Cram The Pance - S1E39 Hodgkin and Non Hodgkin Lymphoma

Episode Date: October 29, 2021

Lymphoma review for your Pance, Panre, and Eor's.►Paypal Donation Link: https://bit.ly/3dxmTql  (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so let's learn a little bit about lymphoma. There's not a crazy amount that you need to know for lymphoma, but there's definitely some high-eield things, some buzzwords that they like to bring up on the exam. So focus on the stuff you need to know, and I won't waste your time with the stuff. I don't think you do. As always, thank you so much for all of the really kind comments,

the support. I really do appreciate it. And I just wanted to thank you again for that. So let's go ahead and get started with lymphoma. First thing that I'm going to do is I'm going to break down the word lymphoma. So we can kind of understand what's going on here. So lymph stands for lymphocytes. OMA stands for tumor. So essentially we have a tumor derived from lymphocytes.

Now, what about Hodgkin versus non-Hodgkin? What's that all about? Well, all that means is either the presence or the absence of something known as Reed Sternberg cells. Hodgkins, you got Reitz-Sernberg cells, non-Hodgkin's, you don't. And that's basically it with non-Hodgkin and Hodgkin lymphoma. I'll go over Reed-Sternberg cells once we break down the individual diseases and talk a little bit more about that. All right. So with that being said, we have a basic understanding of what the actual terminology means. Let's start with Hodgkin lymphoma. I feel of the two, this one probably comes up a bit more on the exams. I feel like there's a few more of the buzzwords and things like that. So Hachkin lymphoma, this is a hematologic malignancy of mature B cells

originating in the lymphatic system. So B cell has this abnormal gene arrangement in these patients. And due to this abnormality, instead of the cell going through the regular apoptosis, the program cell death, living its life and then ceasing to exist. The cell decides not to do that anymore and divides uncontrollably, which leads to this neoplastic cell enlargement of the lymph nodes. And all of these other clinical manifestations will go over in a second. Now, what are you going to see in Hodgkin lymphoma? Like I just hung over before, you're going to have the presence of Reed Sternberg cells. That is pathonomotic for Hodgkin lymphoma. If you forget every other thing about lymphoma, do not forget Reed Sternberg cells,

Hodgkin lymphoma. That's super important. So it differentiates Hodgkin from non-Hodgkin is the presence of these cells. They're multinucon. Cells, usually they're binoculated. So two nuclei fuse together, and the two nuclei next to each other actually look like owlies. And that's why sometimes you'll hear these cells being referred to as having an ally appearance on microscopy. So remember that hot chicken has Reed-Stermberg cells, not hot chicken does not.

Little FYI, not important for the exam. But just so you know, it's possible to have the presence of a mononuclear variant of Reed Sternberg cells, and they're just called plain old hotchkin cells. just so you know that, a little bit of extra knowledge. Hodgkin lymphoma has a bimodal age distribution, meaning hodgekin lymphoma can be seen in young people and old patients. So it has a peak in late adolescence in young adulthood, and then a second peak in older adults.

Hodgekin lymphoma has a contiguous spread to local lymph nodes. This is a good thing. That's why it has the better prognosis between the two. So dissemination generally proceeds from a single lymph node region to an adjacent lymph node. So Hotchkin generally remains localized. That's a good thing. That's why the prognosis is generally better. Extranodal spread that will see a non-Hodgkin lymphoma that will go over later is very rare in Hotskin lymphoma. It doesn't usually spread. It spreads to the nearby lymph nodes. So slowly spreads to nearby adjacent lymph nodes, that contiguous spread as it's called, which gives it a better

prognosis. I know I said that like three times. Risk factors. So there's a few different risk factors. There's immunosuppression. There's a bunch of them. There's really only one I think you should commit to memory. And that's Epstein-Barr virus. So Epstein-Barr virus has an association with hot chicken lymphoma. It's usually something they like to mention in the vignette. So look out for this. In immunocompetent patients, healthy patients, it's not really that common. But in patients with HIV, AIDS, other immunosuppressive conditions, almost all cases of hotchicin lymphoma in this patient population are EVV-positive. So remember that, too. Now, types, just like in risk factors, there's a bunch of them. I don't think it's

important to know all of them. It's just not high yield, and I don't think it's going to come up. There's only one I would suggest committing to memory, and just because it's the most common type, not that there's anything special about it. And it's a variant of classic hodgement lymphoma known as nodular sclerosing. Most common type, close to 70% of the cases. Clinical manifestations, three things that you need to know. First one, the biggest one, and this is key for all of lymphoma, is non-tender lymphadenopathy. I'll say that again, tender lymphadenopathy. The neck being your most common sight to see this in Hodgkin lymphoma. So this is going to be your most common presentation for a patient with Hodgkin lymphoma.

It's seen in more than two-thirds of patients at presentation. The involved lymph nodes are usually going to have a firm, rubbery consistency. And again, that key, they're non-tender. And that's what separates it from reactive lymphadenopathy that's painful. And reactive lymphadenopathy, that's the type you see of an acute infection. So again, this is going to be non-tender. And as I mentioned before, the neck is going to be the most common sight of involvement in hotchigan lymphoma. Around 60 to 80 percent of patients have enlarged cervical or superclavicular nodes. One final interesting note about the non-tender lymphadenopathy that I went over. So patients with Hodgkin lymphoma, again, normally it's not going to hurt the lymphadenopathy that they have unless in some patients, they drink alcohol.

It's really bizarre. So patients with Hodgkin lymphoma that had that non-tender lymphadenopathy, even if they drink, a small amount of alcohol within minutes, the lymph nodes actually become painful. Only happens in about 10% of patients, but it's extremely specific when it's seen to hot chicken lymphoma. So that's just an interesting thing to note. Another thing that you need to know for clinical manifestations is going to be a medistinal mass.

This is usually discovered in a patient that comes in. They have some shortness of breath, retro sternal chest pain, a cough. You do a chest x-ray, and you discover a medial mass on a tuxinal mass. the chest x-ray. So that's another thing you may see in Hodgkin lymphoma. And then finally, this is another important one, B symptoms. So B as in boy symptoms, fever, night sweats, weight loss. So your constitutional or B symptoms, much more common in Hodgkin compared to non-Hodgkin lymphoma. And it's seen around 50% of patients with advanced disease. The B symptoms are caused by cytokine released from those malignant cells we talked about earlier. So again, B symptoms is something

else you may see in your patients, particularly in advanced disease, not so much early on. Diagnosis is pretty simple. There's two things you need to know, biopsy and imaging to stage it. So first you've cut it out to confirm the diagnosis. You have to do that obviously. And then you do some imaging to see how far along it is. So the biopsy part, you're going to do that with an excisional or incisional biopsy of the affected lymph node. You're not going to do a fine needle aspiration. That may be one of the answer choices, but that's not going to be your answer. Generally doesn't provide sufficient enough tissue. You normally have to do an excisional biopsy to get a good diagnosis.

So you find an effective lymph node, cut it out. And what are you looking for when you actually do the biopsy? I want you think about that for a second. Read Sternberg cells. That's the key. Those bi or multi-lobe nuclei that look like allies. And then you do your imaging. Normally it's going to be with a pet CT.

That's your staging. Once you've diagnosed with biopsy, you'll look for organ involvement and stage the lymphoma. Treatment, I don't think you're going to get a question on treatment. It's very advanced. There's so many different chemo regimens. It's just kind of outside of our scope of practice. and it's complicated. I really don't think they'll give you a question on it.

But with that being said, just know that when you have a patient with lymphoma, the standard treatment is going to be with chemo and radiation. Now, the most common chemo regimen for Hodgkin lymphoma is something the mnemonic is known as A, B, B, as in B, as in B, as in boy, V as in Verdi, and D as in dog. And that stands for adriomycin, which is the brand name for dachorubicin, bleomycin, finblastine, and da carbazine. So that's usually carried out for three to four cycles, followed by radiation therapy. Again, I don't think it's super important to know.

But if you remember it, it might maybe come up in a question if they want to be mean and give you that. So these regimens for Hodgkin lymphoma actually work really well. And over the past century, Hodgkin lymphoma went from being this relatively fatal to disease to one that's curable in around 75% of patients worldwide. The problem is, is with the treatment itself. So the majority of patients are going to be cured of their lymphoma, but there's so much treatment-related toxicities that's become a competing cause of late mortality.

So just another thing that's a little bit of extra knowledge for you, not that I feel like it's necessary for the exam. So Hachia lymphoma, there's a few things you need to know. How do I, or how have I come up? What's the way I'll have you remember that? What's a good way? So I came up with this mnemonic for you to remember Hodgeke and lymphoma. So what I want you to remember, what we went over before, Hotchial lymphoma is all about your B cells,

your B as in boy cells. Hotchial lymphoma is all about the B cells. So when you think of hotchial lymphoma, think of the letter B because it's about the B cells. First B stands for B cell malignancy. This is a B cell malignancy originating in the lymphatic system. Second B stands for B symptoms because they're more common in Hocke lymphoma, your fever, night sweats, etc. Third B stands for EBV infection. Remember the B in the middle. there, Epstein-Barr virus, EBV infection. Remember the relationship between Epstein-Barr infection and Hodgkin lymphoma. Next B stands for bin-nucleated cells. Remember those are your Reed-Sternberg cells, bi-nucleated cells that look like allies. Next B stands for bimodal distribution,

young and old. And then finally, the last B stands for bound in place. Because remember, it's usually localized. Extranodal spread is rare. It's bound in place. It's usually stuck, and it has that contiguous spread. All right, that is Hodgeke-Lymphoma. Let's move work our way down to non-Hodgkin lymphoma. So non-Hodgkin lymphoma is a heterogeneous group of malignancies of the lymphoid system derived from B-anty cells. Remember, we said in Hotschkin, it was basically a disease of B-cells, but non-Hodchkin can be of B-ant-T cells. B-cells being much more common, though, about 80 to 85%, but it can be seen in either. Now, key for non-Hodchkin lymphoma, absence of Reed-Sternberg cells. Remember, non-Hodgkin lymphoma, unlike Hodgkin, no Reed-Sternberg

cells are seeing in these patients. Next thing you need to know for this, it has a hematogynous or non-contiguous spread. That's bad. So in Hodgkin lymphoma, we discuss it usually spreads contiguously from local lymph node to the next local lymph node, which is why it has the favorable diagnosis between the two. But non-Hanskin, unfortunately, it can have this hematogynist spread, which means it's spread through the blood. And this is why we usually see a poor prognosis, because it can spread all over the body. You have this extranodal spread, particularly in the GI track, that's your most common area for it to spread to, but it can also spread to the brain, the skin.

And that's why sometimes you're going to see Hodgkin lymphoma being referred to as a type of leukemia because these abnormal cells escape the solid lymph nodes and they get into the bloodstream so it can actually become a type of leukemia. All right. Now, types, just like in Hodgkin, there's a bunch of different types of non-Hodgkin lymphoma. And unless you want to specialize in hematology, don't worry about memorizing all of them. There's only two that I think you might get tested on, and that's diffuse large B cell and Burkitt lymphoma.

Emphasis being on Burkitt lymphoma, since it seems to come up the most. And there's a bunch of buzzwords you need to know for it. Now, diffuse large B cell, the only thing I think you should know about this is that it's your most common subtype. There's really nothing else to know about it. It is very aggressive, and it accounts for around 25% of adult non-hotogen lymphoma cases. So remember, diffuse large B cell, that's your most common non-Hodgkin lymphoma. that's about all you need to know about that.

Now, Burkitt lymphoma, on the other hand, there's a few things you need to know. If you're going to remember one thing about non-hotoccal lymphoma, I would say remember burkitt lymphoma. That always seems to come up on exams. Now, what do you need to know about berkitt lymphoma? So, one, on biopsy, it has what's known as a starry sky appearance. Definitely remember that. So this is caused from these numerous benign macrophages, these histocytes, they've ingested

tumor cells and they're called tingible body macrophages. They're darker on appearance. Don't worry about why. They're not going to ask you why, but I just wanted to kind of throw that in so you have an idea. So don't worry so much about what creates the starry sky appearance. Just know that if you see mentioned a starry sky appearance on a biopsy right away. Be thinking Burkitt lymphoma. Next thing, Epstein bar virus. So in Burkitt lymphoma, chronic Epstein bar virus infection plays a really big role, particularly in the endemic African type of Burkitt lymphoma. So EBV, big time role here. And then the third thing, the endemic African subtype I just went over can present as a jaw or facial bone tumor in up to 60% of cases. So this doesn't really

sound like it's that important, but it definitely comes up. So remember that Burkitt, the African subtype can have this jaw or facial bone malignancies, the swelling. And if you look at pictures on Google, it's, it's very impressive, how large the swelling, how bad the swelling can be. Anyway, so those are the three things I think you should remember. Now, how do you remember that? So I have this way, this visual. It works out a lot better if I could show you a picture, but obviously I can't. This is a podcast.

So you're just going to have to kind of be creative and I'm going to paint a picture in your head. So you have Burkitt lymphoma. As soon as you see Burkitt lymphoma, I don't want you to remember Burkitt lymphoma. I want you to remember Bercite lymphoma. K-I-T-E, like the kite you fly in the sky. So as soon as you see Bercite, think of Bercite lymphoma. I want you to think of somebody kite surfing in the middle of the ocean.

I don't know if you've ever seen that where they hold onto that bar and they're on that little surfboard thing and they have a big kite in the middle of the sky and they're kite surfing. So as soon as you see Bercite lymphoma, think of Bercite lymphoma and think of a guy kite sailing in the middle of the ocean. Now he's kite surfing in the middle of the ocean and it's the middle of the night. Pitch black, dark, all you see is stars in the sky. So you see Birk, kit lymphoma, think Berk kite, kite sailing in the middle of the night,

starry sky appearance. That's your first thing to remember. Next, he's in the middle of the ocean. All of a sudden, he looks around him. He's being circled by a big, great white shark, not just any great white shark, but it's jaws. Jaws from the movie. I'm sure we all know who Jaws is.

Jaws, remember, jaw malignancies in the endemic African subtype. That helps you remember the jaw malignancy that you'll see in these patients. If you've ever seen somebody kite surfing, you see they hold on to that big bar to control the kite. That's actually called a control bar. So you see them holding a big bar in the middle of the ocean controlling the kite that helps you remember Epstein Bar virus. And then finally, remember that shark that was swimming around jaws. Well, if you look up on Google, this is true. I'm not making it up.

Most shark attacks actually occur off of the coast of Africa, specifically South Africa. That helps you remember the endemic African type that's related to the jaw swelling in the Epstein bar virus. So again, for kit lymphoma, you right away think of burkite lymphoma. A guy is kite surfing in the middle of the ocean, pitch black, dark, starry sky appearance. All of a sudden, he's being circled by a shark. That's jaws, jaw malignancy. He's holding a big bar controlling the kite. That helps you remember Epstein bar virus. And finally, the reason there's a shark there is because he's in the most populated area of sharks. And that's off the coast of Africa. That helps you remember your endemic African type. I know that's a lot to remember, but if you just put that visual in your

head you might remember it worst case if you see burkeet you just remember burkeye and think of a kite flying in the middle of a dark sky you remember starry sky appearance that might be enough to get it right there so but hopefully you remember the other stuff it always helped me i never forgot that visual um even though i've never seen non-hotchkin lymphoma in you know in practice um obviously because i work in endocrinology so i don't really see that ever so but i've never forgotten that visual all right let's move on to clinical manifestations big one as always like i said anytime we're talking about lymphoma always be thinking non-tender lymphoma always be thinking adepathy. So lymphadenopathy, generally firm and painless. It's going to present in more than

two-thirds of patients with non-Hodgkin lymphomaat presentation. Same as in Hodgkin. But what you need to focus on for clinical manifestations outside of that, again, like I went over before, is your extra nodal involvement. Now, extranotal, again, this is spreading. Now, where are you most commonly going to see this? I went over this before. GI track. That's going to be your most common area. So again, this is something that's more common in non-Hodgkins. That wasn't common in Hodgkin lymphoma because Hodgkin lymphoma was bound in place. Remember, that's one of your bees with a contiguous spread. Non-Hodgkin can travel and spread throughout the body, non-contiguously. Again, most commonplace, GI tracts. So they may present with a bowel obstruction. Skin is going to be

your second most common area for it to spread to. So make sure you always examine skin very carefully in these patients biopsy anywhere. They have any suspicion for the presence of lymphoma. And then finally, in male patients with non-Hodgkin lymphoma, they may have spread to the testicles. So they may have testicular non-hachial lymphoma that constitutes about 1% of all cases in males. So again, be aware non-Hodgkin can spread main area on the exam, again, to look out for is the GI tract. Now, you may have noticed I didn't mention B symptoms. So does that mean patients with non-Hodgkin lymphoma don't have B symptoms?

Does not mean that at all. But for the sake of the exam, sometimes you remember things for the exam that's going to be different than real life. And this is one of those cases. So you can have B symptoms in non-hachial lymphoma. It's more common in Hodgachia. So if you see B symptoms on an exam question, be thinking Hodgkin lymphoma rather than non-Hodgkin, more common in Hodgkin.

Diagnosis, same thing as in Hodgkin lymphoma. Cut it out, biopsy, stage it with imaging again. So do your excisional biopsy and then go ahead and do your staging with PET-C-T, nice and simple. Treatment, again, I don't think they're going to give you a question on treatment. But remember, it's going to be chemo radiation and what is the most common type of chemo you're going to do with non-hotic lymphoma? This is going to be a mnemonic called R. R-chop, C-H-O-P.

So what does that stand for? Rituximab, cyclophomide, hydroxydan Rubicin, which is another, I guess, I think, a brand name for dachorubicin, Ancovorin, which is the brand name for Vin-Cristin, and then Prednis-Zone. So that's what R-CHOP stands for. You're probably not going to remember all those I would never tell you to. But if they did give you a question and you remember R-CHOP, you might be able to figure it out on the answer choices. All right, so what do you need to know for your non-hachial lymphoma?

there's really three things I think you should focus on. One, of course, is the absence of Reed-Stermberg cells. Two is the extra nodal involvement. Remember the GI track being the most common. And then finally, remember your Burkitt, aka Burkite lymphoma. Okay. So I just want to really quickly go over side-by-side Hodgkin versus non-Hodgkin, focusing on some of the keys just to wrap this up.

So again, Hodgkin, presence of Reed-Sternberg cells. Non-Hodgkin, no-Ridlundberg cells. Hachkin, contiguous spread. That's a good thing. non-Hodgkin non-contiguous spread. That's a bad thing. Hot-kin lymphoma, be thinking B symptoms. Non-Hodgkin lymphoma, remember B symptoms not as common.

They can still happen, though. Hachial lymphoma, most common type is your nodular sclerosing. Non-hachial lymphoma, most common type is your diffuse large B cell. Hotchial lymphoma, if we're going to remember a chemo, remember the ABVD regimen, non-Hodgulimoma, R-CHOP regimen. And then finally, Hodgkin lymphoma, EBV is common to have. And a non-haggial lymphoma, if you see it on a question, you should be thinking burkitt lymphoma. If you see EBV on non-hajsic lymphoma, right away be thinking burkitt.

Okay, let's do five questions and wrap it up. Question one, 32-year-old male presents to the office today with pain and swelling in his jaw for the past few months. Upon a potemptating history from the patient, he learned he recently moved here from South Africa about six months ago. Should already kind of know what this is. On physical exam, non-tender, submandibular and axillary lymph nodes are palpated, and a large mass is visualized. on the right lower side of the mandible. The lymph nodes are biopsyed, which display large, bright histocytes scattered throughout a background of darker basophilic tumor cells, almost creating the appearance of stars in

a dark sky. What is the likely diagnosis in this patient? I hope you get a question that has as many buzzwords as I threw in that question. So obviously, that's not that difficult. I'm sure you were able to realize that's Burkitt lymphoma. You have a patient that recently moved from Africa, which we know is the endemic form of brachate lymphoma. He describes jaw pain.

We know 60% of cases of endemic, Burkate lymphoma involved that jaw on facial bones, non-tender lymphadenopathy on exam. And then finally, that starry sky appearance on biopsy, all key findings of burkate lymphoma, which is a subtype remember of non-hotachial lymphoma. Do not forget your burkite lymphoma

and that visual I gave you. Question two, what is the most common type of hot skin lymphoma? That is going to be nodular sclerosing, most common type in about 70% of cases of the classic Hachkin lymphoma. Question three, large by or multinucleated cells sometimes referred to as having an owl eye appearance on histology.

Commonly seen in Hotschkin lymphoma are known as, that's an easy one, Reed-Sternberg cells. Question four, a 22-year-old female presents to the office today complaining of persistent fever and unexplained weight loss. On physical exam, non-tender lymph adenopathy is noted. Biopsy is obtained out the affected lymph nodes revealing Reed-Stermberg cells. Painless lymph nodes palpated on an exam were likely located in which part of the body in this patient. And that would be the neck, the cervical, the superclivicular region.

So this patient has Hodgkin lymphoma, evident by the non-tender lymphadenopathy, the B symptoms. And then, of course, all you needed was those Reed-Sternberg cells. That's all you needed them to tell you pathonomonic for hodgem lymphoma. And remember, in hodchic lymphoma, the neck is the most common site for lymphadenopathy, with 60 to 80 percent of patients having enlarged cervical or cervical or. superclivicular nodes. Question 5. A 57-year-old female presents to the office to review the recent results of her imaging

tests she had done after being diagnosed with non-hoccal lymphoma. The results of the PET CT reveal that the lymphoma has spread, which area of the body will likely show extranodal involvement on the PET CT? So that is going to be the GI tract. Remember, that's the most common site of extranotal disease in non-hachial lymphoma is the gastrointestinal tract. And remember again, of course, extranatal disease is much more common. not Hodgkin lymphoma compared to Hodgkin lymphoma, where extra nodal spread is rare.

All right, that is lymphoma. Please let me know if it's helpful or if there's any suggestions you have for me in future podcasts. And if you haven't checked out the YouTube channel yet, please do. I have a lot of good visuals to go along with the audio. And thank you so much for listening. And good luck on your pants, your panery, your EORs, and good luck in PA school.