Test your knowledge on Non-Hodgkin's lymphoma

Read the haematology article on Non-Hodgkin's lymphoma then answer these three questions to check your understanding. You may want to document your answers and any learning points to save in your CPD Organiser along with the article.

Lymphadenopathy is one of the most common presenting symptoms (Photograph: SPL)
Lymphadenopathy is one of the most common presenting symptoms (Photograph: SPL)

Read our clinical feature on Non-Hodgkin's Lymphona

Question 1
  A 45-year-old man, previously fit and well, presented with a left-sided cervical mass and tiredness, although has continued to work full-time.  He has been diagnosed with diffuse large B-cell lymphoma, and staging scans have revealed mediastinal and para-aortic involvement in addition to the cervical mass; the bone marrow biopsy was negative.  His LDH is elevated.  He is due to start multi-agent chemotherapy including rituximab and wishes to discuss his diagnosis with you.  What is his prognosis?
The outlook for patients with diffuse large B cell lymphoma is good compared with many other malignancies, with about 80 per cent entering complete remission and two thirds achieving a long-term cure.  The IPI score can refine the statistics for an individual.  This patient has an IPI of 2 out of 5 (scoring a point each for stage III disease and elevated LDH; no points for age, performance status or extranodal invovlement).  His prognosis would therefore be better than average.
Question 2
 The same patient completes a planned course of six cycles of R-CHOP chemotherapy, achieving complete remission.  He is concerned about the possibility of relapse and wants to know what symptoms he should be looking out for.
The chance of relapse is highest in the first few years and few patients relapse beyond five years.  Recurrent disease is likely to manifest itself with similar symptoms to his initial presentation, i.e. persistent lymphadenopathy in the same or different anatomical locations.  Abdominal disease may cause distension, discomfort or palpable masses.  Recurrence could be heralded by B symptoms (weight loss, night sweats, fevers) even though these were not prominent at his initial diagnosis, although this makes it somewhat less likely.  Aggressive lymphoma is likely to make itself known within a few months and the patient can be reassured that, if he is feeling well with no palpable masses, he is unlikely to be harbouring occult recurrence.  In addition, as his LDH was elevated at prognosis, this is likely to be a useful marker, and a normal LDH would be reassuring.
Question 3
Five years later, there has been no lymphoma recurrence and the patient is to be discharged from routine follow-up in the lymphoma clinic.  In what ways could his treatment adversely affect his long-term health, and what measures can be taken to minimise these adverse effects?

As this patient did not receive radiotherapy, long-term effects are reduced.  However, there is a small increased risk of further malignancies and cardiovascular disease.  The patient should be advised to quit smoking if he is a smoker and pay attention to other cardiac risk factors.  He should have his blood pressure and cholesterol checked occasionally.

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