|Year : 2017 | Volume
| Issue : 3 | Page : 140-144
Clinicopathological profile of patients with non-hodgkin's lymphoma at a regional cancer center in Northeast India
Adhikarimayum Ambika Devi, Takhenchangbam Dhaneshor Sharma, Yengkhom Indibor Singh, Hage Sonia
Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||14-Feb-2018|
Adhikarimayum Ambika Devi
Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Context: Incidence of non-Hodgkin's lymphoma (NHL) is increasing in all parts of the world, especially over the past few decades. An insight into the clinical presentation may help in the prevention, control, and treatment of NHL. Aim: To observe the clinicopathological patterns of NHL among patients in Northeast India. Subjects and Methods: A retrospective case study on 100 proven cases of NHL registered at the Regional Institute of Medical Sciences, Manipur, during the period January 2013–May 2017 was conducted, and data were reviewed and analyzed. Statistical Analysis Used: Data were analyzed using SPSS-21 and results were presented in percentages and simple frequency. Results: Majority (43.0%) of the patients were in the age group of 41 and 60 years. The mean age was 54.01 ± 18.1 years. Male:female ratio was 1.2:1. The most common presenting symptom was neck swelling (57.0%), and peripheral lymphadenopathy (76.0%) was the most common sign. Primary site distribution was nodal (57.0%) and extra-nodal NHL (43.0%). Most common nodal site involved was cervical lymph nodes (65.0%), and gastrointestinal tract (17.0%) was the most common extranodal subsite. Majority of the patients were in stage II (36.0%) at the time of diagnosis. B-cell NHL accounts for 66.0% compared to T-cell lymphoma (23.0%). Diffuse large B-cell lymphoma was the most frequent B-cell lymphoma (45.0%), and anaplastic large cell lymphoma was the most common T-cell variant (15.0%). Conclusions: A thorough insight into the clinical spectrum of NHL is necessary for optimum management and improved treatment outcome.
Keywords: Clinical presentation, non-Hodgkin's lymphoma, pathological profile
|How to cite this article:|
Devi AA, Sharma TD, Singh YI, Sonia H. Clinicopathological profile of patients with non-hodgkin's lymphoma at a regional cancer center in Northeast India. J Sci Soc 2017;44:140-4
|How to cite this URL:|
Devi AA, Sharma TD, Singh YI, Sonia H. Clinicopathological profile of patients with non-hodgkin's lymphoma at a regional cancer center in Northeast India. J Sci Soc [serial online] 2017 [cited 2019 Jan 23];44:140-4. Available from: http://www.jscisociety.com/text.asp?2017/44/3/140/225507
| Introduction|| |
Non-Hodgkin's lymphomas (NHL) are a diverse group of lymphoproliferative diseases with different clinical and histological appearances. It accounts for 3% of all malignancies worldwide with a rising trend during the past few decades.,
The overall incidence of NHL shows considerable variations across geographic regions. In India, Delhi has the highest age-adjusted incidence rates (AARs). Manipur state shows AAR per 100,000 populations to be 2.6 in males and 2.5 among females.
The most well-established risk factor of NHL is immunosuppression. Others include primary disorders of immune dysfunction, organ-transplant recipients, HIV/AIDS, infectious agents (Epstein–Barr virus, human T-cell leukemia virus type 1, human herpesvirus 8, Helicobacter pylori), and autoimmune and other chronic inflammatory disorders.
Most patients present with painless generalized lymphadenopathy. Others may present with extranodal disease, the main sites being gastrointestinal tract, head and neck, and skin, but virtually any tissue or organ can be affected.
Due to limited local data on NHL, a thorough insight into the clinical spectrum of NHL is necessary for optimum management and improved treatment outcome. Hence, we conducted this retrospective study to observe the clinicopathological patterns of NHL among patients in this region of India.
Aims and objectives
To evaluate the clinicopathological patterns of NHL among patients in Northeast India.
| Subjects and Methods|| |
The departmental case records of all proven NHL patients presented at our center between January 2013 and May 2017 were evaluated. Case records were reviewed for demographical details, presenting complaints, and symptoms. All cases underwent initial staging workup by Ann Arbor System and histological classification according to 2008 WHO classification of lymphoid neoplasms. Imaging reports such as chest X-rays, abdominal and pelvic ultrasounds, computed tomography scans of brain, head and neck, thorax, and abdomen, and magnetic resonance imaging scans were also reviewed. Details of immunohistochemistry findings if any (CD 20, CD 3, CD 5, CD 45/LCA, CD 10, CD 56, and CD 30) were also reviewed. Other relevant test reports such as bone marrow examination and cerebrospinal fluid analysis were also reviewed. Data were analyzed using IBM SPSS statistics 21 (IBM Corp, 1995, 2012) and results are presented in percentages and simple frequency.
| Results|| |
One hundred patients between the above-mentioned dates were evaluable. The mean age at diagnosis was 54.01 ± 18.1 years. Maximum cases were in the age group of 41–60 years (43.0%) as seen in [Figure 1] with a male-female ratio of 1.2:1. Clinical profile of ptients are shown in [Table 1].
|Figure 1: Age distribution of patients (n = 100). NHL = non-Hodgkin's Lymphoma|
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Neck swelling was the most common presenting complaint (57.0%), followed by abdominal pain (28.0%), weight loss (36.0%), fever (32.0%), anorexia and fatigue (42.0%), and dysphagia (26.0%). The occurrence of “B” symptoms (fever >38°C, night sweats, or weight loss >10% of body weight in the last 6 months, or a combination of these) was noted in 48 (48.0%) cases of NHL.
Forty cases (40.0%) were tobacco users, 14 patients (14.0%) were addicted to alcohol, and in 10 (10.0%) cases, there had been a history of both tobacco and alcohol addiction.
Peripheral lymphadenopathy being the most common sign was detected in 76 cases (76.0%) of NHL. Anemia was present in 46 cases (46.0%). Hepatomegaly and splenomegaly were found in 44 cases (44.0%) and 30 cases (30.0%), respectively. Pedal edema was observed in 3 (3.0%), ascites in 7 (7.0%), and pleural effusion in 5 (5.0%) cases.
The most common involved lymph node sites were cervical lymph (65.0%), inguinal (20.0%), axillary (18.0%), supraclavicular (15.0%), mediastinal (7.0%), para-aortic nodes (7.0%), and others; less common sites were hilar, gastrohepatic, celiac, iliac, retropectoral nodes (7.0%).
The distribution according to the primary site presentation was nodal NHL − 57 (57.0%) and extra-nodal NHL − 43 (43.0%). Among nodal NHL, majority of the patients (31.0%) had <3 nodal site involvement, 8 patients (8.0%) had involvement of 4–6 nodal sites, and 5 patients (5.0%) had more than 6 nodal sites involvement [Table 2].
Organ involvement in extra-nodal NHL included gastrointestinal tract (GIT) in 17.0%, head and neck areas (14.0%), skin (4%), liver (3.0%), and bone marrow (13.0%); unusual sites were testis (1.0%), adrenal (1.0%), lung (1.0%), and renal (1.0%). Among extra-nodal NHL, 24 patients (24.0%) have single extranodal site involvement while 19 patients (19.0%) had multifocal disease [Table 3].
Among the total cases, 48 (48.0%) patients had bulky disease. Thirteen patients (13.0%) have bone marrow involvement.
According to immunophenotype examination, majority of the NHL were B-cell type (66.0%) and T-cell type was seen in 23 cases (23.0%) as shown in [Table 4]. Immunophenotype could not be ascertained in 11 cases (11.0%). Among the B-cell lymphoma, majority of the cases were diffuse large B-cell lymphoma (DLBCL) seen in 45%, followed by Burkitt's lymphoma (6.0%), follicular lymphoma (5.0%), mantle cell lymphoma (5.0%), large B-cell (2.0%), splenic marginal zone lymphoma (1.0%), mucosa-associated lymphoid tissue lymphoma (1.0%), and plasma cell myeloma (1.0%) as seen in [Figure 2]. B-cell markers CD20 and CD45 positivity was noted in 96.7% and 90.9% of B-cell lymphomas, respectively.
|Figure 2: Histologic characteristics (n = 100). DLBCL- Diffuse large B-cell lymphoma, MALT- Mucosa-associated lymphoid tissue, NOS- Not otherwise specified|
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Majority of T-cell lymphoma were anaplastic large cell lymphoma (ALCL), noted in 15.0% followed by angioimmunoblastic lymphoma (5.0%), primary cutaneous T-cell lymphoma (2.0%), and NK/T-cell lymphoma, nasal type (1.0%). T-cell marker CD3 was immunoreactive in 75.0% of T-cell lymphomas.
| Discussion|| |
NHL occurs more frequently in adults. The mean age of occurrence in most Western and Asian countries is between 50 and 60 years of age., The mean age in our present study was 54.01 ± 18.1 years, which was higher than that in Darjeeling, India, with a mean age of 39.9 years.
We found a male-to-female ratio of 1.2, which differs largely with other studies elsewhere in the country where the ratio was 3., However, it was consistent with ratio of 1.6 in Asia, 1.2 and 1.1 in North America and Europe, respectively.
The most frequent symptom in our study was neck swelling (57.0%), and the most common presenting sign is peripheral lymphadenopathy (76.0%), similar to the study from Darjeeling where neck swelling (65.8%) and peripheral lymphadenopathy (94.7%) were most frequent. The most commonly involved lymph node group was cervical (65.0%), followed by intra-abdominal (28.0%) and inguinal nodes (20.0%) in our study, while in the above study, the most frequent was cervical (78.95%) and axillary (55.3%). In a study from Pakistan, however, para-aortic lymph nodes was most frequently involved followed by cervical and axillary. A European study has also documented cervical lymphadenopathy in 41% followed by intra-abdominal (35%) and inguinal lymphadenopathy (26%).
Forty-eight (48.0%) cases in our study presented with B- symptoms which was comparatively higher than South India (23.9%) and Pakistan (36.7%),, but lower number of cases have been reported as compared to studies from Darjeeling (63.16%) and Pakistan (61%).,
Hepatomegaly was noted in 44% cases and splenomegaly in 30% cases in our study. A Pakistani study has documented 19.4% and 48.6%, and a European study reported 6% and 17% of hepatomegaly and splenomegaly cases, respectively, but higher number of cases were observed in another study from Pakistan where 83.6% and 44.8% cases of the same were reported.,,
Forty-three cases in our study (43.0%) had extranodal involvement on initial presentation which was consistent with 42.6% extranodal disease from a study in South India but higher compared to North India (23.5%).,
The most common extranodal site involved in our study was GIT (17.0%), followed by head-and-neck lymphomas (14.0%). A study from South India reported head and neck as the most frequent site followed by GIT. Bone marrow was the most common extranodal site from a study in Pakistan, and another study from South India reported the central nervous system as the most frequent extranodal site., Among GIT lymphomas, stomach is the most common GIT site in a European study and in South India, but in our study there was equal incidence of both stomach (7.0%) and large bowel lymphomas (7.0%).,
In our study, B-cell lymphoma comprises 66.0% and T-cell lymphomas constituted 23.0% similar to other studies in South India where B-cell and T-cell formed 79.1%–79.3% and 16.2%–18.8%, respectively.,
The most common B-cell subtype is DLBCL (45.0%) and among T-cell subtype is ALCL (15.0%). It is consistent with an Indian study where DLBCL formed 34% of all NHLs; however, among T-cells, T-cell lymphoblastic lymphoma was the most common subtype (6%). Compared to an Indian study where frequency of DLBCL (50.2%) was followed by follicular lymphoma (13.2%), our study had low frequency of follicular type (5.0%). However, this trend of low frequency of follicular type (1.8%) was observed in Asian studies too.
In our study, B-cell markers CD20 and CD45 positivity was noted in 96.7% and 90.9% of B-cell lymphomas, respectively, while CD3 marker for T-cell was immunoreactive in 75.0% of T-cell lymphomas. In a South Indian study, 38 cases (72%) showed B-cell expression and 12 cases (22.5%) showed T-cell expression while three cases did not express either marker. Immunohistochemistry has an important role in lymphoma for subtyping, prognostication, and the potential for targeted therapy.
| Conclusions|| |
The incidence of NHL is increasing worldwide especially over the past few decades. NHL shows wide variation in its clinical presentation and pathological profile. A thorough insight into the clinical spectrum of NHL is necessary for optimum management and improved treatment outcome.
We would like to acknowledge the Regional Institute of Medical Sciences, Imphal, for providing data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fisher SG, Fisher RI. The epidemiology of non-Hodgkin's lymphoma. Oncogene 2004;23:6524-34.
Nair R, Arora N, Mallath MK. Epidemiology of non-Hodgkin's lymphoma in India. Oncology 2016;91 Suppl 1:18-25.
Ekström-Smedby K. Epidemiology and etiology of non-Hodgkin lymphoma – A review. Acta Oncol 2006;45:258-71.
Shankland KR, Armitage JO, Hancock BW. Non-Hodgkin lymphoma. Lancet 2012;380:848-57.
García Zueco JC, Delgado MP, Giraldo MP, Perella M, Torres M, Valero MI, et al.
Non-Hodgkin's lymphomas. I. Clinico-biological features of 307 cases. Sangre (Barc) 1992;37:331-6.
Yoon SO, Suh C, Lee DH, Chi HS, Park CJ, Jang SS, et al.
Distribution of lymphoid neoplasms in the republic of Korea: Analysis of 5318 cases according to the World Health Organization classification. Am J Hematol 2010;85:760-4.
Chakrabarti S, Sarkar S, Goswami BK, Mondal S, Roy A, Das S, et al.
Hodgkin's and non-Hodgkin's lymphomas in an Indian rural medical institution: Comparative clinicopathologic analysis. Asian Pac J Cancer Prev 2010;11:1605-8.
Bhardwaj A, Kishore S, Kusum A. Comparative analysis of the distribution of various subtypes of lymphoid malignanciesin Uttarakhand with other regions in India. Ind Med Gaz 2012;4:147-52.
Hingorjo MR, Syed S. Presentation, staging and diagnosis of lymphoma: A clinical perspective. J Ayub Med Coll Abbottabad 2008;20:100-3.
Krol AD, le Cessie S, Snijder S, Kluin-Nelemans JC, Kluin PM, Noordijk EM, et al.
Primary extranodal non-Hodgkin's lymphoma (NHL): The impact of alternative definitions tested in the comprehensive cancer centre West population-based NHL registry. Ann Oncol 2003;14:131-9.
Neeravari VS, Bannigidad D. Clinical spectrum of non-Hodgkin lymphoma: A hospital based study of 410 Cases. Ann Appl Bio Sci 2016;3:89-93.
Lal A, Bhurgri Y, Vaziri I, Rizvi NB, Sadaf A, Sartajuddin S, et al.
Extranodal non-Hodgkin's lymphomas – A retrospective review of clinico-pathologic features and outcomes in comparison with nodal non-Hodgkin's lymphomas. Asian Pac J Cancer Prev 2008;9:453-8.
Aziz Z, Rehman A, Akram M, Saeed A. Non-Hodgkin's lymphoma in Pakistan: A clinicopathological profile of 175 patients. J Pak Med Assoc 1999;49:11-5.
Bhatia P, Das R, Ahluwalia J, Malhotra P, Varma N, Varma S, et al.
Hematological evaluation of primary extra nodal versus nodal NHL: A Study from North India. Indian J Hematol Blood Transfus 2011;27:88-92.
Mishra P, Das S, Kar R, Jacob SE, Basu D. Primary extranodal non-Hodgkin lymphoma: A 3-year record-based descriptive study from a tertiary care center in Southern India. Indian J Pathol Microbiol 2015;58:296-300.
] [Full text]
Padhi S, Paul TR, Challa S, Prayaga AK, Rajappa S, Raghunadharao D, et al.
Primary extra nodal non Hodgkin lymphoma: A 5 year retrospective analysis. Asian Pac J Cancer Prev 2012;13:4889-95.
Papaxoinis G, Papageorgiou S, Rontogianni D, Kaloutsi V, Fountzilas G, Pavlidis N, et al.
Primary gastrointestinal non-Hodgkin's lymphoma: A clinicopathologic study of 128 cases in Greece. A Hellenic cooperative oncology group study (HeCOG). Leuk Lymphoma 2006;47:2140-6.
Naresh KN, Srinivas V, Soman CS. Distribution of various subtypes of non-Hodgkin's lymphoma in India: A study of 2773 lymphomas using R.E.A.L. and WHO classifications. Ann Oncol 2000;11 Suppl 1:63-7.
Sahni CS, Desai SB. Distribution and clinicopathologic characteristics of non-Hodgkin's lymphoma in India: A study of 935 cases using WHO classification of lymphoid neoplasms (2000). Leuk Lymphoma 2007;48:122-33.
Kalyan K, Basu D, Soundararaghavan J. Immunohistochemical typing of non-Hodgkin's lymphoma-comparing working formulation and WHO classification. Indian J Pathol Microbiol 2006;49:203-7.
Rao IS. Role of immunohistochemistry in lymphoma. Indian J Med Paediatr Oncol 2010;31:145-7.
] [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]