Nodular lymphocyte predominant Hodgkin lymphoma

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Nodular lymphocyte predominant Hodgkin lymphoma
Popcorn cell in nodular lymphocyte predominant Hodgkin lymphoma - very high mag cropped.jpg
Micrograph of a lymph node biopsy showing nodular lymphocyte predominant Hodgkin lymphoma, with the Reed–Sternberg cell variant that has a popcorn-shaped nucleus (left-bottom of image). H&E stain.
Specialty Hematology and oncology
Frequency0.1-0.2 cases / 100000 per year

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is a slow-growing CD20 positive form of Hodgkin lymphoma, a cancer of the immune system's B cells. [1] [2]

Contents

NLPHL is an uncommon sub-type of Hodgkin lymphoma, making up 5-10% of Hodgkin lymphomas. [3] It is distinguished from classic Hodgkin lymphoma by the presence of CD20 positive lymphocyte predominant cells, also known as popcorn cells due to their polylobated nuclei, which look like popcorn. [3] [4] [5]

There are small but clear differences in prognosis between the various forms. Lymphocyte predominant HL is an uncommon subtype composed of vague nodules of numerous reactive lymphocytes admixed with large popcorn-shaped RSC. Unlike classic RSC, the non-classic popcorn-shaped RS cells of NLPHL are CD15 and CD30 negative while positive for the B cell marker CD20. The anti-CD20 monoclonal antibody Rituximab has been used in lymphocyte predominant Hodgkin lymphoma with encouraging results. [6]

BCL6 gene rearrangements have been frequently observed. [7] [8]

Signs and symptoms

B symptoms are uncommon. [9] [4]

Diagnosis

Hodgkin lymphoma, nodular lymphocyte predominant (low power view). Notice the nodular architecture and the areas of "mottling". (H&E) Hodgkin lymphoma, nodular lymphocyte predominant - low power view - H&E - by Gabriel Caponetti.jpg
Hodgkin lymphoma, nodular lymphocyte predominant (low power view). Notice the nodular architecture and the areas of "mottling". (H&E)
Hodgkin lymphoma, nodular lymphocyte predominant (high power view). Notice the presence of LP cells, also known as "popcorn cells". (H&E) Hodgkin lymphoma, nodular lymphocyte predominant - high power view - H&E - by Gabriel Caponetti.jpg
Hodgkin lymphoma, nodular lymphocyte predominant (high power view). Notice the presence of LP cells, also known as "popcorn cells". (H&E)

The characteristics of NLPHL differ from classical Hodgkin lymphoma (cHL). [9] Lymphocyte predominant (LP) ("popcorn") cells are present embedded in nodules consisting of B cells [10] and other reactive cells (mainly reactive T cells). [9] Reed-Sternberg and Hodgkin (RSH) cells are rarely seen, and immunohistochemistry shows a different pattern on the malignant cells; RSH cells typically express CD15 and CD30, whereas LP cells lack expression of these markers, but express B cell markers like CD20, CD22, and CD79a and also express the common leukocyte antigen CD45, which is uncommon on RSH cells. [9] The LP cells have scant cytoplasm and one folded or multilobated nuclei with prominent, mostly basophilic nucleoli. [10] Expert pathology review of multiple morphologic and immunophenotypic features [10] including the use of immunohistochemistry is essential. [11] [12]

Tumors generally located in the peripheral lymph nodes, [13] which can be detected via PET scan and CT scan.

Ann Arbor staging is used to classify tumors and symptoms. Stage IV disease is very rare. [14]

Sex

There is a male predominance of NLPHL diagnosis. [9] [15] [14]

Early detection

Diagnosis usually occurs at an early stage of disease progression. [9] [15] [14]

Management

A treatment guide provided by NCCN Guidelines for Patients is available, [16] while the NCCN Clinical Practice Guidelines in Oncology provides a reference for clinicians. [17] Any proposed therapeutic strategy must have minimal acute and long-term toxicities. [15]

Watchful waiting

Watchful waiting (watch and wait) is defined as a period of observation of at least 3 months without any treatment. [18]

Surgical excision

Surgical lymph node excision may be carried out at the time of diagnosis in certain cases such in children diagnosed at an early stage of progression. [15] One study found sustained complete remission in half of the cases with a watch-and-wait strategy after surgical lymph node excision at the time of diagnosis. [15]

Radiation therapy

Studies indicate that radiation therapy (radio therapy) may reduce the risk of progression in adults. [18] [11] In one study, stage I-II patients treated with radiation therapy showed 10-year cause-specific survival of 98%, and the rate of developing radiotherapy-related second malignancies was not increased by the treatment (1% after 10 years). [19] A study published in 2013 on large group of patients with early-stage NLPHL indicated support for using limited-field radiation therapy as the sole treatment of early-stage disease. [11] In a study of 1,162 NLPHL patients from the Surveillance, Epidemiology and End Results (SEER) cancer registry program, radiation therapy improved overall survival and disease specific survival. [20]

Immunotherapy

An example antibody for use in immunotherapy is Rituximab. Rituximab has specific use in treatment of NLPHL as it is a chimeric monoclonal antibody against the protein CD20. [18] Studies indicate Rituximab offers potential in relapsed or refractory patients, [21] and also in front-line treatment [4] especially in advanced stages. [15] Because of a tendency for relapse, maintenance treatment such as every 6 months for 2 years is suggested. [14] Rituximab has been shown to improve patient outcomes after histological transformation. [22]

Chemotherapy

Possible options such as anthracycline-containing regimens include ABVD, BEACOPP and CHOP. [18] Results of a trial with COPP/ABV in children suggested positive results with chemotherapy alone are possible without the need for radiation therapy. [23] Optimal chemotherapy is a topic for debate, for example there is evidence of support for treatment with R-CHOP instead of ABVD, results showing high rates (40%) of relapse after 10 years since ABVD chemotherapy. [14] BEACOPP has higher reported toxicity risk. [24]

Combined treatment

One study reported combined radiation therapy (radio therapy) and antibody Rituximab. [18] R-CHOP optionally followed by radiation therapy is recommended in newly diagnosed late stage disease, while for early stage disease radio therapy alone (stage IA without risk factors) or a brief ABVD-based chemotherapy followed by radiation therapy (early stages other than stage IA without risk factors) was advised. [24]

Prognosis

Prognosis is favourable in comparison with classic HL [20] despite a tendency for disease recurrence requiring long term followup. [15] [14] Relapse can occur at a comparatively late stage in comparison to classic HL. [14] There is limited information regarding the outcome for patients with advanced-stage progression. [14]

Ethnicity

One study in the United States has suggested improved overall survival in response to chemotherapy for African Americans. [25]

Histological transformation

Histologic transformation to diffuse large B-cell lymphoma (DLBCL) can occur in up to 12% of cases. [15] After transformation, neoplastic cells carry monoclonal immunoglobulin gene rearrangements. [15] Histological transformation may lead to poor prognosis [14] and therefore repeat biopsy is required at relapse. [15] One study found a transformation rate of 7.6%, and suggested that prior exposure to chemotherapy and a presentation with splenic involvement were associated with increased risks of transformation. [22]

See also

Related Research Articles

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Non-Hodgkin lymphoma (NHL), also known as non-Hodgkin's lymphoma, is a group of blood cancers that includes all types of lymphomas except Hodgkin lymphomas. Symptoms include enlarged lymph nodes, fever, night sweats, weight loss, and tiredness. Other symptoms may include bone pain, chest pain, or itchiness. Some forms are slow-growing while others are fast-growing.

<span class="mw-page-title-main">Lymphoma</span> Hematologic cancer that affects lymphocytes

Lymphoma is a group of blood and lymph tumors that develop from lymphocytes. The name typically refers to just the cancerous versions rather than all such tumours. Signs and symptoms may include enlarged lymph nodes, fever, drenching sweats, unintended weight loss, itching, and constantly feeling tired. The enlarged lymph nodes are usually painless. The sweats are most common at night.

<span class="mw-page-title-main">Chronic lymphocytic leukemia</span> Medical condition

Chronic lymphocytic leukemia (CLL) is a type of cancer in which the bone marrow makes too many lymphocytes. Early on, there are typically no symptoms. Later, non-painful lymph node swelling, feeling tired, fever, night sweats, or weight loss for no clear reason may occur. Enlargement of the spleen and low red blood cells (anemia) may also occur. It typically worsens gradually over years.

<span class="mw-page-title-main">Anaplastic large-cell lymphoma</span> Medical condition

Anaplastic large-cell lymphoma (ALCL) refers to a group of non-Hodgkin lymphomas in which aberrant T cells proliferate uncontrollably. Considered as a single entity, ALCL is the most common type of peripheral lymphoma and represents ~10% of all peripheral lymphomas in children. The incidence of ALCL is estimated to be 0.25 cases per 100,000 people in the United States of America. There are four distinct types of anaplastic large-cell lymphomas that on microscopic examination share certain key histopathological features and tumor marker proteins. However, the four types have very different clinical presentations, gene abnormalities, prognoses, and/or treatments.

<span class="mw-page-title-main">Rituximab</span> Pharmaceutical drug

Rituximab, sold under the brand name Rituxan among others, is a monoclonal antibody medication used to treat certain autoimmune diseases and types of cancer. It is used for non-Hodgkin lymphoma, chronic lymphocytic leukemia, rheumatoid arthritis, granulomatosis with polyangiitis, idiopathic thrombocytopenic purpura, pemphigus vulgaris, myasthenia gravis and Epstein–Barr virus-positive mucocutaneous ulcers. It is given by slow injection into a vein. Biosimilars of Rituxan include Blitzima, Riabni, Ritemvia, Rituenza, Rixathon, Ruxience, and Truxima.

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<span class="mw-page-title-main">Follicular lymphoma</span> Medical condition

Follicular lymphoma (FL) is a cancer that involves certain types of white blood cells known as lymphocytes. The cancer originates from the uncontrolled division of specific types of B-cells known as centrocytes and centroblasts. These cells normally occupy the follicles (nodular swirls of various types of lymphocytes) in the germinal centers of lymphoid tissues such as lymph nodes. The cancerous cells in FL typically form follicular or follicle-like structures (see adjacent Figure) in the tissues they invade. These structures are usually the dominant histological feature of this cancer.

<span class="mw-page-title-main">MALT lymphoma</span> Medical condition

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<span class="mw-page-title-main">Diffuse large B-cell lymphoma</span> Type of blood cancer

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<span class="mw-page-title-main">Hodgkin lymphoma</span> Type of blood and immune-system cancer

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