Makindo Medical Notes

Lymphoma is a group of blood cancers that arise from lymphocytes (B cells, T cells, or NK cells) in the lymphatic system, which plays a key role in immune defense. It is broadly classified into: Hodgkin Lymphoma (HL) defined by the presence of Reed-Sternberg cells, typically spreads in a contiguous nodal pattern. Non-Hodgkin Lymphoma (NHL) 🔵: A diverse group, ranging from indolent (e.g., follicular lymphoma) to highly aggressive (e.g., Burkitt lymphoma, diffuse large B-cell lymphoma).

Both types present with lymphadenopathy, but differ in pathology, spread, prognosis, and management.

🧬 Pathophysiology

• Lymphomas result from genetic mutations in lymphocytes → uncontrolled proliferation and failure of apoptosis.
• HL: Reed-Sternberg cells produce cytokines that attract inflammatory cells → classical “mixed inflammatory background.”
• NHL: More heterogeneous; B-cell lymphomas most common, but T-cell subtypes exist. Frequently associated with chromosomal translocations (e.g., t(14;18) in follicular lymphoma, t(8;14) in Burkitt lymphoma).
• Extranodal involvement (e.g., GI tract, skin, CNS, bone marrow) is much more common in NHL than HL.

⚖️ Comparison of Hodgkin vs Non-Hodgkin Lymphoma

Feature	Hodgkin Lymphoma (HL) 🟢	Non-Hodgkin Lymphoma (NHL) 🔵
Cell of Origin	B cells with Reed-Sternberg cells (large, abnormal binucleated cells).	B cells or T cells. Reed-Sternberg cells absent.
Age	Bimodal: 15–35 years & >55 years.	Any age; incidence ↑ with age.
Symptoms	Painless cervical/axillary lymphadenopathy. B symptoms: Fever, night sweats, weight loss. Pruritus, alcohol-induced pain.	Painless, often widespread lymphadenopathy. B symptoms less common but possible. Site-specific symptoms: abdominal pain (mesenteric nodes), cough/dyspnoea (mediastinal nodes).
Spread Pattern	Contiguous nodal spread.	Non-contiguous, unpredictable; extranodal disease common.
Subtypes	Classical HL (Nodular sclerosis, Mixed cellularity, Lymphocyte-rich, Lymphocyte-depleted).	B-cell (e.g., DLBCL, Follicular, Burkitt) or T-cell lymphomas.
Prognosis	Generally excellent; curable in majority with modern therapy.	Variable: indolent forms may be chronic; aggressive forms can be cured if treated promptly.
Treatment	Chemotherapy (ABVD regimen). Radiotherapy in early stages. Stem cell transplant for relapsed/refractory disease.	CHOP ± Rituximab (R-CHOP) for B-cell lymphomas. Targeted therapy (e.g., BTK inhibitors in mantle cell lymphoma). Stem cell transplant or CAR-T in select cases.

🔍 Diagnosis

• Excisional lymph node biopsy → gold standard. Fine needle aspirates are insufficient.
• Histology: look for Reed-Sternberg cells in HL.
• Immunophenotyping & flow cytometry → subclassify NHL.
• Staging: PET-CT scan for extent of disease.
• Bone marrow biopsy for staging in NHL.

📊 Staging (Ann Arbor System)

• Stage I: Single lymph node region or single extralymphatic site.
• Stage II: ≥2 nodal regions on same side of diaphragm.
• Stage III: Nodal regions on both sides of diaphragm.
• Stage IV: Disseminated involvement (e.g., bone marrow, liver).

🩺 Clinical Pearls

• HL often presents with alcohol-induced pain at lymph nodes — pathognomonic but rare.
• Always ask about B symptoms — these influence staging and prognosis.
• Pruritus and mediastinal mass are common red flags in HL.
• Extranodal disease (esp. GI, CNS, skin) → think NHL.

🧠 Reed-Sternberg Cell

🧾 Vignette 1 – Hodgkin’s Lymphoma

A 24-year-old woman presents with a painless lump in her neck for 3 months. She reports night sweats, weight loss, and intermittent fevers. Examination reveals a firm, rubbery, non-tender cervical lymph node. A chest X-ray shows a mediastinal mass.

• Key point: Young adult, “B symptoms,” mediastinal disease common.
• Histology: Reed–Sternberg cells (CD15+, CD30+).

🧾 Vignette 2 – Non-Hodgkin’s Lymphoma (Diffuse Large B-cell)

A 65-year-old man presents with rapidly enlarging axillary nodes and shortness of breath. He feels fatigued and unwell. Blood tests show elevated LDH and uric acid.

• Key point: Aggressive NHL, older adults, high cell turnover.
• Complication: Tumour lysis syndrome risk.

🧾 Vignette 3 – Non-Hodgkin’s Lymphoma (Indolent type, Follicular)

A 72-year-old woman presents with generalised lymphadenopathy picked up incidentally. She has no B symptoms and feels well. Blood tests are unremarkable.

• Key point: Slow-growing, indolent NHL, often widespread at diagnosis.
• Management: Sometimes “watch and wait” if asymptomatic.

📚 Summary

👉 Lymphoma = malignancy of lymphocytes. 🟢 HL: Reed-Sternberg, contiguous spread, bimodal age, good prognosis. 🔵 NHL: No RS cells, non-contiguous spread, variable behaviour, many subtypes. 💊 Treatment: chemo ± radiotherapy, immunotherapy, targeted therapy.

🧾 Clinical Case Examples – Lymphoma

Case 1 – Classic Hodgkin Lymphoma 🟢 A 22-year-old university student presents with a 3-month history of a painless lump in the left side of her neck. She has noticed drenching night sweats and has unintentionally lost 6 kg. Drinking alcohol causes pain in the swollen node. 👉 Likely diagnosis: Classical Hodgkin lymphoma. 👉 Key points: Reed–Sternberg cells on biopsy, mediastinal mass common, “B symptoms” present. 👉 Management: ABVD chemotherapy ± radiotherapy depending on stage.

Case 2 – Aggressive Non-Hodgkin Lymphoma (DLBCL) 🔵 A 67-year-old man presents with rapidly enlarging right axillary lymph nodes and breathlessness. He reports fatigue, fever, and weight loss. Bloods show raised LDH and uric acid. 👉 Likely diagnosis: Diffuse large B-cell lymphoma. 👉 Key points: Fast-growing, high cell turnover, risk of tumour lysis syndrome. 👉 Management: R-CHOP regimen, supportive care (allopurinol/rasburicase for TLS prevention).

Case 3 – Indolent Non-Hodgkin Lymphoma (Follicular) 🌀 A 74-year-old woman is found to have generalised, non-tender lymphadenopathy during a routine GP exam. She feels well and denies fever, sweats, or weight loss. 👉 Likely diagnosis: Follicular lymphoma. 👉 Key points: Indolent, often diagnosed incidentally, widespread at presentation. 👉 Management: “Watch and wait” if asymptomatic; R-CHOP or rituximab if progressive or symptomatic.

Case 4 – Extranodal NHL (GI tract) 🍽️ A 55-year-old man presents with abdominal pain, diarrhoea, and weight loss. Endoscopy shows a gastric mass, and biopsy confirms MALT lymphoma. 👉 Likely diagnosis: Extranodal marginal zone (MALT) lymphoma. 👉 Key points: Often linked with chronic H. pylori infection. 👉 Management: Eradication of H. pylori may induce remission; immunochemotherapy if refractory.

Case 5 – Paediatric Burkitt Lymphoma ⚡ An 8-year-old boy in sub-Saharan Africa presents with rapidly growing jaw swelling and night sweats. Biopsy confirms Burkitt lymphoma (t(8;14) translocation). 👉 Likely diagnosis: Endemic Burkitt lymphoma. 👉 Key points: Extremely aggressive, associated with EBV. 👉 Management: Urgent intensive chemotherapy; very chemo-sensitive but needs early intervention.

Case 6 – Immunocompromised Patient 🌡️ A 40-year-old man with untreated HIV presents with fever, sweats, and generalised lymphadenopathy. Excisional biopsy shows high-grade B-cell lymphoma. 👉 Likely diagnosis: HIV-associated NHL. 👉 Key points: Immunodeficiency increases NHL risk; often aggressive with extranodal disease. 👉 Management: HAART optimisation + chemotherapy (R-CHOP). Close infection monitoring.

Case 7 – Relapsed HL 🔄 A 30-year-old man treated for Hodgkin lymphoma at age 22 presents with new mediastinal lymphadenopathy. He reports cough and fatigue. 👉 Likely diagnosis: Relapsed Hodgkin lymphoma. 👉 Key points: Relapse years after remission; consider stem cell transplant if fit. 👉 Management: Salvage chemotherapy + autologous stem cell transplant.