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Lymphoma

Clinical Oncology

The human body has a system of lymphatic vessels and lymph nodes, allowing lymphocytes to circulate through various organs and tissues to combat bacterial infections. However, when lymphocytes undergo malignant mutations, they continuously increase and accumulate in lymph nodes, forming tumours that may spread to the bone marrow, liver, and other organs. This type of cancer originating in the lymphatic system is known as "lymphoma."

Lymphoma can generally be divided into two major categories: Hodgkin lymphoma and non-Hodgkin lymphoma. In Hong Kong and the surrounding Asian regions, the incidence of non-Hodgkin lymphoma is higher, and it is also one of the top ten deadly cancers in Hong Kong.

Symptoms

The most noticeable symptom of lymphoma is the presence of painless lumps in the neck, armpits, or groin area (between the lower abdomen and thighs). In addition, lymphoma patients may experience night sweats, fever, persistent itching all over the body, frequent fatigue, loss of appetite, and unexplained weight loss. While these symptoms may also be associated with other conditions, it is essential to seek medical attention promptly if you notice these signs in your body for further evaluation to determine if you have lymphoma.

Factors

The human body is filled with an extensive network of lymphatic vessels and lymph nodes, allowing tiny lymphocytes to circulate to various organs and tissues, playing a role in defending against bacterial infections. However, lymphocytes can undergo malignant transformations, leading to uncontrolled division and growth. Sometimes, these abnormal lymphocytes do not undergo cell death, even when ageing. As these abnormal lymphocytes gradually replace normal cells, the immune system's ability to fight infections weakens. Meanwhile, lymph nodes enlarge, forming painless tumours. These accessible tumours are known as "lymphomas," lymphatic cancer.

Risk factors for lymphoma
The exact causes of lymphoma are still under extensive research in the medical field. Based on various cases, the following factors may increase the risk of developing lymphoma:

Gene mutations.
Viral infections (such as HIV, EBV, etc.).
Bacterial infections (such as Helicobacter pylori).
Radiation exposure.
Chemical agents.
Abnormalities in the body's immune system (such as rheumatoid arthritis, HIV, and immunosuppressive therapy post-organ transplantation).

Lymphoma cells generally originate in the neck, but the tumour may gradually spread to any body part, including the liver, spleen, and bone marrow. If cancer cells have already been applied to the bone marrow and begin to interfere with the blood system, patients may experience symptoms such as swelling, anaemia, and frequent bacterial infections.

Diagnosis

If symptoms suggestive of lymphoma are found in the body, it is advisable to seek prompt medical examination. Before conducting the examination, the doctor will first palpate the patient's neck, armpits, chest, or groin to observe any signs of swelling. Subsequently, a preliminary examination will be carried out, with one common method being the biopsy of live tissue. There are two ways to obtain live tissue:

Needle Biopsy: The doctor inserts a needle into the tumour and removes a small piece of tissue.
Excisional Biopsy: The doctor performs either full-body or localized anaesthesia for the patient and then removes an entire lump. After obtaining the live tissue sample, the doctor examines it under a microscope to determine the presence of lymphoma cells.

If a patient is diagnosed with lymphoma, further in-depth examinations will be conducted to understand the extent of cancer in the body.

Blood Tests	A blood sample is drawn to check the counts of red blood cells, white blood cells, and platelets. Low blood counts may indicate lymphoma has already spread to the bone marrow. Additionally, as lymphoma tumours can affect the functioning of the liver and kidneys, doctors can use blood counts to understand whether these organs have been attacked by lymphoma cells.
Chest X-Ray	Using X-ray imaging, doctors examine whether lymphoma tumours have spread to the lymph nodes in the chest or lungs.
Throat Examination	The doctor examines the tonsils and other parts of the throat to observe whether the lymph nodes are enlarged.
Bone Marrow Sampling	Some bone and bone marrow samples are extracted and examined under a microscope to check for lymphoma cells.
Ultrasound	By using a computer to transform collected echoes into images, doctors can check for any abnormal findings in relevant areas.
CT Scan	A liquid contrast agent is used to ensure precise imaging. Multiple images of the chest and abdomen are taken, which are then input into a computer to obtain detailed internal images.
Gallium Scan	Gallium is a weak radioactive substance. Doctors inject it into the veins near the swollen lymph nodes and perform a scan a few days after the injection.
Lumbar Puncture	The doctor uses a thin needle to extract a sample of cerebrospinal fluid from the patient's spine. It is then sent to a laboratory for testing to observe if it contains any lymphoma cells.
Lymphangiography	This test checks whether lymphoma has spread to the abdomen or pelvis, although CT scans gradually replace it. The doctor first performs local anaesthesia on the patient's feet, then injects a blue dye into the skin of the feet to make the lymphatic vessels connecting the lymph nodes visible. Subsequently, a second oily dye is injected into the lymphatic vessels at the top of the feet, and the flow of the shade is observed on an X-ray screen. If the lymph nodes contain lymphoma cells, they will appear different from normal lymph nodes in shape.
MRI	The patient lies inside a metal cylinder, and a magnesium scan of the patient's body's cross-sectional view is taken.

Generally, lymphoma can be divided into two major categories and four stages.

Hodgkin Lymphoma	Non-Hodgkin Lymphoma
It predominantly affects young adults aged 15 to 30 and older individuals aged 50 and above. More common in male patients Characterized by the presence of Reed-Sternberg cells In the early stages, tumours are often concentrated in the lymph nodes of the neck and gradually spread to adjacent lymph nodes, including those in the armpits and chest.	It is more commonly found in older individuals. No Reed-Sternberg cells Clinical manifestations and pathological features are more complex and varied. There is a possibility of occurring in tissues outside the lymphatic system, including the nasal cavity, nasopharynx, tonsils, gastrointestinal tract, skin, bone marrow, and central nervous system.

Stage	Extent
Stage I	One group of lymph nodes is affected.
Stage II	Two or more groups of lymph nodes are involved, and it occurs only on the left or right side of the diaphragm.
Stage III	Lymphoma is present on both sides of the diaphragm.
Stage IV	The cancer has spread beyond the lymph nodes, such as the liver, lungs, and other parts.

Treatment

The choice of treatment for patients depends on the type of lymphoma.

Hodgkin's lymphoma: If cancer cells have not spread and there are no symptoms of sweating and weight loss, radiation therapy should be used. If cancer cells have already spread throughout the body or if the mentioned symptoms are present, chemotherapy should be used. Some patients may receive a combination of both treatments.
Non-Hodgkin's lymphoma: For low-grade lymphomas, where cancer cells grow slowly, patients may not require treatment or may only need to take oral medications at home. For aggressive lymphomas, where cancer cells develop rapidly, intensive and high-dose chemotherapy is required. Other options include peripheral blood stem cell transplantation and purine analogue drugs.

Chemotherapy	Administered via intravenous injection into the arm or taken orally, particular anticancer drugs flow through the bloodstream, mainly targeting the lymphatic system within the body, disrupting and destroying the growth of lymphoma cells.
Radiation therapy	When lymphoma affects one or a few lymph nodes within the body, high-energy radiation can destroy cancer cells and prevent their division. Purine analogue drugs.
Purine Analogues Drugs	A relatively new treatment approach consisting of a group of metabolism-altering chemical drugs that can inhibit the formation of lymphoma cells and repair a patient's DNA. Treatment can be administered through intravenous or subcutaneous injection methods.
Peripheral blood stem cell transplantation	If the treatments above are ineffective against lymphoma tumours or if lymphoma recurs after treatment, this approach may be necessary. High-dose chemotherapy can destroy bone marrow, but transplanting stem cells from blood vessels or bone marrow can help restore average blood cell counts.