Lymphoma Management
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Direct answer
A whole lymph node — excision biopsy, not fine-needle aspiration — remains the non-negotiable first step in suspected lymphoma, because architecture and immunohistochemistry decide everything downstream; in India this rule carries extra weight, since tuberculosis mimics lymphoma node for node and only histology separates them. Hodgkin lymphoma, Reed-Sternberg CD30 and CD15 positive, is treated with two to six cycles of ABVD guided by interim PET-CT read on the Deauville scale; diffuse large B-cell lymphoma, the commonest aggressive non-Hodgkin lymphoma, receives six cycles of R-CHOP with intrathecal prophylaxis in selected high-risk patients. PET-CT stages both, and a score of 4 or less on Deauville means metabolic complete response.
What you must remember
- Biopsy rules: excision biopsy preferred, core needle acceptable when nodes are inaccessible; fine-needle aspiration cytology alone is inadequate — it sees cells but not architecture.
- Hodgkin markers: classic Reed-Sternberg cells are CD30 and CD15 positive, CD45 negative; nodular lymphocyte-predominant Hodgkin swaps these for CD20-positive popcorn cells and is treated more like indolent lymphoma, often with anti-CD20 therapy alone in early stage.
- ABVD: adriamycin, bleomycin, vinblastine, dacarbazine — two cycles for favourable early stage, four for unfavourable early stage, six for advanced; interim PET with Deauville 1–4 allows de-escalation in favourable responses.
- Deauville 5 (uptake greater than liver) on interim scan warrants biopsy before escalation, because false positives from inflammation, infection or tuberculosis are common in India.
- DLBCL standard: R-CHOP every 21 days for six cycles with growth-factor support; add intrathecal methotrexate for testicular, paranasal, breast or marrow-involving disease and other central nervous system risk constellations.
- Double-hit lymphoma (MYC plus BCL2 rearrangements) will not be cured by R-CHOP — intensive regimens such as DA-EPOCH-R plus transplant consideration.
- Follicular lymphoma: watch and wait remains legitimate for asymptomatic disease; treat symptoms or bulk with anti-CD20-based chemoimmunotherapy.
- Gastric MALT lymphoma stage I is treated first with Helicobacter pylori eradication — remission in most, with molecular follow-up of the t(11;18)-negative majority responding best.
- Extranodal NK/T-cell lymphoma, nasal type — over-represented in Indian and East Asian practice — responds to asparaginase-based regimens with early radiotherapy, not to conventional anthracycline regimens.
Staging and first-line decisions by subtype
A 24-year-old presents with a rubbery cervical node and drenching night sweats. The node is excised: nodular sclerosis classical Hodgkin lymphoma. PET-CT stages him as IIB with bulk. He receives two cycles of ABVD, then an interim PET showing Deauville 3 — residual uptake below liver — which is metabolic complete response; he completes four total cycles with involved-field radiotherapy and is cured with survival odds above 90%. Had his interim scan shown Deauville 5, the correct move is biopsy of the hot site before escalating to escalated chemotherapy, because granulomatous inflammation in an Indian patient is as likely as relapse.
Shift the same age to a rapidly growing nodal mass with lactate dehydrogenase thrice normal: diffuse large B-cell lymphoma on biopsy, CD20 positive. R-CHOP begins within a week, with hepatitis B screening beforehand (rituximab can reactivate hepatitis B — a mandatory pre-treatment test in India), tumour lysis precautions, and intrathecal prophylaxis because the marrow is involved. Two years later a slow-growing node returns as follicular lymphoma — the natural history of transformation and relapse — and the conversation moves to watchful waiting or anti-CD20 chemoimmunotherapy.
Close with the nasal-type variant: a 40-year-old with a destructive nasal mass and haemoptysis. Biopsy shows CD56-positive extranodal NK/T-cell lymphoma. Anthracycline-based R-CHOP underperforms here; asparaginase-containing regimens with concurrent radiotherapy are the answer, illustrating why histology, not habit, drives lymphoma therapy.
Where students slip
The reflex error is accepting a fine-needle aspiration diagnosis of "lymphoma" — the examiner will plant a cytology report in the stem precisely to test whether you demand an excision biopsy. The second slip is reading an interim PET without Deauville language: uptake that is "persistent" but below liver (score 3) is complete response, and escalating therapy for it over-treats. Third is forgetting hepatitis B serology before rituximab. Fourth, in the Indian setting, is failing to consider tuberculosis in a granuloma-studded node or a fluorodeoxyglucose-avid mediastinal mass — the biopsy exists precisely to settle that question.
Frequently asked questions
Why is fine-needle aspiration inadequate for lymphoma?
Cytology samples cells without architecture, so it cannot grade follicular lymphoma, identify Hodgkin in a fibrotic node, or exclude tuberculosis — excision biopsy is the standard.
What does a Deauville score of 3 mean?
Uptake greater than mediastinum but not greater than liver — counted as complete metabolic response on interim or end-of-treatment PET-CT.
What is the first-line therapy for advanced Hodgkin lymphoma?
Six cycles of ABVD, adapted by interim PET-CT response; escalated regimens reserved for adverse features or non-response.
Which DLBCL patients need central nervous system prophylaxis?
Those with testicular, paranasal, breast or bone marrow involvement, or multiple extranodal sites with high lactate dehydrogenase — intrathecal or systemic methotrexate.
How is stage I gastric MALT lymphoma treated first?
Helicobacter pylori eradication with confirmation of clearance, which induces remission in most localised cases; radiotherapy for non-responders.
Which lymphoma subtype common in India needs asparaginase-based therapy?
Extranodal NK/T-cell lymphoma, nasal type — asparaginase regimens with early radiotherapy, since anthracycline-based therapy fails.