Chapter 9: Lymphoma W & L Chapter 29
22. Which treatment field for HD includes the iliac lymph node chain? a. mantle b. inverted-Y (Abdominal portion) c. inverted-Y (Pelvic portion) d. all of the above
ANS: C Included in the inverted Y field are the retroperitoneal, common iliac, and inguinal lymph nodes.
12. What stage is a Hodgkin lymphoma with extralymphatic extension? a. stage I b. stage II c. stage III d. stage IV
ANS: D As defined by the AJCC, stage IV Hodgkin's disease is defined as disease with extension to extralymphatic tissues.
What is the largest lymph organ?
The spleen
RT Early side effects?
hair loss, sore throat, skin erythema, dysphagia
What is the RT for NHL?
it is very sensitive to radiation are much more lethal
What are the 3 different tonsils?
pharyngeal tonsils (adenoids) in nasoparynx palatine tonsils are in posterior lateral wall of oropharynx Lingual tonsils are at the base of the tongue in oropharynx
Which nodes are included in the inverted Y field? 1. Retroperitoneal 2. common iliac 3. inguinal 4. popliteal
1,2,3
The lymphatic system consists of: 1. Fluid 2. Vessels 3. Arteries 4. Organs 5. Nodes
1,2,4,5 fluid, vessels, organs, nodes
What are the major lymph node chains involved with Hodgkins? HD
1. Waldeyer's ring (tonsillar lymphatic tissue surrounding nasopharynx and oropharynx) cervical, preauricular, occipital lymph nodes 2. Supraclavicular and infraclavicular lymph nodes 3. axillary lymph nodes 4. thorax (hilar and mediastinal nodes) 5. abdominal cavity (including para-aortic) 6. pelvic cavity (iliac nodes) 7. inguinal and femoral lymph nodes
How does Non-Hodgkin's lymphoma differ from Hodgkins?
1. occur primarily in older persons; median age is 67 2. they can originate in the lymph nodes or in extranodal tissue 3. more likely to spread randomly, rather than orderly 4. multiple sites are often involved and extranodal lesions are common 5. prognosis of NHL is strongly dependent on the specific histology 6. NHLs encompass a wide variety of diseases
How many NSHL patients will present with B symptoms?
1/3
Lymphomas are the 3rd most common childhood malignancy accounting for what %
10% of all childhood cancers 2/3 of these are NHL
What is the epidemiology of Hodgkin lymphoma?
2008 stats- 8220 new cases; 1350 will die less than 1% of newly diagnosed cancer male over female ratio
What is the suggested dose for local control of NHL?
35 to 45 Gy
Where is the thoracic duct?
35 to 45 cm in length and begins in front of the second lumbar vertebra (L2) and is called the cisterna chyli
What is the median age for NHL?
65; peaking age 80 to 84
Although the median age to get NHL is 67 when does the incidence actually peak?
80 to 84
What is the overall survival of HD?
90% due to advanced treatment
HD occurs in younger people of what age?
< 40 median age is 38
What two groups is HD subdivided into?
A or B groups Fever, night sweats, weight loss will be indicated as B symptoms (eg IIB) B symptoms indicate worse prognosis
What is the standard treatment for Hodgkins today?
ABVD chemo regimen alone or in combination with radiation 30 - 36 Gy to just the involved lymph node region
CNS and gastric lymphomas in NHL are 60 times more common in patients with?
AIDS than the general population
18. Which treatment field for HD includes the axillary lymph node chain? a. mantle b. inverted-Y (Abdominal portion) c. inverted-Y (Pelvic portion) d. all of the above
ANS: A A mantle field is illustrated in Figure 29-3. It includes all major lymph node regions above the diaphragm: submandibular, occipital, cervical, supraclavicular, infraclavicular, axillary, hilar, and mediastinal.
19. Which treatment field for HD includes the cervical lymph node chain? a. mantle b. inverted-Y (abdominal portion) c. inverted-Y (pelvic portion) d. all of the above
ANS: A A mantle field is illustrated in Figure 29-3. It includes all major lymph node regions above the diaphragm: submandibular, occipital, cervical, supraclavicular, infraclavicular, axillary, hilar, and mediastinal.
23. Which treatment field for HD includes the mediastinal lymph node chain? a. mantle b. inverted-Y (Abdominal portion) c. inverted-Y (Pelvic portion) d. all of the above
ANS: A A mantle field is illustrated in Figure 29-3. It includes all major lymph node regions above the diaphragm: submandibular, occipital, cervical, supraclavicular, infraclavicular, axillary, hilar, and mediastinal.
7. What landmark is typically used to determine the lower border of the mantle field? a. T10 b. T12 c. carina d. xyphoid
ANS: A A mantle field is illustrated in Figure 29-3. It includes all major lymph node regions above the diaphragm: submandibular, occipital, cervical, supraclavicular, infraclavicular, axillary, hilar, and mediastinal. Anteriorly, the superior border is at the inferior portion of the mandible, and the inferior border is at the level of the insertion of the diaphragm (usually around T10). REF: Chapter 29, Lymphoreticular System Tumors, p. 615
15. What is the most common presenting symptom of HD? a. painless mass b. headache c. persistent cough d. dysphagia
ANS: A Hodgkin lymphoma usually appears as a painless mass that the patient discovers.
9. What stage is a Hodgkin lymphoma affecting only the right cervical lymph nodes? a. stage I b. stage II c. stage III d. stage IV
ANS: A The Ann Arbor staging system has been the accepted method of classification for Hodgkin disease since 1971. According to the Ann Arbor system, stage I is demonstrated by involvement of a single lymph node region (I) or localized involvement of a single extralymphatic organ or site in the absence of any lymph node involvement (IE) (rare in Hodgkin lymphoma).
3. The spleen is commonly associated with which of the following blood cell types? a. Red blood cells b. B-cell lymphocytes c. T-cell lymphocytes d. macrophages
ANS: A The spleen filters the blood similar to the way that lymph nodes filter lymphatic fluid, but through the action of its phagocytes, it destroys damaged red blood cells and the remains of ruptured cells carried in the bloodstream.
2. In what general anatomical location is Waldeyer ring located? a. mouth b. anus c. small intestine d. axilla
ANS: A Waldeyer ring is a grouping of lymph nodes in the oropharynx (mouth).
5. The abdominal para-aortic treatment portal includes what organ(s)? a. kidneys b. spleen c. pancreas d. liver
ANS: B AP/PA radiation to the subdiaphragmatic lymph nodes includes the para-aortic nodes and the spleen (or the splenic pedicle if the spleen had been removed).
25. Which lymphoma is most common in young African males? a. T-cell lymphoma b. Burkitt lymphoma c. Hodgkin disease d. follicular lymphoma
ANS: B Burkitt lymphoma is common in Africa but rare in other countries, although patients with acquired immunodeficiency syndrome (AIDS) tend to get this form of lymphoma.
10. Which stage is a Hodgkin lymphoma affecting two lymph node groups on the same side of the diaphragm? a. stage I b. stage II c. stage III d. stage IV
ANS: B The Ann Arbor staging system has been the accepted method of classification for Hodgkin's disease since 1971. According to the Ann Arbor system, stage II is demonstrated by involvement of two or more lymph node regions on the same side of the diaphragm.
20. Which treatment field for HD includes the para-aortic lymph node chain? a. mantle b. inverted-Y (Abdominal portion) c. inverted-Y (Pelvic portion) d. all of the above
ANS: B The most common treatment of the subdiaphragmatic fields is the treatment of the para-aortic nodes and the spleen or splenic pedicle when no evidence of subdiaphragmatic disease is present.
26. Which of the following organs is most closely associated with the lymphatic system? a. heart b. spleen c. pancreas d. liver
ANS: B The spleen is the largest lymphatic organ.
6. What is the standard dose delivered for the treatment of NHL? a. 1600 to 2000 cGy b. 2600 to 3000 cGy c. 3000 to 4500 cGy d. 4600 to 5000 cGy
ANS: C Although exact doses will vary, most NHLs that are treated with radiation therapy receive doses between 30 Gy and 45 Gy.
14. What stage is a Hodgkin lymphoma that involves SCV lymph nodes and the spleen? a. stage I b. stage II c. stage III d. stage IV
ANS: C As defined by the AJCC, stage III Hodgkin's disease has nodal involvement on both sides of the diaphragm and can be accompanied by splenic involvement. When the spleen is involved in the disease, it meets the criteria for stage III.
11. What stage is a Hodgkin lymphoma affecting the hilar nodes and the periaortic nodes? a. stage I b. stage II c. stage III d. stage IV
ANS: C As defined by the AJCC, stage III Hodgkin's disease has nodal involvement on both sides of the diaphragm. The hilar nodes are located above the diaphragm and the periaortics are located below, thus meeting the criteria for stage III.
16. Which of the following chemotherapy regimens is not used to treat Hodgkin's disease? I. CHOP II. MOPP III. ABVD a. I and II b. I and III c. II and III d. I, II, and III
ANS: C CHOP is useful in the treatment of NHL, but not HD.
17. Which treatment field for HD includes the inguinal lymph node chain? a. mantle b. inverted-Y (abdominal portion) c. inverted-Y (pelvic portion) d. all of the above
ANS: C Included in the inverted Y field are the retroperitoneal, common iliac, and inguinal lymph nodes.
21. Which treatment field for HD includes the retroperitoneal lymph node chain? a. mantle b. inverted-Y (Abdominal portion) c. inverted-Y (Pelvic portion) d. all of the above
ANS: C Included in the inverted Y field are the retroperitoneal, common iliac, and inguinal lymph nodes.
4. The thymus is commonly associated with which of the following blood cell types? a. red blood cells b. B-cell lymphocytes c. T-cell lymphocytes d. macrophages
ANS: C The thymus contains large numbers of lymphocytes (called thymocytes), most of which remain inactive. However, some thymocytes develop into T lymphocytes.
13. What is the most common long-term side effect of total lymphoid irradiation? a. skin erythema b. dysphagia c. secondary malignancy d. developmental anomalies
ANS: C Treatment-related second malignancies can be a long term side effect as the use of ionizing radiation can cause cellular changes that manifest as cancer.
8. What landmark is typically used to determine the lower border of the abdominal portion of the inverted-Y field? a. L1-2 b. L2-3 c. L3-4 d. L4-5
ANS: D The inferior border is typically L4 or L5 or below the bifurcation of the aorta.
24. Which lymph node chain is more likely to be the original site of Hodgkin lymphoma? a. pelvic b. inguinal c. para-aortic d. axillary
ANS: D The most common sites of presentation are in the neck and supraclavicular regions. Mediastinal masses are usually detected on a radiograph of the chest. Most patients have the disease above the diaphragm.
27. Which of the following is not a B symptom? a. weight loss b. night sweats c. fever d. diarrhea
ANS: D Unexplained fevers (over 38° C, or 100.4° F), drenching night sweats, and weight loss of 10% of body weight in 6 months are referred to as B symptoms.
1. A mantle field is used to treat which type of cancer? a. mycosis fungoides b. multiple myeloma c. non-Hodgkin lymphoma (NHL) d. Hodgkin disease (HD)
ANS: D When found in lymph nodes above the diaphragm, HD is treated using a mantle field.
5. NHLs are highly curable.
ANS: F Although cure rates for individual NHLs will vary and some may be less aggressive, NHLs are not typically considered highly curable.
4. NHLs are adequately staged using the Ann Arbor staging system.
ANS: F Although the Ann Arbor system is most commonly used for the staging of NHLs, it is not completely satisfactory. In contrast to Hodgkin's lymphoma, many patients with NHL have advanced disease. The Ann Arbor system also fails to account for bulky disease, which plays a significant role in lymphomas because many patients have advanced disease but experience relatively long survival. Although the diaphragm plays an important role in the staging of HD, it is insignificant in the progression of lymphomas. Therefore, a major factor in the Ann Arbor system is inconsequential in NHLs.
1. Follicular lymphoma is the most common form of NHL.
ANS: F NHLs can be histopathologically classified as follicular (or nodular) and diffuse, with 40% appearing as follicular and 60% as diffuse.
7. The presence of Reed-Sternberg cells in NHL is part of the factors that distinguish these tumors from HD.
ANS: F Reed-Sternberg cells are present in Hodgkin lymphomas.
3. Infections with certain viruses are a risk factor for HD.
ANS: T Burkitt lymphoma is caused by the Epstein-Barr virus. Serologic (blood) studies have shown an association between human T-cell leukemia/lymphoma virus (HTLV-1) and T-cell leukemia/lymphoma.
2. HD can be treated with mantle, para-aortic, and inverted-Y fields.
ANS: T HD can be treated with mantle, para-aortic, and inverted-Y fields (sometimes the para-aortic field is included as part of the overall term "inverted-Y"). REF: Chapter 29, Lymphoreticular System Tumors, pp. 613-616
6. The incidence of NHL is higher than that of HD.
ANS: T The National Cancer Institute estimates that approximately 8220 individuals will be diagnosed with Hodgkin lymphoma in 2008. An estimated 66,120 new cases of NHL will be diagnosed in 2008.
NHL may arise in a. Lymph nodes b. GI tract c. Waldeyer ring
All of them
Which of the following might describe non-Hodgkins lymphoma? 1. originates in lymph nodes or in extranodal tissue 2. most likely to spread randomly 3. commonly arising in GI tract
All of them
What is the most common staging system for lymphomas?
Ann Arbor
What are the borders of RT for Hodgkins lymphoma?
Anterior-superior border is at the inferior portion of mandible Inferior - is at the level of insertion of diaphragm (T10) Posterior - the superior border includes the occipital nodes and the inferior border is the same as it is anteriorly (T10) Laterally - axilla nodes are included
exact cause of NHL are largely unknown, but lymphomas are genetic alterations of?
B or Tlymphocytes cells
What is the most common type of NHL?
B-type lymphocytes (B cells)
What is the hematopoietic system made up of?
Blood lymphatic tissue bone marrow spleen
Irradiation is the primary treatment modality for the majority of patients with early stages of Hodgkin disease. T or F
Both-RT used to be but because of late effects chemo is being used as primary along with RT
What are some NHL chemo combinations?
CHOP (cyclophosphamine, doxorubicin, vincristine, prednisone MACOP-B (methotrexate, doxorubicin, cyclophopshamide, vincristine, bleomycin, predinsone
Every region of the body that has blood supply has these lymphatic capillaries. What are the exceptions?
CNS and bone marrow are avascular
What is the primary treatment for both HD and NHL?
Chemotherapy combination chemo is used carefully to limit the risk of known latent effects, such as the development of leukemia (AML) and infertility
What is the more common histologic NHL type?
Diffuse - 60% B or T cell origin runs a more aggressive course spreading quickly to other nodes and extranodal sites increased involvement in bone marrow and Waldeyer ring
What are the 3 types of blood cells?
Erythrocytes(RBC) Leukocytes (WBC) Thrombocytes (platelets)
What are the NHL histologic classifications?
Follicular (nodular) Diffuse
What is the other histologic NHL type?
Follicular (nodular) 40% B cell origin it runs an indolant course with prolonged survival (5-7 years) usually appear below diaphragm and involve mesenteric lymph nodes usually not found in children; do not commonly invovle the Waldeyer ring
What is the most common extranodal NHL lymphoma?
GI tract lymphoma
Which type is bimodal, HD or NHL?
HD is bimodal and occurs in two age groups; 15-40 years old and over 55
What are the 2 main histologies of lymphoma?
Hodgkin Lymphoma (HD) Non-Hodgkin Lymphoma (NHL)
What is important to block when treating HD?
Lungs (AP/PA) but inclusive of adequate margin Humeral heads Larynx blocked anteriorly unless bulky disease adjacent Cord block posteriorly, dependent on total dose Heart - cardiac silhouette treated to 15 Gy; block to apex of heart thereafter; at 30 Gy to 35 Gy add a subcarinal block (5 cm inferior to the carina)
What parts make up the Lymphatic System?
Lymphatic vessels Lymph Lymphatic organs thymus tonsils thoracic duct right lymphatic duct lymph nodes
What is the pathology of Hodgkins lymphoma?
Lymphocyte-rich Hodgkin Lymphoma (LRHL) Nodular sclerosing Hodgkin lymphoma (NSHL) Mixed ceulluarity Hodgkin lymphoma (MCHL) Lymphocyte depleted Hodgkin lymphoma (LDHL)
What are some HD sample chemo combinations?
MOPP (Nitrogen Mustard, Oncovin (vincristine), procarbazine and prednisone) COPP (cyclophosphamide, oncovin, procarbazine, prednisone ABVD (Adriamycin, bleomycin, vinblastine, dacarbazine) etoposide has been increasingly incorporated into treatment regimens to reduce gonadal toxicity
What is the 3rd most common childhood malignancy?
NHL 10% of all childhood cancers
Does the spleen filter lymph?
No, it doesn't have afferent lymphatic vessels
The presence of what cell determines whether the diagnosis is Hodgkin's lymphoma or Non-Hodgkin's lymphoma (NHL)
Reed-sternberg cell
Staging of lymphomas may also include the following letters denoting organ
S = spleen H = Liver L = lung M = Marrow P = pleura O = osseous D = skin
How is Hodgkin lymphoma staged?
Stages I - IV using Ann Arbor Staging Method
What are the treatment options for lymphomas?
The most common is combinations of chemo and RT
What is the lymphatic flow overview
Tissue fluid: leaves the cellular interstitial spaces and becomes lymph; as it enters a lymphatic capillary, it merges with other capillaries to form an afferent lymphatic vessel, which enters a lymph node where lymph is filtered. it then leaves the node via an efferent lymphatic vessel, which travels to other nodes, then merges with other vessels for form a lymphatic trunk, which merges with other trunks and joins a collecting duct, either the right lymphatic or the thoracic which empties into a subclavian vein, where lymph is returned to the bloodstream
How is RT used in treating Hodgkin lymphoma?
Traditional total-nodal irradiation (stage I and II) the contiguous lymphatic chains irradiated, which included the supradiaphragmatic lymph nodes to the anterior and posterior fields called the mantle field;
NHL is most likely to spread randomly, rather than orderly as HD does?
True
Non-Hodgkin lymphoma (NHL) differ in a couple ways from Hodgkin (HD) one is that it occurs primarily on older persons.
True
What are the major lymph nodes for both HD and NHL?
Waldeyer ring (tonsillar lymphatic tissue surrounding nasopharynx and oropharyx) and cervical, preauricular and occipital lymph nodes. tonsils include nasopharynx, tubal (pharngeal-aenoids) palatine and lingual Supraclav and infraclavicular axillary Thorax (hilar and mediastinal) Abdominal cavity (paraaortic nodes) pelvic cavity ( iliac nodes) Inguinal and femoral major lymphatic regions of the body
NHL differs from Hodgkins disease in which of the following ways a. occurs in older persons b. can originate in extralymphatic tissue c. is less likely to spread randomly
a and b
What is the Reed-sternberg cell?
a giant connective tissue cell containing one or two large nuclei
What is prevalence?
a statistic of primary interest in public health as it identifies the level of burden of disease. expresses new and preexisting patients alive on a certain date is a function of both the incidence of the disease and survival
The _____ lymph nodes are typically treated in a mantle irradiation field a. hilar b. para-aortic c. inguinal d. Waldeyers ring
a. hilar
Which subtype of Hodgkins lymphoma offers the most favorable prognosis? a. lymphocytic predominance b. nodular sclerosis c. mixed cellularity d. lymphocytic depletion
a. lymphocytic predominance
Which of the following organs atrophies after puberty? a. thymus b. thyroid c. spleen d. liver
a. thymus
What nodes are most commonly involved with MCHL?
abdomen and spleen
Where do most patients have the disease?
above the diaphragm
What are other functions of the lymph system?
absorbs fats and transports them to the bloodstream plays a major role in the body's defense and immunity. immunity is the ability to fight off infectious organisms foreign bodies, and diseases. specifically ymphocytes and macrophages recognize and respond to the foreign matter
What does LDHL present with?
advanced disease in spleen, liver and bone marrow with B symptoms. carries the worse prognosis
Lymph flows through a node in one direction entering ___ lymphatic vessels and flowing out by way of ____ lymphatic vessel
afferent efferent
The following radiographic studies are commonly used in the diagnostic workup of lymphoma a. thoracic CT scan b. PET scan c. MRI
all of them
Which of the following are common side effects of radiation therapy to the abdomen? a. nausea b. vomiting c. fatigue
all of them
How are side effects of RT for Hodgkins managed?
antiemetics nongreasy skin creams protection from sunlight rest altered diet (soft bland foods, no alcohol) throat lozenges diarrhea medication or low residue diet
What is Periphery (secondary lymph tissue) NHL?
antigen-specific reactions occur Lymph nodes, spleen and mucosa-associated lymphoid tissue (MALT) found in epithelium of nasopharynx and oropharynx (Waldeyer ring) GI tract, distal ileum, (payer patches) colon, and rectum
When will the swelling of the lymph node go down?
as the pathogen is devitalized (eg if infection-antibiotics are used)
Classification for staging of lymphomasis traditionally a. TNM b. Ann Arbor c. Duke classification d. AJC
b ann arbor
B cells mature in which of the following? a. thymus b. bone marrow c. spleen d. liver
b bone marrow
The thoracic duct is the main collecting duct of the lymphatic system and begins in the: a. suprasternal notch b. cisterna chyli c. inguinal areas d. T12
b cisterna chyli
Transient dysphgia is an acute side affect after irradiation for Hodgkin. Dysphagia is a. difficulty breathing b. difficulty swallowing c. discomfort to stomach d. difficulty urinating
b difficulty swallowing
A large binucleate or polynucleate cell present for a diagnosis of Hodgkins is referred to as a. Ann Arbor cell b. Reed-Sternberg cell c. Thomas Hodgkin cell d. Epstein-Barr cell
b reed-sternberg cell
A young woman has swelling in her lower neck for suspected HD. A chest x-ray also revealed mediastinal adenopathy. She had not experienced any fever, night sweats, or weight loss. staging would be? a. IA b. IIA c. IIB d. IIIA
b. IIA
The thymus gland functions in immunity by producing a.blood b. T cells c. B cells d. C cells
b. T cells
When extremely large fields are treated ( as in mantle and paraaortic) above and below the diaphragm, an appropriate separation must be left between the fields a. shrinking field b. gap c. algebraic formula d. geometric formula
b. gap
The most favorable of the four subtypes of HD is? a. lymphatic predominance b. nodular sclerosis c. mixed cellularity d. lymphocyte depletion
b. nodular sclerosis
The largest single mass of lymphatic tissue in the body is a. liver b. spleen c. bone marrow d. thymus
b. spleen
which vessel returns lymph from the entire body back into the bloodstream, with the exception of the upper right limb and the right side of the thorax, head and neck? a. cisterna chyli b. thoracic duct c. right lymphatic duct d. superior vena cava
b. thoracic duct
When is the incident peak of getting HD?
before adolescence is the peak in under-developed countries but in the mid to late 20s in industrialized countries
The spleen is often removed during laparotomy for biopsy and staging purposes; what assumes the spleens function then?
bone marrow and liver
What other treatment can be used if other options are not successful?
bone marrow transplants
When is lymphedema a problem in RT?
breast cancer treatment because during surgery to remove and stage cancer they often take out many axillary lymph nodes to see if the cancer has spread. doing this disrupts the natural flow of lymph. the arm can swell often reducing circulation and there is the danger of infection of that limb. it can be controlled by wearing compression bandages and through therapeutic exercises. surgeons have also started using the technique sentinel node biopsy in hopes of reducing this risk
Lymph nodes are what length? a. 4 to 6 cm b. 10 to 15 cm c. 1 to 25 mm d. 2 to 4 in
c 1 to 25 mm
a 23 year old male patient has an enlarged cervical lymph node. diagnostic workup reveals positive mediastinal and axillary nodes as well. based on this info the patient would be stage: a. I b. IE c. II d. IIE
c II because nodes are all above diaphragm
Subdiaphragmatic field arrangements used in the inverted Y commonly include a. para-aortic nodes b. inguinal nodes c. both a and b c. neither a nor b
c both para-aortic and inguinal
The following may be seen as an acute complication of treatment a. radiation pneumonitis b. L'hermitte's syndrome c. fatigue d. all the above
c fatigue
The following is not a B symptom? a. fever higher than 38C b. night sweats c. itching d. weight loss
c itching
The optimal dose to the mantle field a. 2000-3500 cGy b. 3000 cGy c. 3500-4400cGy d. 5000-6500cGy
c. 3500-4400 cGy
In NHL lymphocytes pathologically arrange themselves in patterns called a. follicular b. nodular c. both a and b c. neither
c. both a and b
Which lymph node groups are treated in a mantle field? a. mediastinal b. axillary c. both a and b d. neither a and b
c. both a and b would also include the cervical
Seventy five percent of all Hodgkin disease will have a. lymphocytic predominance b. lymphocytic depletion c. nodular sclerosis d. mixed cellularity
c. nodular sclerosis
When treating a posterior mantle field, the superior field border should include the _____ lymph node group a. para-aortic b. hilar c. occipital d. axillary
c. occipital
The most common presenting symptom for Hodkgins disease is a. abdominal mass b. painless axillary node enlargement c. painless cervical node enlargement d. painless inguinal node enlargement e. mediastinal mass
c. painless cervical node enlargement
What is the etiology of Hodgkin Lymphoma?
cause unknown Viral/contagious Epstein Barr virus (EBV) genome is in the DNA cell of the reed-sternberg Defective T cell function
The lymphatic capillaries collect what?
cellular debris, sloughed off cells,and foreign substances that occur in the intercellular spaces and transported away for filtration
Is the thymus larger in adults or children?
children and more active in pediatric immunity
How is Non-Hodgkin lymphoma workup done?
complete history and physical cytologic evaluations HIV test Blood chemistry urinalysis LDH Liver function serum alkaline phosphate Same x-ray with GI and SB bone marrow biopsy CT, MRI, PET
How is Hodgkin lymphoma workup done?
complete history and physical lab studies (CBC/platelet) liver/renal function blood chemistry, thyroid function Chest, CT, MRI, PET/CT with FDG Gallium, bone scan bone marrow biopsy B symptoms
What are the lymphatic vessels?
contain lymph start in spaces between cells referred to as lymphatic capillaries
In the treatment fields of Waldeyer ring for non-hodgkin lymphoma, the fields' delineation closely resembles that of carcinoma of the a. supraclavicular fossa nodes b. orbit c. pelvis d. nasopharynx
d nasopharynx
In Hodgkin disease, involvement of several nodal regions of both sides of the diaphragm accompanied by localized involvement of an extralymphatic site in stage a. II b. IIE c. III d. IIIE
d. IIIE
Staging for Hodgkin disease also includes an A-B grouping. which symptom is not one of the classical B symptoms? a. profuse night sweas b. weight loss greater than 10% of body weight c. unexplained fever above 38 C d. unexplained pruritus
d. unexplained pruritis it's not a classical B symptom
Which of the following is not considered a tonsil? a. pharyngeal b. palatine c. lingual d. vallecula
d. vallecula
What are side effects of RT for NHL if mouth and neck treated?
dry mouth difficulty swallowing loss of appetite mucositis a Candida infection altered taste redness of skin sore throat hair loss transient dysphagia from esophagitis dry cough
What are other symptoms of HD?
enlarged lymph nodes neck, clavicular, axilla, groin area node enlargement mediastinal mass if x-ray enlarged spleen or abdomen bony tenderness pleurel effusion
What happens if substances are trapped inside the reticular fibers and pathways thoughout the noede?
excessive fluid accumulation occurs producing swelling of node called edema (due to heightened phagocytic activity)
What is the Lymph?
excessive tissue fluid consisting mostly of water and plasma proteins from capillaries; plasma-liquid portion of the blood; 90% water; 10% proteins, nutrients, electrolytes, respiratory gases etc
What are the RT acute side effects for Hodgkins?
fatigue occipital hair loss skin erythema sore throat (esophagitis) altered taste (with preauricle nodes) transient dysphagia from radiation induced esophagitis dry cough nausea occasional vomiting diarrhea (rare)
What does the spleen do?
filters blood removes old red blood cells manufactures lymphocytes (B) for immunity surveillance stores blood
What is the extended field irradiation?
followed by the AP/PA subdiaphragmatic lymph nodes including the paraaortic nodes and the spleen
What are leukocytes?
formed in red bone marrow, mainly found in the lymphatic tissue of the spleen and include ymphocytes and monocytes; responsible for body's defense
What are some chemotherapy and RT side effects?
hair loss, mouth sores, suppressed immune system, bruising, fatigue. long term side effects - sterility
What is epidemiology of Non-Hodgkin Lymphoma?
has been in increased incidence of 65% 2008 stats-66,120 new cases with 19,160 deaths males over females and white males have higher incidence Burkitt lymphoma and AIDS (Africa)
Radiation carditis is a chronic side effect after irradiation to the mantle field; this is inflammation of the a. pharynx b. heart c. lung d. axilla
heart
When is NHL more common to occur?
in the 40 - 70 age range
What does the thymus contain?
large number of lymphocytes called thymocytes. most will remain inactive but some develop into T lymphocytes, which play a role in immunity
is the thoracic duct larger or smaller than the right lymphatic duct?
larger
What do lymphatic capillaries join to form?
larger lymphatic vessels
What are lymph nodes?
located along the path of lymph vessels vary in size from 2 to 30 mm in length and often occur in groups
Where is the thymus located?
located along the trachea superior to heart and posterior to the sternum in upper thorax
Where are the tonsils located?
located at junction of oral cavity and pharynx
What are survival rates of NHL based on?
location, stage and subtype of disease.
What is lymphedema?
lymphatic obstruction, a condition of localized fluid retention caused by compromised lymphatic system.
What is the least common type of HD?
lymphocyte depleted hodgkin lymphoma? (LDHL) occurs in older patients and HIV infected
What are the most common sites for NSHL?
mediastinum and supradiaphragmatic
What is the next most common type of HD?
mixed cellularity hodgkin lymphoma (MCHL) accounts for 15-30%. occurs at any age, lacking early adult peak of NSHL
What are side effects of RT for NHL if abdomen treated?
nausea and vomiting fatigue
What are thrombocytes?
necessary for blood clotting and respond within seconds to initiate the coagulation system
HD usually presents as a painless mass, where are they most common?
neck and supraclavicular regions
Is there a known cause of Hodgkins lymphoma?
no specific cause
What is the most common subtype of HD?
nodular sclerosing hodgkin lymphoma (NSHL)- 60-80% of all cases. mostly in adolescents and young adults.
What is the lymph drainage and spread patterns of non-hodgkins lymphoma?
nonpredictable, noncontiguous spread randomly may involve the upper digestive tract, CNS, skin, GI tract, Waldeyer ring or peyer patches
Is flow through these capillaries one or two directional?
one direction only
What are clinical presentations of HD lymphoma?
painless mass in neck and supraclavicular area Mediastinal node - chest x-ray Most disease above diaphragm
What are signs and symptoms of Hodkins?
painless swelling of nodes, fever, drenching night sweats, weight loss (10% body weight in 6 months) (the B symtpoms) fatigue, coughing or breathing problems (from mediastinal node involvement)
How is the patient set up for the mantle field?
patient is supine with arms akimbo (elbows bent) and hands on the hips or above head; chin must be extended as much as possible to prevent exposure to mouth from exit dose of posterior field; treatment in posterior field forces the chin superiorly and eliminates the exit dose to the oral cavity; body molds are helpful for these treatment
How is NHL staged?
patients usually have more advanced disease NHL is usually more bulky disease Diaphragm has less of a role than in HD Ann Arbor is used mostly, but not significant with NHL
RT late side effects?
pneumonitis, hypothyroidisim, herpes zoster, Lhermittes sign
Where is the spleen located?
posterior to and to the left of the stomach in the abdomen
What is Primary (central lymph tissue) NHL?
precursor cells both B and T occurs in the bone marrow and thymus
What is the lymph drainage and spread patterns of Hodgkins lymphoma?
predictable pattern of spread: referred to as contiguous spread is predictable to adjacent lymph node or region (viscera spread) rapidity of the growth is not predictable late stages and spread may include spleen, liver, and/or bone marrow very late stage-lungs, skeletal
What are distinguishing factors of HD?
presence of the reed-sternberg cell cell contains 1 or 2 large nuclei occurs anywhere that lymph travels spreads in a contiguous manner
What is the function of the tonsils?
protect against foreign body infiltration by producing lymphocytes they are lymphatic nodules embedded in the mucous membrane
What is incidence?
reflects new cases of a condition diagnosed during a given period of time
What does the right lymphatic duct do?
serves only the right arm and right side of head and neck and drains into right subclavian vein is only about 1-2 cm in length
What is the thoracic duct?
serves the lower extremities, abdomen, left arm, and left side of the head and neck drains into the left subclavian vein
What are symptoms of NHL?
similar to HD unlike HD, NHL can arise in lymph nodes, GI tract, Waldeyer ring, CNS (AIDS) shortness of breath (lung involvement) abdominal pain or change of bowel habits may indicate pelvic disease headaches, vision, seizures GI, CNS, Waldeyer ring
What occurs in the Thymus?
site where T lymphocytes mature
What does the smaller efferent vessels accomplish in the lymph nodes?
slows lymph out of the node facilitates effective filtering of the lymph through phagocytosis, the endothelial cells of the node engulfs, devitalize and remove the contaminants
What are erythrocytes?
smallest of all blood cells; transport oxygen and carbon dioxide throughout the body
What is the largest lymph tissue?
spleen
What are the lymphatic organs?
spleen, thymus, tonsils,
What are distinguishing factors of NHL?
spreads randomly lymphoid tissue: primary and peripheral contains B and T precursor cells Classified as follicular or diffuse
What do the thoracic duct and right lymphatic duct flow into?
subclavian veins
What lymph nodes are involved in the mantle field?
submandibular, occipital, cervical, supraclavicular, infraclavicular, axillary, hilar and mediastinal areas
Lymphatic system overview
subsystem of the circulatory system closely relates to the cardiovascular system composed of specialized connective tissue containing large quantities of lymphocytes consist of lymphatic vessel, organs, nodes and lymph occurs throughout the body
What is thought to increase risk of NHLs?
suppression of the immune system, includes infection with HIV, organ or bone marrow transplant, rheumatoid arthritis and inherited immune deficiencies The use of herbicides and pesticides
What are some factors that may be associated with Hodgkin's?
the Epstein Barr virus has been found in the DNA of the reed-sternberg cell this is also the virus that causes mono
Hodgkin's lymphoma is treated as a separate category of lymphomas because?
the Reed-sternberg cell in lymph nodes of patients It has a predictable, systematic, or contiguous pattern through the lymph
How does lymph differ from blood?
the absence of formed elements in it
What is the most common histopathology of Hodgkin lymphoma HD?
the reed-stenberg cell. This cell contains two nuclei with prominent nucleoli
What has the greatest effect on the prognosis of the patient with Hodgkins?
the stage
These larger vessels follow veins and arteries and eventually empty into one of these two ducts in the upper thoracic:
the thoracic duct or right lymphatic duct
How do lymphatic vessels differ in structure from veins?
they have capacity for repair and regeneration
Lymphatic vessels resemble veins in structure but have?
thinner walls and more valves promoting one way flow
What are the two collecting ducts for lymph located in the upper thorax?
thoracic and right lymphatic duct that dump into the subclavian vein
How does lymph travel to the thoracic duct?
travels through lower extremities to the cisterna chyli and continues upward to the thoracic duct
What would total node irradiation refer to?
treatment of the pelvic, retroperitoneal, and inguinal nodes in addition to supradiaphragmatic and subdiaphragmatic nodes
AIDS associated lymphomas are usually intermediate and high grade disease and highly aggressive? true false
true
Chemotherapy treatment regimens have had an increasing role in lymphoma management true false
true
What are the two main types of NHL?
two main types that develop in to lymphomas are: B-type lymphocytes (B cells) most common T-lymphocytes (T cells)
What are the pathologies of Non-Hodgkin Lymphoma NHL?
two types of lymphoid tissues: 1. primary (central lymph tissue) 2. Periphery (secondary lymph tissue)
What are the systemic B symptoms of HD?
unexplained fevers (>38C) drenching night sweats 10% weight loss Pruitis (itching) alcohol induced pain
About 1/3 of patients will experience B symptoms, what are they?
unexplained fevers (higher than 100.4) drenching night sweats and weight loss of 10% of their body weight in 6 months. Generalized pruritus (severe itching) and or alcohol induced pain in the disease-involved tissues may also be included in B
what is etiology of NHL?
unknown genetic alterations of the B or T lymphocytes ionizing radiation ankylosing spondylitis EBV could also play a role; but most people with this do not develop Hodgkins
What is the most important function of the lymph system?
vessels rain tissue spaces of interstitial fluid that escapes from blood capillaries and loose connective tissues, filters it and returns it to the bloodstream. this is important in maintaining the overall fluid levels in the body
Are lymphomas chemosensitive and radiosensitive?
yes
Do lymph nodes contain both afferent and efferent vessels?
yes, have afferent, oneway valves entering the lymph node at several points and efferent vessels, smaller in diameter leaving the node. both are one way valves, in and out
Is NHL treated with both RT and chemo?
yes, treated with both radiation to involved site (and draining nodal groups on the same side of the diaphragm) and chemotherapy for systemic treatment
