Lymphoma

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Lymphoma refers to a group of blood cancers that specifically affect a type of white blood cell called the lymphocyte. Lymphocytes are present in blood and the lymphatic system, and function to defend the body against infection. When a person has lymphoma, lymphocytes divide at an abnormal rate and do not die when they should.

Types of Lymphoma

Types of Lymphoma

The two main types of lymphoma are:

  1. Non-Hodgkin lymphoma (NHL)
  2. Hodgkin lymphoma

Non-Hodgkin lymphoma (NHL) is the more common form of lymphoma. There are two types of lymphocytes – B lymphocytes and T lymphocytes. NHL develops mostly from B lymphocytes. They also do not show the presence of Reed-Sternberg cells. NHL has can happen at any age, and shows a non-contiguous spreading pattern.

Types of NHL are:

  • Diffuse large B cell lymphoma (most common type in adults)
  • Marginal zone lymphoma
  • Follicular lymphoma
  • T cell lymphoma
  • Mantle cell lymphoma
  • Hairy cell leukaemia
  • Burkitt lymphoma

Hodgkin lymphoma (HL) is less common than Non-Hodgkin lymphoma (NHL) and is characterized by the presence of Reed-Sternberg cells seen under microscopy. HL essentially develops in a localized chain of lymph nodes. The cervical lymphatic chain is frequently involved (neck nodes), although it can also develop in the mesenteric and paraaortic chains. It spreads contiguously (from one node to another, or to adjacent tissues) and rarely involves extra-nodal sites. HL also has a bimodal age distribution, generally differentiated into peak age groups of 15 to 34 years old, and those over 50 years.

The two main types of Hodgkin lymphoma are:

  1. Classical Hodgkin lymphoma which has 4 subtypes:
  • Nodular sclerosis classical Hodgkin lymphoma
  • Mixed cellularity classical Hodgkin lymphoma
  • Lymphocyte-rich classical Hodgkin lymphoma
  • Lymphocyte-depleted classical Hodgkin lymphoma
  1. Nodular lymphocyte-predominant Hodgkin lymphoma
Lymphoma Symptoms

The symptoms of both Hodgkin and non-Hodgkin lymphomas are:

  • Painless swollen lymph nodes in the neck, under the arms, or in the groin
  • Fever
  • Night sweats
  • Extreme fatigue
  • Unexplained weight loss
  • Difficulty getting over a common cold or an infection
  • Anaemia
  • Itching with or without a rash
Lymphoma Risk Factors

The exact cause of lymphoma is unknown. However, the possible risk factors of Hodgkin Lymphoma are:

  • Family history of lymphoma – Having a parent or sibling with the disease.
  • Compromised immune system – Having a compromised immune system from HIV/AIDS, or from immunosuppressants to prevent organ transplant rejection.
  • Age – There is a bimodal distribution of incidences, with peak age groups at 15 to 34 years old, and those over 50 years
  • Gender – More men and women get HL
  • Epstein-Barr virus infection (people who have had EBV infection may have a slightly increased risk to developing HL)

The known risk factors of Non-Hodgkin Lymphoma are:

  • Age – The risk of being diagnosed with non-Hodgkin lymphoma increases with age.
  • Gender – Men have a slightly greater chance of developing the disease than women.
  • Exposure to chemicals – People exposed to certain chemicals, such as exposure to pesticides, fertilizers, herbicides and insecticides, may be at risk.
  • Exposure to radiation – People exposed to nuclear or industrial sources may also increase risk.
  • Immune deficiencies – People with weak immune system for instance due to inherited conditions or HIV infection.
  • Human T-cell lymphotropic virus (HTLV-1) infection increases the risk of certain T cell lymphomas
  • Human herpes 8 virus infection also may predispose to a rare form of lymphoma
Lymphoma Staging

Staging is important to determine extent of spread and treatment options. The current staging system for HL and NHL is the Lugano classification/ Ann Arbor system.

Stage I – Either criteria mean Stage I

  • The lymphoma is in only 1 lymph node area or lymphoid organ.
  • The cancer is found only in 1 area of a single organ outside of the lymph system (IE).

Stage II – Either of the following

  • The lymphoma is in 2 or more groups of lymph nodes on the same side of (above or below) the diaphragm (the muscle that separates the chest cavity and abdomen).
  • The lymphoma is in a group of lymph node(s) and in one area of a nearby organ (IIE). It may also affect other groups of lymph nodes on the same side of the diaphragm.

Stage III – Either of the following

  • The lymphoma is in lymph node areas on both sides of (above and below) the diaphragm.
  • The lymphoma is in lymph nodes above the diaphragm, and in the spleen.

Stage IV – The lymphoma has diffused or disseminated into at least one or more organ outside the lymph system such as liver, bone marrow, pleura or cerebrospinal fluid.

Lymphoma Diagnosis

Diagnosis usually begins with a physical exam with the doctor checking for swollen lymph nodes and organs throughout the body to look for general signs of the disease.

  • Blood tests – A complete blood count (CBC) can be used to determine the levels of the platelet count or white blood cell count. If the levels are low, it may indicate that lymphoma is present in the bone marrow or blood.
  • Biopsy – A procedure to remove tissue samples, used to determine whether any of the tissue cells are cancerous or precancerous.
  • Computerized Tomography (CT) scan – X-rays and a computer is used to produce detailed pictures on tissue details, tumour size and extent of spread. A special dye called contrast medium will be administered to you to help improve the quality of the pictures.
  • Positron Emission Tomography-Computed Tomography (PET-CT) scan – PET-CT scan is an imaging test which a radioactive drug (radiotracer) is administered into the person to help reveal how the tissues and organs are functioning. The tracer will collect in the area that has higher levels of chemical activity, which corresponds to areas of the cancer. PET-CT scan may sometimes spot the cancer before it appears on other imaging tests.
  • Magnetic resonance imaging (MRI) – MRI uses a powerful magnetic field, radiofrequency pulses and a computer to produce detailed pictures of internal body structures. It is useful in detecting signs of central nervous system lymphoma which is a rare type of non-Hodgkin lymphoma (CNSL).

Lymphoma Treatments

Chemotherapy is a treatment option that involves the use of drugs given by injection or, occasionally, orally to prevent the cancer cells’ ability from dividing and reproducing. Chemotherapy treats cancer by penetrating the tissues and organs via the bloodstream. Chemotherapy drugs are toxic to the cancer cells but they may also cause some side effects to the normal tissues. The chemotherapy drugs work on the cells that are in the dividing stage, which causes the cells die off, but they have minimal effect on cells that are not dividing.

Immunotherapy is a type of treatment that uses the body’s immune system to fight cancer by stimulating the immune system to help it do its job more effectively. It uses molecular mechanisms and immunomodulating drugs to kill cancer cells or limit their growth

Types of Immunotherapy drugs used to treat lymphoma:
  • Rituximab is classified as a type of monoclonal antibody that will attach protein found on the surface of blood cells with cancer and by attaching to it would enable one’s own immune system to destroy the cancer cells as well as annihilating the cancer cells on its own.
  • Brentuximab is used to slow down or stop the growth of cancer cells.
  • Pembrolizumab is an immunotherapy drug used to block the PD-1 pathway which will help prevent cancer cells from hiding and enables the immune system to function as it meant to do thus detect as well as fight the cancer cells.
  • Nivolumab is used to treat adults with Classical Hodgkin Lymphoma (CHL) if the cancer has recurred or spread after stem cell transplant.
  • Polatuzumab vedotin is attaches to cancer cells in a targeted way and delivers vedotin to kill the cancer cell.

Targeted therapy – Targeted therapy works by acting on specific cellular processes by targeting cellular proteins to inhibit growth and development of cancer cells. Targeted lymphoma is more precise in treating lymphoma as compared to chemotherapy, which lowers the effect of treatment on healthy cells, reducing side effects of the treatment. Targeted therapy is able to:

  • Arrest the development of new blood vessels that feed the cancer cell
  • Trigger the immune system to attack the cancer cell
  • Change proteins within the cancer cell
  • Block or turning off signals telling the cancer cell to grow or divide
  • Carry toxins directly to the cancer cell

Chimeric Antigen Receptor T-cells (CAR T-Cell) – is genetically engineered to produce an artificial T-cell receptor, which give these T-cells the new ability to target a specific protein. The infused CAR T-cells may eradicate all of the cancer cells and may remain in the body months after infusion has been completed, providing immune-surveillance resulting in prolonged remission and survival.

Stem Cell or Bone Marrow Transplant – Inserts your own stem cells or a donor’s stem cells that have been collected through the bloodstream. Treatments like radiotherapy or chemotherapy has a high chance of killing lymphoma cells, but it may also kill your stem cells in your bone marrow in the process. After the treatment, the stem cells are inserted into your bloodstream through a drip. The cells will travel back to your bone marrow where they can start making blood cells again, and your bone marrow gradually recovers.

Hematopoietic stem cell transplantation (HSCT) is a method of infusing hematopoietic stem cells to restore bone marrow function in cancer patients.

Radiotherapy uses high doses of radiation to destroy lymphoma cells to prevent them from spreading or to shrink painful tumours in the spleen or lymph nodes. It is recommended for patients with poor functional status. This is a localized form of treatment, which means it only affects the part or parts of the body being treated. Lymphoma cells are much more sensitive to radiotherapy as compared to most other types of cancer cells. Therefore, the radiation dose used is usually relatively low to treat lymphoma, so side effects are often mild.

Halcyon Radiotherapy

Halcyon Radiotherapy System at Beacon Hospital enables:

  • Fast and precise X-ray dose delivered to each tumour with high accuracy over a minimum number of treatment sessions
  • Reduces unwanted radiation dose, thus, minimizing side effects

Unlike any other radiation delivery system, the Halcyon technology’s beam-on time could be as fast as 1-minute plus. Its gantry rotates 4 times faster than a standard linear accelerator and its multi-leaf collimator (MLC) can move twice faster than traditional MLCs. All of these features help towards improving the time it takes to treat the patients, making the patients feel more comfortable.

TrueBeam 2.7 Radiosurgery / Radiotherapy System

TrueBeam 2.7 Radiosurgery/Radiotherapy System at Beacon Hospital offers:

  • HyperArc™ High-Definition Radiotherapy and Radiosurgery

HyperArc™ high-definition Radiotherapy system represents a significant step forward for high quality Linac-based Radiosurgery, with an easy delivery of non-coplanar Stereotactic Radiosurgery (SRS) treatments. HyperArc™ could irradiate multiple tumours at the same time without repositioning the patient, which provides better management of patient motions while saving time for the patient and the clinical team. HyperArc™ ensures the planners achieve extremely compact dose distributions consistently and efficiently while maintaining patient safety.

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