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Overview |
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Definition |
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Lymphomas, or malignant lymphocytic neoplasms of the immune system, may be
broadly separated under categories of non-Hodgkin's, Hodgkin's, and cutaneous
T-cell lymphoma. The largest group of immune system neoplasms, with an annual
incidence of approximately 43,000 cases, is non-Hodgkin's lymphoma. It
encompasses 10 distinct disease entities divided into indolent or aggressive
categories. Hodgkin's is distinguished by the presence of the Reed-Sternberg
(R-S) cells, a multinuclear giant cell, and largely affects the lymphatic
system, spleen, and liver. Incidence rate for Hodgkin's in the U.S. is
approximately 3 to 4 cases per 100,000. A less common lymphoma, cutaneous T
cell, has numerous subtypes with vastly different clinical
presentations. |
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Etiology |
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The etiology of lymphomas is unclear. Hodgkin's and non-Hodgkin's have
correlation with known risks. Genetic or geographic clusters suggest possibility
of causative infectious agent. |
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Risk Factors |
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Non-Hodgkin's:
- Congenital immunodeficiency (e.g., ataxia-telangietasia,
Wiscott-Aldridge syndrome)
- Infections— Epstein-Barr virus (EBV),
Helicobacter pylori, Kaposi's sarcoma herpes virus (HIV-related
lymphoma), human T-cell leukemia virus type 1 (HTLV-1)
- Immunosuppressive therapy following organ transplant
- Primary Sjogren's syndrome, or secondary to lupus
erythematosus
- Prior chemotherapy or radiation exposure or therapy
- Exposure to herbicides, paint thinner, hair dyes, formaldehyde, lead
arsenate, creosote, benzene
Hodgkin's:
- Immunodeficiency and autoimmune diseases
- Bimodal—late teens to early adulthood, and
then over 65
- EBV
- Employment in woodworking or wood-related industries (occupation most
consistently associated with Hodgkin's disease)
- Mononucleosis
- HIV
- Tonsillectomy
- Higher education and socioeconomic status
- Genetic predisposition
- Whites > blacks
- Men > women
- Same sex siblings—10 times greater
risk
Cutaneous T Cell:
- HTLV-1
- Exposure to certain chemicals or
solvents
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Signs and Symptoms |
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Non-Hodgkin's:
- Rubbery and mobile, or hard and fixed nodes, usually in cervical or
supraclavicular area
- Painful masses—unusual for low grade; may be
warm and erythematous for intermediate and high grade
- Liver, spleen, bone marrow, extranodal involvement
- Low-grade nodes wax and wane; higher-grade nodes abruptly appear and
enlarge
Hodgkin's:
- Initially painless enlarged lymph node in neck, groin,
axilla
- Pain—back, abdomen, chest (especially with
alcohol consumption)
- Fever, fatigue, night sweats, weight loss
- Chronic pruritus
- Cough or shortness of breath relieved by sitting
up
Cutaneous T Cell:
- Skin patches—erythematous, scaly
- Plaques
- Secondary infections
- Tumors—lymph nodes, spleen, liver,
lung
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Differential
Diagnosis |
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- Collagen vascular disorders
- Lymphadenopathy from AIDS, mononucleosis, cytomegalovirus,
tuberculosis, syphilis, sarcoidosis, and other
causes
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Diagnosis |
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Physical Examination |
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After a complete history, all lymph node areas are examined (e.g.,
preauricular, epitrochlear, and popliteal nodes plus Waldeyer's ring). Tests for
suspected extranodal involvement are performed. Determination of presence of a
mass in the liver, spleen, or abdomen is made. |
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Laboratory Tests |
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- Lymph nodes, bone marrow, gastroscopic, and/or skin biopsy
- Complete blood count
- Erythrocyte sedimentation rate
- Antibody tests for HTLV-1 or HIV
- Liver, renal function tests
- Cerebrospinal fluid or pleural
cytology
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Pathology/Pathophysiology |
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Non-Hodgkin's:
- B cell monoclonal surface immunoglobulin and B or T cell
differentiation antigens in all histologic subtypes
- Enlarged nodes—resulting in lymphedema,
ureteral obstruction, epidural spinal cord compression
- Bulky lymph node masses (> 10 cm) compress the mesentry,
mediastinum, and retroperitoneum
- Involvement of Waldeyer's ring
Hodgkin's:
- Classic—malignant, large multinucleated
Reed-Sternberg (RS) cells; tumors contain many T lymphocytes, eosinophils,
neutrophils, and histiocytes; mononuclear or lacunar variants; nodular, diffuse,
or interfollicular patterns; 40% to 70% are EBV-positive
- Nodular lymphocyte predominance—rare form;
lymphocytic and histiocytic tumor cell; popcorn cell; nodular
pattern
Cutaneous T Cell:
- Malignant proliferation of T cells
- Mycosis fungoides cell—lymphocytes with
large, hyperchromatic, convoluted nuclei; scanty cytoplasm
- Sezary's syndrome—a variant of the above,
generalized redness and scaling of the skin with circulating atypical
lyphocytes
- Plaques—acanthosis and elongation of rete
ridges
- Patchy band-like infiltrate of lymphocytes and histiocytes
- Pautrier's microabscesses
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Imaging |
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- Chest, pelvic, intrathoracic area, abdominal computed tomography (CT)
if indicated
- Chest radiography
- Bone scan or radiographs if indicated
- Lymphography—especially with inguinal or
iliac involvement
- Gallium scan—images neoplasms especially in
the liver, spleen, bone, skeleton
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Other Diagnostic
Procedures |
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- Excision of lymph node(s) for biopsy
- Staging for Hodgkin's, sometimes also used for
non-Hodgkin's—identifies sites of tumor involvement in
relation to the diaphragm and best treatment strategy
- Staging laparotomy with splenectomy—invasive;
reduces need for chemotherapy; allows smaller radiation fields; unnecessary if
chemotherapy is part of treatment
plan
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Treatment Options |
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Treatment Strategy |
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Treatment is based on diagnostic information involving history, histologic
subtype, staging, tumor bulk, general health, and age. |
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Drug Therapies |
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Non-Hodgkin's:
- Regional radiation—infrequently used due to
early hematogenous spread
- Single-agent or multiagent chemotherapy with or without
radiation—for low-grade stage III or IV
- Chemotherapy—initial response good then
gradual resistance; higher doses needed to treat aggressive and recurrent
disease
- Example of multiagent chemotherapy: cyclophosphamide (750
mg/m2 IV d 1), doxorubicin (50 mg/m2 IV d 1), vincristine
(1.4 mg/m2 IV d 1), and prednisone (100 mg/m2 IV daily PO
d 1–5) [CHOP]—21-day
cycle
- Alpha interferon after initial
chemotherapy—reduces remission, may increase
survival
- Bone marrow transplant—salvage
therapy
Hodgkin's:
- Radiation alone or with chemotherapy (based on presence of prognostic
indicators)—combination therapy increases freedom from
recurrence but not survival rates
- Six cycles of multiagent chemotherapy followed by regional or mantle
irradiation—effective for large mediastinal adenopathy
or bulky tumor
- Radiation side effects include dry mouth, pharyngitis, nausea,
dermatitis, fatigue.
- Example of multiagent chemotherapy: doxorubicin (25 mg/m2
IV), bleomycin (10 mg/m2 IV), vinblastine (6 mg/m2 IV),
and dacarbazine (375 mg/m2 IV) [ABVD], repeated every two weeks; side
effects include nausea, vomiting, hair loss, fatigue, myelosuppression
Cutaneous T Cell:
- Emollients, moisturizers, topical steroids
- Topical chemotherapy—mechlorethamine
hydrochloride (nitrogen mustard HN2); long-term use causes squamous cell
carcinoma
- Systemic chemotherapy (e.g., mechlorethamine, vincristine, prednisone,
procarbazine)
- Psoralen plus ultraviolet A with
chemotherapy—relapses if not continued; risk of
malignant melanoma
- Electron beam therapy—penetrates only upper
dermis
- Retinoids and interferon—promising,
especially in combination
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Surgical Procedures |
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Surgical removal of neoplasm if indicated |
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Complementary and Alternative
Therapies |
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Herbal therapies may be beneficial in supporting the lymph system as well as
enhancing immunity. Diet and nutritional supplements optimize detoxification and
antioxidant activities. Improved relaxation and decreased stress, through such
activities as guided imagery, tai chi, yoga, and meditation are helpful in
promoting a sense of well-being. Intimacy and support from others helps promote
a positive and empowering attitude. |
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Nutrition |
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- Avoid foods that may interfere with optimal immune function, such as
refined foods, sugar, alcohol, caffeine, and saturated fats (e.g., animal
products).
- Use only organically-raised foods. Include foods that support
detoxification, immunity, and are high in antioxidant nutrients, such as beets,
carrots, artichokes, yams, onions, garlic, dark leafy greens, yellow and orange
vegetables, shiitake mushrooms, green tea, and filtered water. Green tea may
potentiate the effects of doxorubicin.
- Vitamin C (1,000 mg qid), vitamin E (400 IU bid), beta carotene
(50,000 IU one to two times daily), coenzyme Q10 (100 mg tid), and zinc (30
mg/day) for antioxidant protection and immune support. Coenzyme Q10 and
L-carnitine (600 mg tid) may protect against cardiac toxicity secondary to
doxorubicin.
- Selenium (200 mcg bid) and glutathione (500 mg bid) to support
detoxification.
- B-complex (50 to 100 mg) to reduce the effects of stress.
- Juicing: Combine equal parts romaine lettuce, green pepper, celery,
parsley, cucumber, and apple or pear (for flavor). Use organic fruits and
vegetables. Drink one glass per day.
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp.
herb/cup water steeped for 10 minutes (roots need 20 minutes). Traditional
alterative formulas may be employed in lymphoma for detoxification, tumor
inhibition, and immune support. Choose one or more of the
following.
- Commercial Hoxsey-like formulas or trifolium compounds include red
clover (Trifolium pratense), burdock root (Arctium lappa), Oregon
grape (Mahonia aquifolium), queen's delight (Stillingia
sylvatica), barberry (Berberis vulgaris), licorice root
(Glycyrrhiza glabra), poke root (Phytolacca americana), prickly
ash bark (Xanthoxylum clava-herculis), and yellow dock (Rumex
crispus). Take 60 drops bid to tid for six months or longer.
- Scudder's Alterative Compound: combine equal parts of corydalis tubers
(Dicentra Canadensis), black tag alder (Alnus serrulata), mayapple
root (Podophyllum peltatum), figwort (Scrophularia nodosa), and
yellowdock (Rumex crispus). Take 30 to 40 drops tincture tid to qid for
six months.
- Essiac: sheep sorrel (Rumex acetosella), burdock root
(Arctium lappa), slippery elm inner bark (Ulmus fulva), and turkey
rhubarb (Rheum palmatum). Another version, Flor-Essence includes
additional herbs, such as watercress (Nasturtium officinale). Drink one
cup tea bid, or take 2 tbs. formula bid for six months.
For general long-term immune and lymphatic support:
- Combine equal parts of astragalus (Astragalus membranaceus),
lomatium root (Lomatium dissectum), marigold (Calendula
officinalis), red clover (Trifolium pratense), blue flag (Iris
versicolor), and cleavers (Galium aparine). Drink two to three cups
of tea per day.
- Siberian ginseng (Eleutherococcus senticosus): 30 to 60 drops
bid in the morning and at noon to increase stamina. Do not take after 3 pm as it
may induce wakefulness at night.
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Homeopathy |
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May be helpful in addressing symptomatic complaints and strengthening overall
constitution. An experienced homeopath would consider the individual's
constitution and may be effective at decreasing side effects from
chemotherapy. |
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Physical Medicine |
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Contrast hydrotherapy may aid in enhancing immune function and facilitating
the transport of nutrients and waste products. End hot showers with one to two
minutes of cold water spray. Use less extremes of temperature with debility and
weakness. |
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Acupuncture |
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May be helpful in strengthening immunity and detoxification activities. May
decrease side effects from chemotherapy. |
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Patient Monitoring |
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After remission, monitoring for relapse is
crucial. |
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Other
Considerations |
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Prevention |
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Avoidance of known risks |
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Complications/Sequelae |
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- Hodgkin's may develop into non-Hodgkin's
- Late-appearing side effects of radiation and/or chemotherapy,
including secondary malignancies
- Infection due to immunosuppression
- Pulmonary fibrosis
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Prognosis |
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Non-Hodgkin's:
- Stage I and II disease expected five-year survival rate of
90%
- Localized, nonbulky stage I or II with regional
radiation—50% long-term disease free
- Low grade stage III or IV—2.5- to 5-year
median remission rate
- After eight years, with or without treatment, disease has a propensity
to change from indolent to aggressive
Hodgkin's:
- Combined-modality therapy with staging laparotomy and splenectomy
(LAP)10-year survival rate: 89%
- Combined-modality therapy without LAP 10-year survival rate:
87%
- Radiation with LAP 10-year survival rate: 84%
- Most relapses occur within three years
- Fever, night sweats, weight loss, large mediastinal adenopathy, age
> 40 years—poorer prognosis
Cutaneous T Cell:
- Prognosis varies vastly with
subtype
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Pregnancy |
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- Occurrence is one in every 1,000 to 6,000 pregnancies (40% Hodgkin's).
Many of the diagnostic (e.g., laparotomy with splenectomy) and treatment
(radiation, chemotherapy) procedures are contraindicated during pregnancy.
Therapeutic abortion and watchful waiting (at least until the second trimester)
are considered. Delay may affect mother's prognosis, and treatment may be
teratogenic.
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References |
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Boik J. Cancer & Natural Medicine: A Texbook of Basic Science and
Clinical Research. Princeton, Minn: Oregon Medical Press; 1996:70.
Brinker F. The Hoxsey treatment: cancer quackery or effective physiological
adjuvant? J Naturopathic Med. 6(1):9-23.
Cecil RI, Plum F, Bennett JC, eds. Cecil Textbook of Medicine.
20th ed. Philadelphia, PA: W.B. Saunders; 1996.
Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore,
MD: Lippincott Williams & Wilkins, Inc.; 1999.
DeVita VT, ed. Cancer: Principles and Practice of Oncology.
5th ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill;
1998.
Goroll AH, ed. Primary Care Medicine. 3rd ed. Philadelphia,
PA: Lippincott-Raven Publishers; 1995.
Habif TP. Clinical Dermatology. 3rd ed. St. Louis, MO:
Mosby-Year Book; 1996.
McCunney RJ. Hodgkin's disease, work, and the environment. J Occupational
Environ Med. 1999; 41(1).
Moss RW. Alternative pharmacological and biological treatments for cancer:
Ten promising approaches. J Naturopathic Med. 1996; 6(1):23-32.
Rakel RE, ed. Conn's Current Therapy. 51st ed.
Philadelphia, PA: W.B. Saunders; 1999.
Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed.
Durango, Colo: Kivaki Press; 1994:
35-36. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |