Pregnancy with lymphoma
Introduction
Introduction to pregnancy with lymphoma Pregnancy with malignant lymphoma is not common in clinical practice, but it is dangerous to the safety of mother and fetus. It is very worrying. Lymphoma in pregnancy is more common in Hodgkin's lymphoma, mainly manifested as lymphadenopathy, fever, anemia. , weight loss, diagnosis depends on pathological diagnosis. basic knowledge The proportion of illness: 0.0002% Susceptible population: pregnant women Mode of infection: non-infectious Complications: anemia, intestinal obstruction, jaundice, ascites, cirrhosis, uremia
Cause
Pregnancy with lymphoma cause
(1) Causes of the disease
It has been shown that many animals such as chickens, mice, cats and cattle have malignant lymphomas that can be caused by viruses, although in humans, although many clinical manifestations such as fever, hyperhidrosis, and increased white blood cells have been considered for many years. Like infection, it was not until recently that some lymphomas were confirmed to be caused by viruses.
Most of the etiology of lymphoma studies began in high-incidence areas or high-risk groups.
Virus (25%):
Human lymphoma is the first to be confirmed that Burkitt lymphoma is associated with EB virus infection. In Central Africa, this disease mainly occurs in children aged 3 to 12 years old. It is related to certain climatic conditions and can account for more than half of local children's tumors, only 5%. The patient is over 20 years old and has sporadic patients in other parts of the world, but it is a rare case. It has been proven by cell biology techniques that the genome of Epstein-Barr virus can be found in 98% of Burkitt's lymphoma, but it is distributed. Only 15% to 20% of Burkitt's lymphomas contain Epstein-Barr virus, and all of the Epstein-Barr virus antibody antigens in the endemic areas are positive, and the titer is high. The risk of such tumors in children with positive shell antigen is 30 in the control group. Times, infection with certain mites with Epstein-Barr virus can cause malignant lymphoproliferative lesions similar to Burkitt's lymphoma. Therefore, it is currently considered that this disease is a severe and persistent EB virus infection in African children in childhood, and immune function is inhibited. The oncogene is activated, leading to the malignant proliferation of B lymphocytes. It is currently believed that malaria transmitted by mosquitoes is only a cofactor, and malaria infection makes Pakistan reticulation system changes.
Immunosuppression (20%):
The occurrence of lymphoma is closely related to immunosuppression. Because organ transplantation requires long-term medication to suppress the immune mechanism, the incidence of lymphoma is significantly higher than that of the general population, and there are more primary infections. A group of reports can be as high as 69%. In addition, the central nervous system is also invaded (28%) in patients with general lymphoma (1%). The immunosuppressive drugs used also have an effect on the occurrence of lymphoma. In the cyclophosphamide-based regimen, lymphoma accounts for 26% of primary cancers occur earlier, and only 11% use azathioprine (Imolan). In patients with anti-CD3 monoclonal antibodies, lymphoma accounts for 64% of the second primary cancer. %, another fact that has received extensive attention is that many patients with primary immunodeficiency and acquired immunodeficiency (AIDS) are also prone to lymphoma and other tumors, especially in patients with EB virus infection. The rate is higher.
Bacterial infection (18%):
In recent years, it has been reported that Helicobacter pylori (Hp) can cause chronic gastritis, gastric cancer, and can also cause high incidence of gastric lymphoma. In some patients, lymphoma can be reduced after antibiotic treatment. Some authoritative organizations in the United States such as NC-CN have developed in recent years. Among the treatment specifications, antibiotic treatment has been the preferred method for mucosal-associated lymphoma (MALT), which is the first example of antibiotic treatment of tumors.
Environmental factors (15%):
In the early years of the United States, the incidence of lymphoma was several times higher than that of the normal population due to the use of pesticides and pesticides in the midwestern farmers. The US Navy has been involved in paint vessels and veterans who have been exposed to fluoride. The incidence of lymphoma is also high, but very It is difficult to explain the mechanism. It is relatively certain that the atomic bomb victims, the Hiroshima residents who have received radiation above 1Gy and those who have been treated with spondylitis, have a higher incidence of lymphoma than the normal population. They have received radiation in the clinic. And the chemotherapeutic HD patients have a significant increase in the second primary cancer, especially large cell lymphoma, and often invade the digestive tract.
Other (15%):
Some congenital immunodeficiency diseases, such as telangiectasia ataxia, Wiscott-Aldreich syndrome, Chediak-Hig syndrome, etc. are often complicated by malignant lymphoma, and other long-term immunosuppressive drugs are called "immunocytic ( Immunoinflammatory) diseases such as systemic lupus erythematosus, rheumatoid arthritis, Sjögren syndrome (Sjogren's syndrome), immune hemolytic anemia, etc. may also be complicated by malignant lymphoma, long arm (q) translocation of chromosome 14 It is also associated with the occurrence of malignant lymphoma. In addition, long-term use of certain drugs (such as phenytoin, methamphetamine, etc.) can also induce lymphoma, and the etiology of malignant lymphoma has been shown. A variety of factors are related to the occurrence of this disease, and its specific process and detailed mechanism have yet to be further clarified.
(two) pathogenesis
1. Pathogenesis of non-Hodgkin's lymphoma:
Due to the different stages of lymphocyte differentiation, different stages of tumor cells may occur in the invaded lymph nodes or lymphoid tissues. In the same lesion, there may be poorly differentiated tumor cells or cells with more mature differentiation. The progression of the lesion, the histological type of malignant lymphoma may be transformed, such as nodular type can be converted into diffuse type.
The proliferating tumor tissue may be a single cell component, but since the original pluripotent stem cells may differentiate in different directions, sometimes the cellular components may be more than two or more.
In recent years, due to the widespread use of monoclonal antibodies and immunohistochemistry, it has been possible to distinguish T, B lymphocytes in different stages of differentiation.
Tumors that occur in subcapsular cortical thymocytes are usually T-cell acute lymphoblastic leukemia and lymphoblastic lymphoma. All other T-cell lymphomas are derived from more mature T cells, CD4-positive, including adult T-cell lymphoma. (ATL), mycosis fungoides, Sezary syndrome, most so-called peripheral T-cell lymphoma (diffuse large cells in the international work classification, immunoblasts and mixed lymphoma) and more than half of T-cell chronic lymphocytes Leukemia, there are some peripheral T-cell lymphoma, nearly half of T-cell chronic lymphocytic leukemia and some T lymphoproliferative diseases, CD8 positive.
B-cell lymphoma has fewer specific antibodies, but has surface immunoglobulin expression. The earliest B cells have CD10 and CD19 on the surface, and there are terminal transferases in the cell and recombination of heavy-bond genes. , the cytoplasm produces heavy bonds, the reorganization of light bond genes, the reorganization of light bond genes and the loss of terminal transferases, which represent the development of the pre-B cell stage, and the expression of CD10 after cell loss becomes immature B The cells have IgM expression on the surface, and IgD and IgM are produced on the surface of the cell surface expressing CD21 receptor (C3b). The developmental stages of all B cells occur under antigenic stimulation, and the immunoglobulin genes are stimulated by antigen. After secretion and secretion, after this, the cells lose CD21, CD20 and surface immunoglobulin, and the plasma cells markers PC-1 and PC-2 secrete immunoglobulin, which is the development process of cell follicle center B cells, malignant transformation It becomes lymphocytic lymphoma.
The maturation of B cells in the follicular center and the initiation of immunoglobulin genes are regulated by T helper cells, but there are also some unidentified B lymphocytes. The B cells in the mantle cell area seem to be relatively less affected by T cells, which are CD5 positive. This is a full T cell marker and appears to be independent of immunoglobulin.
Most acute lymphocytic leukemias are derived from pre-B cells, Burkitt lymphomas and leukemias are derived from surface IgM-positive immature B cells, and most follicular and diffuse B-cell lymphomas are derived from mature or activated B cells, giant balls. Proteinemia (Waldenstrom syndrome) and multiple myeloma are derived from the terminal stage of differentiation. Chronic lymphocytic leukemia expresses CD5, and diffuse moderately differentiated lymphoma expresses CD5 and CD10, suggesting that these are from the mantle cell region rather than the filter. B cells in the center of the bubble.
The immunophenotyping and clinical manifestations of some lymphomas are still very confusing. Diffuse large cell lymphomas may be the most heterogeneous, and may be derived from B cells, T cells and tissue cells. Therefore, the prognosis of these patients does not depend entirely on clinical stage, adult T Cellular lymphoma is derived from mature T cells from an immunophenotype, but its clinical manifestations are very dangerous, like lymphoblastic lymphoma from immature T cells, which needs further study, especially the role of different genes. .
2. The pathogenesis of Hodgkin's lymphoma:
The vast majority of patients with classic Hodgkin's lymphoma have clonal cytogenetic abnormalities, which vary with different cases, and the abnormalities within the clones are also heterogeneous, suggesting chromosomal instability, many cases show 14q abnormalities, similar B-cell lymphoma, but t(14;18) abnormalities rarely occur, and two groups used fluorescence in situ hybridization (with or without fluorescent immunophenotyping) to find RS in all cases of Hodgkin's lymphoma. The cells showed abnormal clonal values. In the early reports, about one-third of Hodgkin's lymphomas were found to have Bcl-2 rearrangements, but other laboratories did not detect Bcl-2 rearrangements, and, in highly reactive tissues, Bcl-2 rearrangement was also found in reactive tonsils, and EBV-associated transforming proteins were able to up-regulate Bcl-2 in cultured cells. This evidence further indicates the relationship between Bcl-2 expression and Hodgkin's lymphoma, Bcl- 2 The results of immunohistochemical studies of overexpression are inconsistent, however, Bcl-2 expression appears to be unrelated to histology, EBV() or t(14;18) translocation, and enhancement of Bcl-2 expression may be present in background cells. And does not pay much attention to the onset of Hodgkin's lymphoma Role, but a group of researchers applied cytogenetic analysis to clearly confirm the presence of Bcl-2 rearrangement in tumor cells without t(14;18). Recently, new apoptosis inhibition was found in Hodgkin's lymphoma. Factor Bcl-X (L), Bcl-X (L) is positive in 94% of Hodgkin's lymphoma, and most RS cells are highly expressed and have a low expression rate in non-Hodgkin's lymphoma (<20). %), except for reticular central lymphoma, it is speculated that the abnormal expression of Bcl-X(L) in RS may inhibit the apoptosis and may be the cause of Hodgkin's lymphoma. No Bcl-X(L) was found. Correlation with EBV expression, P53 tumor suppressor gene expression has been detected in Homkin and other lymphomas of CD30 by immunohistochemical analysis, but recent studies have found that in 8 cases of Hodgkin's lymphoma, Hodge Both gold and RS cells have no P53 mutation.
Prevention
Pregnancy with lymphoma prevention
Because the cause of lymphoma patients is not yet clear, the method of prevention is nothing more than:
1 Minimize infection and avoid exposure to radiation and other harmful substances, especially drugs that have an inhibitory effect on immune function.
2 Appropriate exercise, enhance physical fitness and improve your disease resistance.
Complication
Pregnancy with lymphoma complications Complications anemia intestinal obstruction jaundice ascites cirrhosis uremia
Complications of malignant lymphoma are mainly seen in anemia, infection, fever, chest tightness, chest pain, cough, shortness of breath, obstruction of swallowing, difficulty breathing, abdominal pain, intestinal obstruction, jaundice, ascites, cirrhosis, hydronephrosis, uremia and neurological symptoms. .
Symptom
Pregnancy with lymphoma symptoms Common symptoms Inguinal lymphadenopathy, edema, nodules, itching, dyspnea, hardening, low heat, night sweats, jaundice
Lymphoma can have no obvious systemic symptoms in the early stage, only manifested as lymphadenopathy, mostly painless, progressive lymphadenopathy, hard lymph nodes, adhesions, especially superficial neck, axillary and inguinal lymph nodes Swollen is the most common, disease progression can occur chills, fever, night sweats, weight loss, fatigue, anorexia, itching and other symptoms, due to abdominal enlargement during pregnancy, the difficulty of correctly observing the abdomen, thus affecting the estimation of the condition and staging.
The clinical stage of ML has become more uniform in the past 30 years. It was originally revised in 1971 by the Rye meeting. It was revised at the Ann Arbor meeting in 1971. It was divided into four phases and each period was divided according to the presence or absence of systemic symptoms. Group A, Group B2, the Ann Arbor staging was further revised in Cotswold, England in 1989, and is currently considered to be a relatively simple staging method.
1. Ann Arbor Clinical Staging (1971):
Stage I: Invasion of a lymph node area (I), or invasion of a single extranodal organ or site (IE).
Stage II: On the side of the diaphragm, invading two or more lymph node areas (II) or extravasively invading one extranodal organ or site (IIE).
Stage III: The affected lymph node area invades one extranodal organ or site (IIIE) or spleen (IIIs) or both (IIIES) on either side of the diaphragm (III) or in addition to localization.
Stage IV: Diffuse or disseminated invasion of one or more extranodal organs with or without lymph node involvement.
Organ invasion is divided into: A. Asymptomatic, B. No cause of fever > 38 ° C, for more than 3 consecutive days, night sweats, no loss of weight loss of 10% within 6 months.
2. Cotswold staging (1989):
Stage I: Invasion of a single lymph node area or invasion of one lymphoid tissue (eg spleen, thymus, Webster's ring).
Stage II: Invasion of 2 or more lymph node areas, both located on one side of the diaphragm (eg 1 site in the mediastinum and 1 site in the hilar lymph node on one side), the number of anatomical sites should be clearly indicated For example, it is written as stage II2III: the invasion of the lymph node area or lymphoid tissue involves both sides of the diaphragm.
III1: With or without spleen, lymph nodes in the abdominal or portal vein are invaded.
III2: There are aortic, ankle, mesenteric lymph nodes invaded.
Stage IV: The site other than the lymph node (S) is invaded and is called E.
A: No systemic symptoms.
B: Unexplained fever>38°C for more than 3 consecutive days, night sweats, weight loss of 10% for unknown reasons within half a year.
X: large tumor mass, greater than about 1/3 of the mediastinum width, and the maximum diameter of the lymph node fusion mass is >10 cm.
E: The external node of the single node is invaded. The lesion invades the organ directly connected with the lymph node or lymphatic tissue. When the tissue is not recorded as stage IV, the letter "E" should be recorded after each period (such as lesion infiltration to the left neck) The skin connected to the lymph nodes was recorded as "IE").
CS: Clinical stage.
PS: pathological staging.
Examine
Examination of pregnancy with lymphoma
1. Transpeptidase (r-GT), 2-MG and ESR increased
Can be used as a reference indicator, in recent years, the literature reported that the level of serum lactate dehydrogenase (LDH) increased to indicate the tumor burden.
2. ESR test
More obvious decline, increased activity period, normal remission period, often can be used to determine the remission period and active period of malignant lymphoma.
3. Peripheral blood
Early patients with more normal blood, secondary autoimmune hemolysis or tumor involving bone marrow can cause anemia, thrombocytopenia and hemorrhage, 9% to 16% of patients can have leukemia transformation, common in diffuse small lymphocytic lymphoma, follicle Lymphoma, lymphoblastic lymphoma and diffuse large cell lymphoma.
4. Biochemical examination
There may be ESR, 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.
5. Immunological phenotypic testing
Monoclonal antibody immunophenotyping can identify the cell lineage and differentiation level of lymphoma cells. Commonly used monoclonal antibody markers for diagnosis and typing include CD45 (white blood cell common antigen) for identifying its white blood cell source; CD19, CD20, CD22, CD45RA, CD5, CD10, CD23, immunoglobulin light chain and are used to identify B lymphocyte phenotype; CD2, CD3, CD5, CD7, CD45RO, CD4, CD8, etc. identify T lymphocyte phenotype; CD30 And CD56 are used to identify anaplastic large cell lymphoma and NK cell lymphoma, respectively, CD34 and TdT are common in lymphoblastic lymphoma phenotype.
6. Chromosome examination
90% of non-Hodgkin's lymphomas have non-random karyotype abnormalities, usually chromosomal translocation, partial deletion and amplification, etc. Different types of non-Hodgkin's lymphoma have their own cytogenetics. Characteristic, non-Hodgkin's lymphoma is a monoclonal malignant proliferation occurring in a single parental cell. The gene rearrangement of tumor cells is highly consistent. IgH gene rearrangement is often used as a gene marker for B cell lymphoma, and TCR or gene rearrangement. Often used as a genetic marker for T-cell lymphoma, the positive rate can reach 70% to 80%. Cytogenetics and gene markers can be used for the diagnosis, classification and detection of small tumor lesions in non-Hodgkin's lymphoma.
7. Pathological examination
Malignant lymphoma should generally be confirmed by pathological examination. Because it is not only necessary to observe the morphology of the cells under the microscope, but also to observe the structure of the entire lymph node and the interstitial cell reaction, it is best to take a complete lymph node for examination, as much as possible. Take a partial lymph node.
For the same reason, needle biopsy sometimes has some reference value for diagnosis, but often does not provide enough material to make a comprehensive diagnosis. In addition, needle aspiration is easy to cause hematoma.
In the following situations, attention should be paid to the possibility of malignant lymphoma. It is best to take lymph nodes early for pathological examination.
(1) Progressive lymphadenopathy without clear cause: especially when the site, hardness, and activity are consistent with the characteristics of the aforementioned malignant lymphoma.
(2) "Lymph node tuberculosis", "chronic lymphadenitis" when the regular course of anti-tuberculosis or general anti-infective treatment is invalid.
(3) Although the lymph nodes and fever are repeated, the general trend is progressive.
(4) Unexplained long-term hypothermia or periodic fever should consider the possibility of malignant lymphoma: especially with itchy skin, sweating, weight loss, and the discovery of superficial lymphadenopathy, especially on bilateral trochlear lymphadenopathy. Time.
Note when taking lymph node biopsy:
1 Because the general patient often has individual parts such as groin, submandibular and other lymph node inflammation, so when choosing lymph nodes, it should be taken faster, the texture is tough and full, in line with the characteristics of malignant lymphoma, the part is neck, underarm and It is better on the trolley.
2 should try to avoid extrusion.
3 should be fixed as soon as possible after removal.
4 If necessary, several parts can be taken from different parts.
5 If the inguinal lymph nodes are taken, the contrast agent should have an effect on the lymph nodes before lymphography.
If there are several lymph nodes in 61 lymphatic areas, larger ones should be selected, but sometimes large lymph nodes often have central necrosis.
Other auxiliary inspections:
Pathological examination
The diagnosis of ML must be biopsy, and its histological nature and type should be determined by pathological examination. Pay attention to the following points:
(1) Take superficial lymph node biopsy, choose to swollen, and have full, spleen and other ML characteristics of the lymph nodes, it is best to complete the resection, in order to observe the structure of the lymph nodes, unless necessary, only partial lymph node biopsy.
(2) Try to choose lymph node biopsy in areas with less inflammatory interference, such as upper lymph nodes, axillary lymph nodes, supraclavicular lymph nodes, axillary lymph nodes, etc., while submandibular lymph nodes are mostly associated with oral inflammation, and inguinal lymph nodes are enlarged. Related to lower limb infections, such as foot and foot infections.
(3) mediastinal lymphadenopathy, especially in patients without superficial lymphadenopathy, should also be used after a comprehensive examination, with mediastinoscopy, even at the chest to take biopsy, because mediastinal lymphadenopathy can be benign or malignant .
(4) Do not squeeze the tissue during the biopsy to avoid affecting the diagnosis.
(5) Needle aspiration puncture or needle aspiration biopsy is not suitable for the diagnosis of ML. Because the tissue is too small, it can neither be qualitative (or barely qualitative), and it can not be classified.
2. Imaging examination
Including X-ray examination, CT, MRI, B-ultrasound, gastrointestinal angiography, PET, pyelography, lymphography, etc., can be selected according to the condition; these examinations can understand the extent and scope of deep lesions, and develop treatment plans for clinical stages. It is an indispensable means to judge the prognosis and observe the clinical efficacy.
Diagnosis
Diagnosis and differentiation of pregnancy with lymphoma
diagnosis
The diagnosis of malignant lymphoma depends mainly on clinical manifestations, X-ray examination and pathological examination, but pathological examination is essential for the diagnosis and classification of malignant lymphoma.
Diagnostic treatment, in clinical practice, it is often possible to see some patients with long-term weight loss, fatigue or unexplained hypothermia; or in some cases, some people have swollen lymph nodes, due to concerns about biopsy caused by dissemination, and diagnostic radiotherapy, However, a considerable number of patients later confirmed that they were not malignant lymphomas.
1. Diagnostic criteria
The basis for the diagnosis of lymphoma is pathological examination.
Reed-Sternberg cells are characteristic of HL. RS cells originate from B cells. They are large in size, rich in cytoplasm and light in nuclear chromatin. There should be at least 2 nuclear lobules or nucleoli (if they are mononuclear, called Hodgkin's cells). The immunophenotype is positive for CD30 and CD15. According to other pathological features, HL is usually divided into 4 subtypes: nodular sclerosis, mixed cell type, lymphocyte-based and lymphocyte-attenuated; in WHO classification Another subtype is proposed: nodular lymphocytes are predominant, and their tumor cells are similar to popcorn, which is a variant of RS cells.
The basic pathological features of NHL are: the normal structure of lymph nodes disappears and is replaced by tumor tissues; the proliferating lymphocytes are heteromorphic; the tumor cells invade the lymphatic capsule, according to the morphology, immunology and molecular biology of tumor cells, NHL can be divided into many subtypes. Currently, the widely used classification methods in the world are REAL classification and WHO classification. Domestically, it is customary to apply the 1982 US work plan.
After the lymphoma is diagnosed, the stage of the disease should be based on the Ann Arbor criteria.
2. Diagnostic evaluation
The diagnosis of lymphoma depends on pathological examination, and sufficient pathological specimens are the primary condition for correct diagnosis. Usually accompanied by superficial lymphadenopathy, routine lymph node biopsy, mediastinal or intra-abdominal lymphadenopathy, and lack of shallow For patients with enlarged lymph nodes, laparotomy or thoracotomy is required to obtain specimens. When the deep lymph nodes are fused into giant pieces, the Tru-Cut needle puncture effect is also quite satisfactory. Only the splenomegaly is clinically highly suspected of lymphoma. Timely splenectomy, liver biopsy at the same time to obtain more diagnostic basis, liver lesions, CT or ultrasound guided liver puncture, to obtain the required liver tissue.
Gastrointestinal microscopy and microscopic biopsy are very important for the diagnosis of gastrointestinal lymphoma, but the biopsy pathology and postoperative pathological results are not completely consistent. The non-conformity rate of a group of cases in Peking Union Medical College Hospital is 25.8%.
A small number of NHL manifested as fever, jaundice, abnormal liver function, whole blood cell decline or neuro-muscular symptoms in the early stage of the disease. There is no clear tumor block or puncture, and contraindications for biopsy. At this time, bone marrow examination is very important, bone marrow aspiration and The biopsy is carried out at the same time, and it needs to be repeated several times if necessary, and new techniques such as chromosome, immunophenotype and gene rearrangement should be tested as soon as possible to confirm the diagnosis at an early date.
The diagnosis of typical lymphoma is not difficult, but the clinician should pay enough attention to the extent and stage of the disease. When the lymphoma is diagnosed by pathological examination, bone marrow examination, chest and abdomen CT must be performed; Contrast, ultrasonography, although cheap, easy, but poor reproducibility, lack of long-term preservation of the image, only suitable for primary screening and follow-up after treatment.
The staging of lymphoma is an important basis for the development of treatment options, especially in HL. The current international Arnbor staging criteria (1971, 1989 Cotswald revision) is mainly applicable to HL. For NHL, this staging standard is not very good. Predicting the prognosis of the disease, therefore, it is possible to make a rough staging in a simple manner. When applying the Ann Arbor staging, one problem often encountered is how to determine the limitation when there is an extranodal organ (or tissue) involved. Lesions (stage I) or diffuse lesions (stage IV) are not described in detail in this literature. They can be understood as diffuse lesions when the entire organ is enlarged and imaging cannot distinguish a single lesion.
Lymphoma is a heterogeneous group of diseases. According to its pathological features, in addition to HL and NHL, there are many subtypes in each category. Pathologists all over the world have worked for half a century. Various classification standards were formulated. In 1994, the REAL program was gradually unified. On the basis of the REAL program, the WHO proposed the WHO classification method in 2000. The WHO classification method is based on the information provided by morphology, immunology and genetics. Emphasize that each subtype may become an independent disease, and that subtypes are not based on individual or group experience and should be widely recognized worldwide, WHO affirms: as technology advances and scholars deeper into lymphoma The understanding of the WHO taxonomy will be revised and improved.
Some doctors have thought that the classification of lymphoma subtypes is too cumbersome and has little value for clinical treatment, but there is increasing evidence that different subtypes of lymphoma may have special treatments, for example, gastric MALT lymphoma. If it is related to Helicobacter pylori, antibiotic treatment is effective; inert B-cell lymphoma is suitable for monoclonal antibody; ALK- anaplastic large cell lymphoma should be autologous hematopoietic stem cell transplantation early, therefore, pathologists and clinicians in China should learn Accept this classification and actively participate in its further revision.
In general, this type of diagnostic treatment is not appropriate unless there are special indications (for example, if a patient has a large mass or has a long-term fever and is given several days of radiotherapy or chemotherapy to create a surgical resection). Yes:
1 The existing radiotherapy and chemotherapy are not specific to the treatment of malignant lymphoma, inflammation, tuberculosis and other granulomas, tumors, etc., so in fact, these treatments can not be used to identify the nature of the disease, but because of cover up Contradictions make the diagnosis more confusing, and sometimes even biopsy can not make a definite diagnosis due to necrosis of the tissue, which will bring difficulties to future treatment.
2 Radiotherapy and most of the existing chemotherapy drugs have immunosuppressive effects, which can bring the opposite effect to patients and promote the development of hidden infections.
3 The short-term and long-term effects of radiotherapy and chemotherapy (such as skin reactions, bone marrow suppression, effects on bone development in children, etc.) are not good for patients.
For patients with confirmed malignant lymphoma, during the observation period after treatment, sometimes fever or individual lymph nodes may not be considered as "relapse" without thinking, but other causes may be sought. Due to the disease itself and long-term treatment, the immune function is often low, easy to catch a cold or general inflammation, so it is also more prone to fever or a certain part of the lymph nodes, if not treated properly, chemotherapy can be given to patients It has caused great harm. We have reported (1978) that one patient with HD had a good stage after treatment, but then continued to have fever, the lungs have radial shadows, and various anti-infective and anti-fungal treatments are ineffective. Therefore, it was suspected that HD recurred and chemotherapy was invaded in the lungs. However, after autopsy confirmed tuberculosis, no residual HD was found. Another young patient was admitted to hospital due to progressive dyspnea, cyanosis, upper body edema, and mediastinum in chest. There is a huge shadow, diagnosed as mediastinal malignant lymphoma with superior vena cava compression, immediately given oxygen inhalation and hydrocortisone and nitrogen mustard treatment, the next day The patient was significantly relieved and was free to move. After X-ray chest radiography, the diagnosis was as before. After one-stage chemotherapy, the patient was changed to radiotherapy. However, after the shadow was slightly reduced, the patient would not continue to shrink. After discussion, the thoracotomy was confirmed to be tuberculosis. These lessons can be taken as a warning.
Differential diagnosis
Clinically, malignant lymphoma is often misdiagnosed. For example, 70% to 80% of patients with malignant lymphoma who have a superficial lymph node enlargement are diagnosed with lymphadenitis or lymph node tuberculosis at the time of initial diagnosis, resulting in delay in treatment. The differential diagnosis of malignant lymphoma is of great significance.
Malignant lymphoma should be identified with the following diseases:
Chronic lymphadenitis
There are obvious infections, and often focal lymphadenopathy, pain and tenderness, generally no more than 2 ~ 3cm, can be reduced after anti-infective treatment, clinically misdiagnosed as malignant lymphoma is the repetitive tonsil in some children The onset of inflammation, due to bacteremia caused by superficial lymph node enlargement, palpation by hand, the tonsil is often softer than the malignant lymphoma invasion of the tonsils, sometimes can squeeze out pus, these children often have lymph nodes due to fever Swollen, shrinking after heat retreat, can exist for many years without development, but these can not be regarded as absolute, some malignant lymphoma, especially HD, may also have periodic fever and lymph node enlargement, shrinking history, Therefore, it should be considered comprehensively.
Because many people suffer from athlete's foot, inguinal lymphadenopathy, especially the long-standing and unchanged flat lymph nodes, there is no significant significance, but there is no obvious cause of bilateral trochlear or neck, supra-sacral lymph nodes, should pay attention to Although it is not certain that it is a malignant lymphoma, it at least marks a systemic lymphoid tissue disease, which should be further examined to determine the nature.
2. Giant lymph node hyperplasia
For an unexplained lymph node enlargement, mainly invading the chest cavity, with the most mediastinum, can also invade the hilar and lung. Other affected parts are the neck, retroperitoneum, pelvis, armpit and soft tissue. Patients often use a lump. Its signs, located in the chest cavity may appear compression symptoms, but often found, there are fever, anemia and plasma protein increased systemic symptoms, after the tumor resection, symptoms disappear, tuberculosis, pulmonary fungal disease, etc., based only on X-ray Examination is sometimes difficult to distinguish from malignant lymphoma and lung lesions. Ga scan is sometimes helpful for diagnosis, especially for the identification of pulmonary fibrosis and lung invasion caused by radiotherapy.
3. The pathological and clinical manifestations of HD and NHL have different characteristics, but these characteristics are relative and only for clinical reference.
