Non-Hodgkin's Malignant Lymphoma in the Elderly
Introduction
Introduction to non-Hodgkin's malignant lymphoma in the elderly Non-Hodgkin's lymphoma is a heterogeneous malignant tumor characterized by clonal proliferation of malignant B lymphocytes or T lymphocytes. It usually originates from lymph nodes and can also originate from any organ in the body. Non-Hodgkin's disease has been called reticulocyte sarcoma and lymphosarcoma. basic knowledge The proportion of illness: 0.002% Susceptible people: the elderly Mode of infection: non-infectious Complications: intestinal obstruction, intussusception, cerebral edema, fracture, renal failure, hypertension, urinary retention
Cause
The cause of non-Hodgkin's malignant lymphoma in the elderly
Infection (35%):
The etiology of non-Hodgkin's lymphoma involves a variety of factors including viruses, bacteria, radiation and certain chemicals. It is known that Epstein-Barr virus is associated with the incidence of Burkitt's lymphoma in high-incidence areas, and 98% of the diseased tissues can detect the Epstein-Barr virus genome. Experiments show that Epstein-Barr virus is a potential oncogenic virus that promotes immortalization of B cells. It is the initial event of Burkitt's lymphoma. It is stimulated by malaria infection or other immune factors to proliferate immortalized B cells and cause chromosomal translocation, leading to c-myc gene. Activation and malignant transformation, nasal type T/NK cell lymphoma is also associated with Epstein-Barr virus, EBV-encoded small RNA is present in 95% of diseased tissues, and adult T-cell lymphoma/leukemia is known to occur in southern Japan and the Caribbean Gulf. It is closely related to human pro-T-cell virus type I (HTLV-I) infection, which has been isolated from tumor tissue of patients. Gastric mucosa-associated lymphoid tissue lymphoma is caused by the initiation of reactive lesions infected with Helicobacter pylori. Malignant changes, clinical observation using anti-helicobacter treatment (eliminating antigen stimulation) lymphoma lesions can disappear.
The body's immune dysfunction (25%):
The immune dysfunction of the body is associated with the onset of non-Hodgkin's lymphoma, AIDS, certain hereditary, acquired immunodeficiency diseases or autoimmune diseases such as ataxia-telangiectasia, combined immunodeficiency syndrome, Rheumatoid arthritis, systemic lupus erythematosus, Sjögrens syndrome, hypogammaglobulinemia, and long-term immunosuppressive therapy (such as organ transplants) are immune to non-Hodgkin High risk factors for the onset of lymphoma.
Long-term use of phenytoin (25%):
Survivors of nuclear explosions and nuclear reactor accidents, the risk of cancer patients receiving radiotherapy and chemotherapy increased, long-term use of phenytoin can cause lymphoid hyperplasia, some of which may occur non-Hodgkin's lymphoma.
Pathogenesis
1. Histopathological features
(1) The normal lymphoid tissue structure of the lesion is completely or partially destroyed.
(2) Presenting a large number of single atypical lymphocytes.
(3) Atypical lymphocytes can infiltrate the capsule and adjacent normal tissues.
(4) There are more pathological divisions.
2. Histopathological classification
The pathological classification of non-Hodgkin's lymphoma has undergone a series of evolutions. In the 1960s, Rappaport's simple morphological classification was widely used. In the 1970s, with the development of immunology and the application of monoclonal antibody technology, there was a distinction between B lymphocytes. Cellular and T-lymphocyte-derived immunological classifications such as Lukes-Collins and Keil. In the 1980s, working formulations were developed to facilitate international academic exchanges. Based on non-Hodgkin's lymphoma immunology, cytogenetics for nearly 10 years. And the great progress made in clinical research has proposed the Modified European-American Lymphoid Tumor Classification (REAL Classification) (1994), on the basis of which the World Health Organization invited relevant experts to develop World Health for Hematopoietic and Lymphoid Tissue Tumors. Tissue classification (WHO classification) (1997), WHO classification is characterized by emphasis on non-Hodgkin's lymphoma histopathology, immunological phenotype, cytogenetics and clinical manifestations, disease course, characteristics of the primary site will be non-ho Qijin lymphoma is defined as different disease types (entities). Although the new classification is of various types, it further clarifies the diseases of non-Hodgkin's lymphoma. Different biological and clinical characteristics between the types of diseases make diagnosis and treatment possible differently, more targeted, more rational, individualized, to improve efficacy and improve prognosis. At present, China is promoting the application of "WHO classification".
Prevention
Non-Hodgkin's malignant lymphoma prevention in the elderly
Major measures for the prevention of malignant diseases of the blood system, including malignant lymphoma, should be taken to avoid causing the disease.
1. Prevent viral infection
Such as EB virus, adult T lymphocyte virus, HIV, etc., in the spring and autumn to prevent colds, strengthen their own protection, overcome bad habits.
2. Remove environmental factors
Such as avoiding exposure to various rays and some radioactive materials, to avoid exposure to related toxic substances, such as benzene, vinyl chloride, rubber, arsenic, gasoline, organic solvent coatings, etc.
3. Prevention and treatment of autoimmune diseases
For example, after various organ transplants, the immune function is low, autoimmune deficiency disease, various cancers after chemotherapy, etc., because graft-versus-host disease or immunosuppressive agents can activate the virus and promote its proliferation of lymphoid tissue.
4. Maintain an optimistic, confident and healthy mentality, appropriate physical exercise, help the stability of the body's immune function, and promptly eliminate the invasion of external factors.
5. For early-stage diagnosis and early comprehensive treatment for dangerous people or those who find risk factors.
The treatment of this disease should be comprehensive, in addition to the treatment of the cause, including nutritional supplements, if necessary, for central venous intubation and parenteral nutrition, supplement blood products as needed, the success or failure of complication prevention often The prognosis of the disease has a major impact, especially the prevention and treatment of opportunistic infections in the immunosuppressive phase. In China, special attention should be paid to tuberculosis, fungal infection, hepatitis and cytomegalovirus infection.
Complication
Non-Hodgkin's malignant lymphoma complications in the elderly Complications, intestinal obstruction, intussusception, cerebral edema, renal failure, hypertension, urinary retention
Gastrointestinal involvement can be complicated by intestinal obstruction, intussusception, cerebral edema, fracture, renal failure, hypertension, and urinary retention.
Symptom
Elderly non-Hodgkin's malignant lymphoma symptoms Common symptoms Loss of chest pain Hearing loss consciousness Disorder edema Diarrhea Abdominal pain Skin itching Bone pain Abdominal mass
Lymph node enlargement
Lymph node enlargement is the most common manifestation of this disease. 60% to 70% of patients are treated with lymphadenopathy. The lymph nodes are often painless, progressive and "rubbery", common neck, armpit, and groin. Abdominal and mediastinal lymph nodes enlarge, swollen lymph nodes can compress adjacent lymphatic vessels, blood vessels, trachea and other causes of limb edema, superior vena cava compression syndrome.
2. The performance of extranodal lesions
About 1/3 of non-Hodgkin's lymphoma originates from lymphoid tissues of extra-lymphatic organs. Primary gastrointestinal lymphoma is the most common extranodal lymphoma, accounting for about 1/3 of extranodal lymphoma, often showing abdominal pain. , vomiting, diarrhea, gastrointestinal bleeding, obstruction and perforation, primary respiratory lymphoma can present chest pain, cough, hemoptysis, dyspnea, primary pharyngeal lymphatic lymphoma may have nasal congestion, blood stasis, tinnitus, hearing loss, Pharyngeal discomfort, ulcers, tonsil enlargement, etc., primary central nervous system lymphoma manifests headache, vomiting, paralysis and disturbance of consciousness, lymphoma involves bone bone pain, limited mobility or pathological fracture, lymphoma involving bone marrow may have Anemia, hemorrhage, skin lesions can show skin macules, lumps, ulcers, etc. In short, non-Hodgkin's lymphoma can be primary or metastatic to any organ in the body, resulting in symptoms and signs of the corresponding organ involvement, resulting in a variety of clinical manifestations , changeable.
3. Systemic symptoms
10% to 20% of patients in the initial diagnosis have systemic symptoms such as fever, night sweats, weight loss and itchy skin.
4. Clinical staging
At the current stage, the Ann Arbor/Cotswords staging system (see the Hodgkin's lymphoma staging section) can be used to accurately understand the extent of tumor lesions and the patient's condition through comprehensive staging, so as to develop a reasonable optimal treatment plan.
5. Dispersion method
The lymphatic metastasis of this disease often shows "jumping" irregular metastasis, and hematogenous dissemination occurs frequently in early stage. Therefore, non-Hodgkin's lymphoma is considered to be a systemic disease.
The clinical manifestations of non-Hodgkin's lymphoma should be increased in alertness to the disease. For unexplained progressive lymphadenopathy, chest or abdominal mass, unexplained fever (especially with a mass) should be thought of. Biopsy.
Examine
Examination of elderly non-Hodgkin's malignant lymphoma
Hematological examination
In early patients, the blood picture is normal. If autoimmune hemolysis or tumor involvement in the bone marrow can cause anemia, thrombocytopenia and hemorrhage, 9% to 16% of patients may have leukemia transformation, which is common in diffuse small lymphocytic lymphoma, lymphoblastia. Cellular lymphoma and diffuse large cell lymphoma.
2. Biochemical examination
There may be erythrocyte sedimentation rate, serum lactate dehydrogenase, 2 microglobulin and alkaline phosphatase increased, monoclonal or polyclonal immunoglobulin increased, the above changes can often be used as indicators of tumor burden and disease detection.
3. Immunological phenotype detection
Tissue section immunohistochemical staining or flow cytometry using monoclonal antibodies for immunophenotyping can be used for the differential diagnosis, diagnosis and typing of NHL. Commonly used monoclonal antibody markers include CD45 (white blood cell common antigen). To identify the source of leukocytes, the positive rate is 70%-80%; CD19, CD20, CD22, CD45RA, CD5, CD10, CD23, immunoglobulin light chain and are used to identify B lymphocyte phenotype, the positive rate is about 90 %; CD2, CD3, CD5, CD7, CD45RO, CD4, CD8, etc. identify T lymphocyte phenotype, the positive rate is about 90%; CD34 and TdT are common in lymphoblastic lymphoma phenotype, CD30 and CD56 are used to identify each Denaturing large cell lymphoma and NK cell lymphoma.
4. Cytogenetics
Cytogenetic studies have shown that 90% of non-Hodgkin's lymphomas have non-random karyotype abnormalities, usually chromosomal translocations, partial deletions and amplification, etc. Different types of non-Hodgkin's lymphoma have their own molecules. Cytogenetic features.
Non-Hodgkin's lymphoma is a monoclonal malignant proliferation that occurs in a single parental cell. The gene rearrangement of tumor cells is highly consistent, while normal lymphoid tissue and benign lymphoid tissue proliferative diseases are polyclonal, so it can be used as non-Hodgkin Lymphoma gene signature, IgH gene rearrangement is often used as a gene marker for B cell lymphoma. TCR or TCR gene rearrangement is often used as a gene marker for T cell lymphoma, and the positive rate can reach 70% to 80%. Cytogenetics And gene markers can be used for the diagnosis, classification and evaluation of prognosis of non-Hodgkin's lymphoma. The detection of monoclonal gene rearrangement by PCR technology is highly sensitive and can be used for the detection of small tumor lesions.
5. Lymph node biopsy
Conducive to pathological diagnosis.
6. Radiological examination
All patients should take X-ray chest positive lateral radiographs, such as chest X-ray findings abnormal or suspicious should be further computed tomography (CT), for abdominal or pelvic mass should be abdominal CT, radionuclide 67Ga scan for evaluation of treatment response Very useful, magnetic resonance (MRI) can identify abnormal findings in other areas. Lymphoma involving the Waldeyer ring is often associated with gastrointestinal lymphoma. Similarly, the gastrointestinal lymphoma often involves the Waldeyer ring. For patients with Waldeyer's ring involvement and those with gastrointestinal symptoms and signs, gastrointestinal barium meal imaging should be performed.
7. Ultrasound examination
B-ultrasound can help to determine hepatosplenomegaly, and can also find tumor nodules in liver and spleen, but can not find diffuse infiltration, B-ultrasound can help find the posterior peritoneum, swollen lymph nodes next to the abdominal aorta.
Diagnosis
Diagnosis and diagnosis of non-Hodgkin's malignant lymphoma in the elderly
diagnosis
Histopathological examination is the main basis for the differential diagnosis and diagnosis of non-Hodgkin's lymphoma. It is essential to identify the hematopoietic tumors. Bone marrow cytology is still needed. The pathological diagnosis of this disease has developed into a traditional form. Based on the combination of immunological markers, cytogenetics and gene markers, the comprehensive diagnosis of multiple indicators can improve the accuracy of diagnosis.
Differential diagnosis
The disease should be noted with lymph node tuberculosis (common lymphadenopathy, fever, night sweats), viral infections such as infectious mononucleosis (often showing fever, lymph nodes and hepatosplenomegaly), lymphadenitis caused by local infection, lymph node metastasis Identification of cancer, sarcoidosis, giant lymph node hyperplasia and Sjogren's syndrome; gastrointestinal lymphoma should be distinguished from gastrointestinal cancer; involvement of mediastinal lymph nodes should be distinguished from lung cancer and thymoma; also need to be acute and chronic Leukemia, malignant histiocytosis, Hodgkin's lymphoma and other hematopoietic tumors.
