppressive drugs or HIV infection. Certain viruses such as HTLV-1 (Human T Cell Leukemia/ Lymphoma Virus), hepatitis C, and Epstein-Barr virus seem to directly affect the DNA of the lymphocytes and help transform them into cancer cells. Helicobacter pylori, a type of bacteria known to precipitate stomach ulcers causes chronic immune system stimulation and has been associated with Mucosa Associated Lymphoid Tissue (MALT) lymphoma of the stomach. Although NHL can affect all age groups, the chance of developing this disease increases with age.
They may vary depending on the location of the tumour in the body. The most common symptoms are enlarged painless lymph nodes in the armpit, neck or in the groin. Others include fever, night sweats, weight loss, breathlessness and abdominal distention.
A biopsy of the tumour is the only way to confirm NHL. Excisional or incisional biopsy of the tumour is usually done if a lymphoma is suspected. A needle biopsy (FNA) is usually not preferred, as it might not draw an adequate sample to make a definite diagnosis. A bone marrow aspiration and biopsy is usually done not to confirm the diagnosis but to stage the disease. It helps to determine if the disease has infiltrated the bone marrow.
Biopsy samples are sent for histopathological examination. Other tests like immunohistochemistry, now cytometry and cytogenetics are essential to establish a definite diagnosis. Immunohistochemistry is the method by which we can examine the cells and determine what antigens are expressed on the surface of the cells by using antibodies that bind to those antigens.
We can also determine how Stem cells removed from donor strongly those antigens are expressed. This will help determine the type of lymphoma with a far greater accuracy, which will aid the treating physician to decide on appropriate treatment and management.
Fluorescent in situ hybridization (FISH) testing is used to look for specific changes in a chromosome such as trans-location and to visualise specific genes or portion of genes aiming at a more accurate diagnosis. Imaging studies like CT scan, Gallium scan and PET scan are useful tools in detecting and monitoring the disease. One must understand that none of these scans can diagnose NHL without histopathological evidence.
In recent years, there has been much progress in treating non-Hodgkin lymphoma. The treatment options for people with NHL depend on the type and its stage, as well as the other prognostic factors of the disease. One of the most common combinations of drugs used in chemotherapy is called CHOP. This includes the drugs cyclophosphamide, doxorubicin, vincristine (oncovin) and prednisolone. Another common combination leaves out doxorubicin and is called CVP.
Antibodies are proteins made by the body’s immune system to help fight infections. Monoclonal antibodies are man made substitutes designed to attack a specific target, on the surface of lymphocytes.
Several monoclonal antibodies are being used now to treat NHL:
- Rituximab is an antibody that attaches to a substance called CD20 found on some types of lymphoma cells.
- Alemtuzumab is an antibody directed at the CD52 antigen and used for some types of peripheral T cell lymphomas.
- Ofatumubab is another monoclonal antibody that targets CD 20 antigen and is used mainly when chemotherapy, rituximab and alemtuzumab do not work.
Stem cell transplants are sometimes used to treat lymphoma patients who are in remission or who have a relapse during or after treatment. These are of two types:
- Allogeneic stem cell transplant: The stem cells come from someone else. The donor’s tissue type (also known as the HLA type) should be almost identical to the patient’s tissue type to help prevent the risk of major problems with the transplant. The stem cells are usually collected from the bone marrow, peripheral blood or umbilical cord blood.
- Autologous stem cell transplant: The patient’s own stem cells are removed from his or her bone marrow or peripheral blood on several occasions. The cells are frozen and stored while the person gets treatment (high-dose chemotherapy and/or radiation), and are then re-infused into the patient’s blood.
Cure is possible
With modern advances in diagnosis, imaging studies and availability of targeted drugs, the outlook for patients diagnosed with non-Hodgkin lymphoma has improved tremendously. The patients respond well to treatment and cure rates have increased significantly. More and more patients are cured of the disease forever, and many others are achieving long-term survival.
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