S1E39 Hodgkin and Non Hodgkin Lymphoma

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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 gonna do is I'm gonna break down the word Lymphoma. So we can kind of understand what's going on here. So Lymphoma, Lymph stands for lymphocytes. Olma 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 Reed Sternberg cells. Non-Hodgkins, 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 Hodgkin 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 and large enough to 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 went over before, you're going to have the presence of Reed Sternberg cells that is pathodomonic for Hodgkin lymphoma. If you forget every other thing about lymphoma, do not forget Reed Sternberg cells. Hodgkin lymphoma, that's super important. So a differentiates Hodgkin from non-Hodgkin is the presence of these cells. They're multi-nucleated cells, usually they're bi-nucleated. So two nuclei fuse together, and the two nuclei next to each other actually look like allies. And that's why sometimes you'll hear these cells being referred to as having an ally appearance on microscopy. So remember that Hodgkin has Reed Sternberg cells non-Hodgkin. There's 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 Hodgkin cells, just so you know that little bit of extra knowledge. Hodgkin lymphoma has a bi-modal age distribution, meaning Hodgkin lymphoma can be seen in young people and old patients. So it has a peak in late adolescence and young adulthood, and then a second peak in older adults. Hodgkin 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 Hodgkin generally remains localized. That's a good thing. That's why the prognosis is generally better. Extra nodal spread that we'll see in non-Hodgkin lymphoma that we'll go over later is very rare in Hodgkin lymphoma. It doesn't usually spread. It spreads to the nearby lymph node. 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 bar virus. So Epstein bar virus has an association with Hodgkin lymphoma. It's usually something they like to mention in the vignettes. 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 Hodgkin 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 Hodgkin 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, non-tender lymphadenopathy. The neck being your most common site 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 2/3 of patients at presentation. The involve 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 in 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 site of involvement in Hodgkin lymphoma. Around 60% to 80% of patients have in large cervical or superclivicular 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 Hodgkin 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 media-stinal 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 media-stinal mass on the chest x-ray. So that's another thing you may see in Hodgkin lymphoma. And then finally, this is another important one, B-symptom. 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, it doesn't provide sufficient enough tissue. You normally have to do an excisional biopsy to get a good diagnosis. So you find an affected lymph node, cut it out, and what are you looking for when you actually do the biopsy? I want you to 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 in staging 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 pneumonic is known as ABVD. So A is an apple, B is an boi, B is in verde, and D is in dog. And that stands for adriamysin, which is the brand name for ducts. Arubisin, bleomysin, binblastine, and decarbazine. 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, the 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 has 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 Hodgkin 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 Hodgkin lymphoma. So whatever you'd remember, what we're going over before, Hodgkin lymphoma is all about your B cells, your B as in boy cells. Hodgkin lymphoma is all about the B cells. So. when you think of Hodgical 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 Hodgical lymphoma, your fever, night sweats, et cetera. 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 in Hodgical lymphoma. Next B stands for by nucleated cells. Remember those are your Reed-Sturmberg cells, by your multi nucleated cells that look like allies. Next B stands for by-modal distribution, young and old. And then finally, the last B stands for bound in place because remember, it's usually localized. Extra nodal spread is rare. It's bound in place. It's usually stuck and then has that contiguous spread. All right, that is Hodgical lymphoma. Let's work our way down to non-Hodgical lymphoma. So non-Hodgical lymphoma is a heterogeneous group of malignancies of the lymphoid system derived from B anti-cells. So remember we said in Hodgical lymphoma is basically a disease of B cells. But non-Hodgical can be of B anti-cells. B cells being much more common though, about 80% to 85%. But it can be seen in either. Now key for non-Hodgical lymphoma, absence of Reed-Sturmberg cells. Remember non-Hodgical lymphoma? Unlike Hodgical, no Reed-Sturmberg cells are seen in these patients. Next thing you need to know for this, it has a hematogenous or non-contiguous spread, that's bad. So in Hodgical lymphoma, we discuss the usually spreads continuously from local lymph node to the next local lymph node, which is why it has the favorable diagnosis between the two. But non-Hodgical, unfortunately, it can have this hematogenous 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 extra nodal spread, particularly in the GI tract. 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 Hodgical 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 Hodgical, there's a bunch of different types of non-Hodgical 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-Hodgical lymphoma cases. So remember, diffuse large B cell, that's your most common non-Hodgical 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. You're going to remember one thing about non-Hodgical lymphoma. I would say remember Burkitt lymphoma. It always seems to come up on exams. Now, what do you need to know about Burkitt 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 histiocytes, they've ingested tumor cells, and they're called tingeable 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 malignancy disease, the swelling. And if you look up pictures on Google, 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 can 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 Burkitt lymphoma, kite, k-i-t-e, like the kite you fly in the sky. So as soon as you see Burkitt, think of Burkitt 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 Burkitt lymphoma, think of Burkitt 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 Burkitt lymphoma, think Burkitt, 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. Next thing, if you've ever seen somebody kite surfing, you see they hold onto that big bar to control the kite. That's actually called a control bar. So you see him 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 they're swimming around jaws? Well, if you look up on Google, this is true. I'm not making it up. Most shark attacks actually curve 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, Burkitt lymphoma. You right away think of Burkitt 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 Burkitt, you just remember Burkitt 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. Even though I've never seen non-hodgkin lymphoma in practice, obviously, because I work in endocrinology so I don't really see that ever. 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 lymphatinopathy. So lymphatinopathy generally firm and painless. It's going to present in more than two thirds of patients with non-hodgkin lymphoma 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, extra nodal, again, this is spreading. Now, where are you most commonly going to see this? I went over this before GI tract. 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-continuously, again, most common place, GI tract. So they may present with a bowel obstruction. Skin is going to be your second most common area for it to spread to. So we make sure you always examine skin very carefully in these patients by FC anywhere. They have any suspicion for the presence of lymphoma. And then finally, in male patients with a non-Hodgkin lymphoma, they may have spread to the testicles. So they may have to stick your non-Hodgkin 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 bee symptoms. So does that mean patients with non-Hodgkin lymphoma don't have bee 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 bee symptoms in non-Hodgkin lymphoma. It's more common in Hodgkin. So if you see bee 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 at stage with imaging again. So do your exigenal biopsy and then go ahead and do your staging with PET CT. 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-Hodgkin lymphoma? This is going to be a mnemonic called R-Chop. R-Chop, CHOP. So what is that stand for? Or Tuxamab, Cyclophosphamide, Hydroxyden Rubicin, which is another, I guess I think, a brand name for Dr. Rubicin. Uncle Vorin, which is the brand name for Vin Christine. And then Prednisone. 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-Hodgkin lymphoma? There's really three things I think you should focus on. One, of course, is the absence of Reed-Sturmberg cells. Two is the extra nodal involvement. Remember the GI tract being the most common. And then finally, remember your Burkit aka Burkit lymphoma. OK. 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. up. So again Hodgkin presence of reed sternbrick cells, non Hodgkin, no reed sternbrick cells. Hodgkin contiguous spread, that's a good thing, non Hodgkin non contiguous spread. That's a bad thing. Hodgkin lymphoma be thinking B symptoms, non Hodgkin lymphoma remember B symptoms not as common, they can't still happen though. Hodgkin lymphoma, most common type is your nodular sclerosing, non Hodgkin lymphoma most common type is your diffuse large B cell. Hodgkin lymphoma if we're gonna remember a chemo, remember the ABVD regimen, non Hodgkin lymphoma, our chop regimen and then finally Hodgkin lymphoma, EBV is common to have and a non Hodgkin lymphoma if you see it on a question you should be thinking Burkitt lymphoma if you see EBV a non Hodgkin lymphoma right away, be thinking Burkitt. Okay, let's do five questions and wrap it up. Question one, 32-year-old male presents at the office today with pain and swelling in his jaw for the past few months. Pondomptating history from the patient, you 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 sub mandibular and axillary lymph nodes are palpated and a large mass is visualized on the right lower side of the mandible. The lymph nodes are biopsy, which is displayed 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. Have a patient that most recently moved from Africa, which we know is the endemic form of Burkitt lymphoma. He describes jaw pain, we know 60% of cases of endemic Burkitt lymphoma evolved at Sean facial bones, non tender lymph at an opathy on exam, and then finally that starry sky appearance on biopsy, all key findings in Burkitt lymphoma, which is a subtype remember of non-hodgkin lymphoma, do not forget your Burkitt lymphoma and that visual I gave you. Question two, what is the most common type of Hodgkin lymphoma that is going to be nodular sclerosing, most common type in about 70% of cases of the classic Hodgkin lymphoma. Question three, large bi or multi-nucleated cells, sometimes referred to as having an owl eye appearance on histology, commonly seen in Hodgkin lymphoma are known as, that's an easy one, Reed Sternberg cells. Question four, a 22-year-old female presents at the office today complaining of persistent fever and unexplained weight loss on physical exam, non-tender lymph at an opathy is noted, biopsy is obtained out the affected lymph nodes revealing Reed Sternberg cells, painless lymph nodes palpate on an exam were likely located in which part of the body in this patient. And that would be the neck, the cervical, the superclavicular region. So this patient has Hodgkin lymphoma evident by the non-tender lymph at an opathy, the B symptoms, and then of course all you needed was those Reed Sternberg cells, that's all you needed them to tell you path into monochronochron lymphoma. And remember in Hodgkin lymphoma the neck is the most common sight for lymph at an opathy with 60 to 80% of patients having enlarged cervical or superclavicular nodes. Question five, a 57-year-old female presents at the office to review the recent results of her imaging tests she had done after being diagnosed with non- Hodgkin lymphoma. The results of the PET CT reveal that the lymphoma has spread, which area of the body will likely show extra nodal involvement on the PET CT. So that is going to be the GI tract. Remember that's the most common sight of extra nodal disease in non- Hodgkin lymphoma is the gastrointestinal tract. And remember again of course extra nodal disease is much more common in non- 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 and future podcasts. And if you haven't checked out the YouTube channel yet, please do 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 pantry, your EORs, and good luck in PA school. "Winning never sounded so good. What would you do if you won big?" At Crown Coins Casino, real people win real prizes every single day. "Hi this is Michael from Georgia I 140K and finally renovated my home." Visit crowncoins.com. Sign up in seconds, enter code Crown and get a free link in the description box below. Sign up in seconds, enter code Crown and get a free lucky wheel bonus. Crowncoins.com. That's C-R-O-W-N coins.com. 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