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SOURCE

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Source: Chan A, Sessions J. Lymphomas. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=133894009. Accessed April 13, 2017.

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DEFINITION

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  • Heterogeneous group of lymphoproliferative disorders.

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ETIOLOGY

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  • Unknown.

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PATHOPHYSIOLOGY

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  • Derived from monoclonal proliferation of malignant B or, less commonly, T lymphocytes and their precursors.

  • Current classification schemes characterize Non-Hodgkin lymphomas (NHLs) according to cell of origin, clinical features, and morphologic features.

  • World Health Organization (WHO) classification terms:

    • Grade refers to histologic parameters such as:

      • Cell and nuclear size.

      • Density of chromatin.

      • Proliferation fraction.

    • Aggressiveness denotes clinical behavior of a tumor.

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EPIDEMIOLOGY

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  • Fifth most common cause of newly diagnosed cancer in the United States.

  • Average age at diagnosis: 67 years.

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RISK FACTORS

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  • Certain infections associated with development of lymphoma:

    • EBV: Burkitt lymphoma.

    • Kaposi sarcoma-associated herpes virus (KSHV)

    • Human T-cell lymphotropic virus type 1: adult T-cell leukemia/lymphoma.

  • Congenital and acquired immunodeficiency states.

  • Exposure to herbicides, chemical solvents, and dyes.

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CLINICAL PRESENTATION

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  • Patients present with variety of symptoms, which depend on site of involvement and whether nodal or extranodal.

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SIGNS AND SYMPTOMS
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  • Adenopathy can be localized or generalized.

    • Involved nodes painless, rubbery, and discrete, and usually located in cervical and supraclavicular regions.

  • Constitutional (B symptoms) in ~40% of patients.

    • Fever.

    • Drenching night sweats.

    • Weight loss.

  • Extranodal disease in 10–35% of patients at diagnosis.

    • Mesenteric or gastrointestinal (GI) involvement:

      • Nausea.

      • Vomiting.

      • Obstruction.

      • Abdominal pain.

      • Palpable abdominal mass.

      • GI bleeding.

    • Bone marrow involvement:

      • Anemia.

      • Neutropenia.

      • Thrombocytopenia.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Pathologic review of tissue obtained by excisional biopsy of involved lymph node.

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LABORATORY TESTS
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  • Metabolic panel.

  • Complete blood count (CBC)

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IMAGING
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  • Chest radiography.

  • Computed tomography (CT) of abdomen and pelvis.

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DIAGNOSTIC PROCEDURES
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  • Excisional lymph node biopsy.

  • Bone marrow aspiration and biopsy.

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STAGING
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  • Systems for classifying NHLs continue to evolve.

    • Slow-growing or indolent lymphomas have favorable outcomes (untreated survival measured in years).

    • Rapid-growing or aggressive lymphomas have unfavorable outcomes (untreated survival measured in weeks to months).

  • International Prognostic Index (IPI) for aggressive lymphomas.

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DIFFERENTIAL DIAGNOSIS
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DESIRED OUTCOMES

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  • Relieve symptoms and, whenever possible, cure patient of disease while minimizing risk of serious toxicity.

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TREATMENT: GENERAL APPROACH

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  • Therapy depends on many factors, including:

    • Patient age.

    • Histologic type.

    • Stage and site of disease.

    • Presence of adverse prognostic ...

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