Non-Hodgkin Lymphoma: Diagnosis and Treatment

This assignment delves into the complexities of Non-Hodgkin Lymphoma (NHL), a heterogeneous group of cancers affecting the immune system. It details the patient care pathway from primary to secondary care, highlighting the crucial role of multidisciplinary teams in diagnosis and treatment. The document emphasizes the use of advanced diagnostic imaging techniques like CT and PET scans for accurate management and treatment planning. Additionally, it discusses the benefits of MDTs for education, research, and audit purposes, illustrating their impact on patient care and overall oncology advancements.

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Non-Hodgkin’s Lymphoma
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1.0 Introduction
Non-Hodgkin’s Lymphoma (NHL) is a heterogeneous group of malignancies originating
from lymphoid tissues, with various clinical and biological features (Armitage 2009). The
purpose of this essay is to discuss the Non-Hodgkin’s Lymphoma pathophysiology, cancer care
pathway, the role of the relevant diagnostic imaging modalities and the significance of a
multidisciplinary team approach care for a symptomatic.
2.0 Pathophysiology
Non-Hodgkin’s Lymphoma represents a clonal expansion of the B, T or natural killer
cells arising from the accumulation of lesions which affect the tumour suppressor genes leading
to cell immortalisation (Lennert 2013). The oncogenes are activated by tumour suppressor or
inactivated by either mutation or chromosomal deletion. Moreover, the genome of other
lymphoma subtypes can be changed due to the introduction of exogenous genes from different
oncogenic viruses. Leonard (2006) asserts that several cytogenetic lesions are thus connected
with certain NHL, showing the presence of certain markers of diagnostic importance when it
comes to classifying different NHL subtypes. Statistically, over 80% of NHLs are from B cells,
while the remainder is derived from T or natural killer cells (Leonard, 2006). The tumours are
characterised by several factors such as the histologic pattern of growth, cell’s origin size, the
rate of proliferation of the origin cell and the differentiation level.
In many of the B cell NHL subtypes, the cell size, as well as pattern of growth can be
crucial determinants of tumour aggressiveness. However, it should be noted that a tumour that
grows in a nodular pattern is less aggressive compared to lymphomas which proliferate in the
diffusion manner (Lemone et al. 2013). Lymphomas of tiny lymphocytes have an extra indolent
course compared to those of large lymphocytes with high-grade aggressiveness.
NHL Risk Factors
Leonard (2006) asserts that adults have a high prevalence of contracting NHL than young
people. Although some lymphomas like endemic Burkitt’s occur among young people, those
aged over 60 years are at high risk of getting NHL. However, diseases such as HIV and Epstein-
Barr viruses (EBV) increase risks of contracting NHL. According to Baum (2014), EBV causes
mononucleosis and is implicated in the aetiology of Burkitt’s lymphoma occurring following an

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organ transplant while HIV weakens immune system predisposing the body to NH. Moreover,
immunosuppressant’s increase the chances of contracting NHL. The drugs weaken the immune
system thus increasing the susceptibility of the body to infections (Wiernik 2013).
Signs and Symptoms of NHL
Non-Hodgkin’s Lymphoma has various signs and symptoms which depend on the
affected body part. According to Dehghani et al. (2015), NHL patients commonly exhibit
constitutional signs and symptoms such as enlarged lymph nodes, losing weight, fever,
unexplained fatigue and itchy skin.
3.0 Patients Care Pathway
Patients’ care pathway forms part of the larger integrated care pathways, which are a
multidisciplinary care plan that detail essential phases in caring for patients with the unique
clinical problem and describing the expected clinical course of patients (Acton 2012). Patient
care pathways include primary, secondary, and tertiary care.
a) Primary Care
An NHL patient comes into contact for the first time with a healthcare provider. In this
case, the General Practitioner (GP) endeavours to know the patient as an individual, tailoring
healthcare services to him. The GP after listening to the patients’ symptoms, eliciting signs and
suspecting NHL as possible diagnosis proceeds to undertake initial work up at establishing the
diagnosis and ruling out differential diagnoses (Brown and Edward 2013). It is required of the
healthcare provider to give detailed information to the patient and his/her relatives on the nature
and purpose of the diagnostic and staging tests. However, with a high index of suspicion for
NHL from clinical findings and test results, the GP can refer a patient to an oncologist within the
hospital for secondary care (National Cancer Intelligence 2010).
b) Secondary Care
Secondary involves specialist care with a haemato-oncologist as the primary care
provider. At secondary stage, a multidisciplinary team approach facilitates in having a holistic

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approach to the NHL patient care. Diagnosis, staging and imaging modalities occur in secondary
care.
Diagnosis and Staging
With suspected NHL at first presentation, an excision biopsy should be the initial
diagnostic procedure (Eller and Diebold 2014). However, needle core biopsy is considered in
those whose surgical procedure risks outweigh the excision biopsy potential benefit. (NICE
Guidelines, NG52). According to NICE pathways, B cell lymphomas are diagnosed using
fluorescence in situ hybridisation (FISH) to identify the MYC rearrangement in all people who
are newly presented with the histological high-grade B cell lymphoma. If an MYC
rearrangement is found, FISH will be used to identify the immunoglobulin partner and the
presence of BCL2 and BCL6 arrangements.
(c) Tertiary Care
Encompassed in the multidisciplinary team approach is tertiary care that incorporates
other patient care groups whose role is vital in healthcare provision for NHL patients. Palliative
care falls here with Hospice centres being at the forefront. In addition, homes that care for the
aged with NHL form part of tertiary care (Evens and Blum 2015). Psychiatry and/or
psychological support for both the patient and his/her relatives are vital and should be included
in the care plan. Outpatient follow-up of the patient where specific dates for a return to the
hospital should be set with well-outlined aims for each visit is a cornerstone in ensuring
continuity of care as well as the best outcome for the patient (Lennert 2013).
Diagnostic Imaging Modalities for NHL – Benefits, and Limitations
1. Chest X-ray (CXR)
A chest radiograph assists in the initial workup of a patient suspected of having NHL. It
yields positive information in about a quarter of NHL patients (Deghani et al. 2015). These
include swollen lymph nodes in the neck and chest areas-mediastinal and hilar lymphadenopathy
(Hayat 2008). Other NHL-associated features revealed by CXR include pleural/pericardial

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effusion and parenchymal involvement. On the downside, a CXR cannot differentiate between a
benign and a malignant node. Also, it delivers radiation through minute doses which
cumulatively can prove hazardous to the patient.
2. Computerised tomography (CT) Scan
The advantage of CT scan stems from its ability to detect swollen lymph nodes,
hepatosplenomegally and filling deficiencies within the spleen and liver. Doctors opt for CT
scanning to get a clear image of the body tissues unlike ordinary X-rays (Eller and Diebold
2004). The scan can also be used to check for different types of cancer in various ways such as to
detect abnormal lumps and tumours. For the definitive diagnosis of an NHL, the computerised
scan can help guide a biopsy needle into the swollen lymph node.The major limitation of CT
scan is its potentially harmful high doses of X-ray radiation delivered in just a single imaging.
Evens and Blum (2015) asserts that CT scan can cause allergic reactions to patients because of
using iodine- based materials in scanning patients. Irritations, metal taste in the mouth and rashes
are some of the major allergic reactions.
3. Magnetic resonance imaging (MRI) Scan
The superiority of MRI over other imaging techniques is in its ability to be used in
different angles to give a nice view of the body tissue in question. Since the MRI scan does not
use radiation in its operation, it can also be used to identify focal areas with marrow involvement
where patients have bone marrow involvement with negative random bone marrow biopsy
(Foster et al. 2009). Some of the limitations for using MRI scan are that it does not show calcium
and bone scans and it is costly to patients compared to other scans. Moreover, movements make
MRI unsuitable for mouth scan because coughing and swallowing lead to the production of blur
image.
4.0 Importance of Multidisciplinary Team Development (MDT)
MDT brings staff with necessary skills, knowledge, as well as experience together and
facilitates extending high-quality care, diagnosis and treatment to team members. The MDT
members attend meetings aimed not only at treating members but also considering patients
wholly. In support to this, MDT takes patients views into account, preferences and circumstances

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in offering appropriate care to the patient’s conditions. Every patient with haematological cancer
must receive care from a haemato-oncology MDT (NICE Guideline, NG47). The team should
hold formal meetings to discuss patient’s care including treatment recommendations and long-
term support. Core team members should include haemato-oncologist, haematopathologist,
clinical nurse specialist for the providence of high-intensity chemotherapy, palliative care
specialist, and support staff to organise team meeting and provide secretarial support, radiologist,
and psychiatrist among others.
Benefits of MDT
Patients receive care from professionals who have specialist knowledge and skills in a
particular type of cancer. Consequently, better awareness coupled with understanding patients’
characteristics through reflective practices facilitates outcomes leading to lowering mortality
equality (National Cancer Intelligence Network 2010). MDT assists in improving health care
standards as well as services. As a result, they help in streamlining treatment pathway and
reducing services duplication. Open discussions during MDT meeting enable peer reviews, in
line with clinical governance principals. MDT also provides an opportunity for educating junior
members through MDT meetings facilitating professional development. Another benefit of MDT
is that it provides research and audit data which benefit not only individual hospitals but also
research firms. For example, National Cancer Intelligence Network (2010) illustrated that
subsequent research from collected data; patients received high-quality clinical trials as a result.
Conclusion
In sums, NHLs are a heterogeneous group of cancers that develop in the body’s immune
system. NHL patients’ care pathway entails primary care where a GP, upon contact with the
patient, runs the initial diagnostic tests and suspecting NHL refers the patient to oncology team
for secondary care. At this stage, a multidisciplinary team comprised of specialists from different
departments offer concerted efforts towards a holistic care for the patient. MDT plays diagnosis
role where several diagnostic imaging techniques come into play, for example, CT scan and PET
scan, as well as a combination of the two whose application in NHL lymphoma patients’ results
in beneficial changes in management, volume definition, and normal tissue dosimetry.

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REFERENCE LIST
Armitage, J. O.,2009. Non-Hodgkin Lymphomas. Philadelphia, Lippincott Williams and Wilkins.
Baum, R. P.,2014. Therapeutic Nuclear Medicine. Heidelberg : Springer
Brown, D., and Edwards, H., 2013. Lewis's Medical Surgical Nursing: Assessment and
Management Of Clinical Problems. London, Elsevier Health Sciences APAC.
Dehghani, M., Haddadi, S., and Vojdani, R., 2015. Signs, Symptoms, and Complications of Non-
Hodgkin’s Lymphoma According to Grade and Stage in South Iran. Asian Pacific Journal of
Cancer Prevention, 16(8), Pp.3551-3557.
Eller, A. C., and Diebold, J., 2004. Histopathology of Nodal and Extranodal Non-Hodgkin's
Lymphomas. Berlin, Heidelberg, Springer Berlin Heidelberg.
Evens, A. M., and Blum, K. A., 2015. Non-Hodgkin Lymphoma: Pathology, Imaging, and
Current Therapy. Cham, Switzerland : Springer.
Foster, T., Miller, J.D., Boye, M.E. and Russell, M.W., 2009, "Economic Burden of Follicular
Non-Hodgkin's Lymphoma", Pharmacoeconomics, Vol. 27, No. 8, Pp. 657-79.
Lemone, P., Burke, K. M., and Levett-Jones, T., 2013. Medical-Surgical Nursing Vs. Sydney,
Pearson Education Australia.
Lennert, K., 2013. Histopathology of Non-Hodgkin’s Lymphomas: Based on the Kiel
Classification. Springer-Verlag.
Leonard, J. P., 2006. Hodgkin's and Non-Hodgkin's Lymphoma. New York, Ny, Springer.
National Cancer Institute. What you need to know about Non-Hodgkin’s lymphoma. Bethesda,
MD. NIH publication No. 87-1567, 1986

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Wiernik, P. H.,2013. Neoplastic Diseases of the Blood. New York, Springer.