Introduction to Non-Hodgkin's Lymphoma (NHL)

Introduction:

non-Hodgkin's lymphoma(non-hodgkin's lymphoma, NHL) isMalignant lymphomaA large proportion of non-Hodgkin's lymphomas in malignant lymphomas in China is much higher than Hodgkin's disease (HD). In recent years, the incidence of NHL in many countries has increased. The pathological type, clinical manifestations and treatment of NHL are far more complicated than HD. From the available data, NHL is a group of very heterogeneous diseases with different causes, pathologies, clinical manifestations and treatments. So far, the total cure rate is also lower than HD. The duration of the disease varies from no obvious symptoms and early tolerable to rapid death. In some types of NHL, 50% of children and about 20% of adult patients develop leukemia-like changes.

Cause:

(1) Causes of the disease

The causes of non-Hodgkin's lymphoma involve a variety of factors including viruses, bacteria, radiation, certain chemicals, and herbicides. Epstein-Barr virus is known to be associated with high-risk Burkitt lymphoma and extranodal T/NK cell lymphoma, nasal type. Adult T-cell lymphoma/leukemia is closely associated with human pro-T-cell virus type I (HTLV1) infection. Gastric mucosa-associated lymphoid tissue lymphoma is a malignant change caused by the initiation of reactive lesions infected by H. pylori. Radiation exposure, such as survivors of nuclear explosions and nuclear reactor accidents, and cancer patients receiving radiation and chemotherapy, are at increased risk of non-Hodgkin's lymphoma.

AIDS, certain hereditary, acquired immunodeficiency diseases or autoimmune diseases such asAtaxia-telangiectasiaJoint immunodeficiency syndrome,Rheumatoid arthritisImmune dysfunction caused by systemic lupus erythematosus, Sjogren's syndrome (Sjogren's syndrome), hypogammaglobulinemia, and long-term immunosuppressive drugs (such as organ transplants) High risk factors for the onset of Hodgkin's lymphoma.

Non-Hodgkin's lymphoma is more common than Hodgkin's disease. The United States diagnoses about 50,000 cases each year. It can occur in all age groups, and the incidence increases with age. Although there are reliable experimental evidences like leukemia suggesting certain lymphomas. Caused by the virus, but the cause is still unclear. For example, HTLV-1 (reverse transcription of human T-cell leukemia-lymphoma virus) has been isolated and appears to be prevalent in southern Japan, the Caribbean, South America and the southeastern United States. Acute adult T cells leukemia-LymphomaThe clinical manifestations of acute attack are skin infiltration, lymphadenopathy, hepatosplenomegaly and leukemia. Leukemia cells are malignant T lymphocytes, mostly with tortuous nucleus. Hypercalcemia often occurs due to humoral factors rather than bone direct Infringed.

In AIDS, the incidence of NHL, especially immunoblasts and Burkitt's lymphoma, has increased. Primary invasion of the central nervous system and diffuse lesions has been reported. About 30% of patients have generalized lymphadenopathy. Appears in lymphoma, suggesting that B cell polyclonal stimulation precedes lymphoma. Some AIDS-associated lymphomas may have C-myc gene rearrangement. It may be effective for chemotherapy, but common and conditional infections occur continuously, which will Caused a short life.

(two) pathogenesis

Due to the different stages of differentiation of lymphocytes, different stages of tumor cells can occur in the affected lymph nodes or lymphoid tissues. In the same lesion, there may be poorly differentiated tumor cells or cells with more mature differentiation. As the lesion progresses, the histological type of malignant lymphoma may change, such as nodular type can be transformed 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 and B lymphocytes at 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, positive for CD4, including adult T-cell lymphoma (ATL), mycosis fungoides, Sezary syndrome, and most so-called peripheral T-cell lymphoma (international work) Diffuse large cells, immunoblasts, and mixed lymphoma in the classification) and more than half of T cell chronic lymphocytic leukemia. There are some peripheral T-cell lymphoma, nearly half of T-cell chronic lymphocytic leukemia and some Tγ lymphoproliferative diseases, CD8 positive.

B-cell lymphoma has fewer specific antibodies but has a surfaceImmunoglobulinexpression. The earliest B cells have the expression of CD10 and CD19 on the surface, and there are terminal transferases in the cells and recombination of the heavy bond genes. Later, the cells express CD20, the μ heavy bond is generated in the cytoplasm, the recombination of the K light bond gene, the recombination of the λ light bond gene, and the terminal transferase loss. These represent the developing pre-B cell stage. After the cell loses the expression of CD10, it becomes an immature B cell with IgM expression on its surface. IgD and IgM are produced on the surface of the cell surface expressing CD21 receptor (C3d). The developmental stage of all B cells occurs under antigenic stimulation, and the immunoglobulin genes are activated and secreted after being stimulated by the antigen. Thereafter, the cells lose CD21, CD20 and surface immunoglobulin, and the markers PC-1 and PC-2 of the plasma cells are secreted to secrete immunoglobulin. This is the development process of B cells in the cell follicle center, which becomes lymphocytic lymphoma after malignant transformation.

The maturation of the B-cells in the follicular center and the initiation of the immunoglobulin genes are regulated by T helper cells, but there are also some unknown B lymphocytes. The B cells in the mantle cell area appear to be relatively less affected by T cells, which are CD5 positive, which 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. Macroglobulinemia (Waldenstrom syndrome) andMultiple myelomaFrom the terminal stage of differentiation, chronic lymphocytic leukemia expresses CD5, and diffuse moderately differentiated lymphoma expresses CD5 and CD10, suggesting that these are B cells from the mantle cell region rather than the follicular center.

The immunophenoty and clinical manifestations of some lymphomas are still very confusing. Diffuse large cell lymphoma 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-cell lymphoma is derived from mature T cells from an immunophenotype, but clinical manifestations are very dangerous, like lymphoblastic lymphoma from immature T cells. These are for further study, especially the role of different genes in them.

symptom:

The disease can be seen at any age, and the clinical manifestations can be summarized as follows:

1. Superficial lymphadenopathy or formation of nodules, masses is the most common first clinical manifestation, accounting for 60% to 70% of all cases, especially cervical lymphadenopathy (49.3%), followed by armpits, groin Lymph nodes (12.9%, 12.7% each). Lymph node masses vary in size, often asymmetrical, firm and elastic, and have no tenderness. In low-grade lymphoma, lymph nodes are mostly scattered, non-adhesive, multiple lymph nodes that are active, while invasive or highly aggressive lymphomas, with rapid progression, lymph nodes often fuse into clusters, sometimes adhering to the basal and skin. And may have local soft tissue infiltration, compression, edema performance.

2. Deep lymph nodes in the body may cause corresponding symptoms due to infiltration, compression, obstruction or tissue destruction due to their occurrence in different sites. For example, mediastinal, hilar lymph node mass can cause chest tightness, chest pain, dyspnea, superior vena cava compression syndrome and other clinical manifestations, intra-abdominal (mesenteric lymph nodes, retroperitoneal lymph nodes) mass, can cause abdominal pain, abdominal mass, intestinal obstruction, ureter Obstruction, renal effusion and other manifestations.

3. Hyperplasia and mass of extranodal lymphoid tissue may also cause corresponding symptoms due to different parts. At the time of initial diagnosis, only the extranodal lesions and no superficial lymph nodes were enlarged, accounting for 21.9%. Extranodal lesions are most common with the pharyngeal ring, which is characterized by a swollen tonsil or a pharyngeal mass. Submucosal lymphoid tissue in the gastrointestinal tract can be invaded to cause abdominal pain, abdominal mass, gastrointestinal obstruction, bleeding, and perforation. When the liver is invaded by lymphoma, it may have swelling and jaundice. Extranodal lymphoma can also invade the orbital eyeball, unilateral or bilateral breast mass, and can invade the bone marrow, causing anemia, bone pain, bone destruction, and even pathological fractures. When the intracranial is violated, it can cause headache, visual impairment and other symptoms of increased intracranial pressure. The lesion can also compress nerves caused by peripheral nerves, such as facial nerve spasms. It can also invade the spinal canal, causing spinal cord compression and paraplegia. Some types of non-Hodgkin's lymphoma, especially T-cell lymphoma, are prone to skin infiltration, nodules or tumors. Mycosis fungoides and Sézary syndrome are special types of cutaneous T-cell lymphoma. There is also a type of extranodal lymphoma, nasal and nasal NK/T-cell lymphoma, formerly known as "middle-line necrotizing granuloma" and "central vascular lymphoma". The most common first-time site in clinical practice is Nasal cavity, followed by ankle, nasopharynx and tonsils.

Because lymphoma can occur from lymph nodes (superficial and deep) and extranodal lymphoid tissues of various organs, and can invade various tissues and organs during its development, its clinical manifestations can be very complicated and diverse. Lymphoma of different tissue types also often has its clinical features.

4. Systemic symptoms Non-Hodgkin's lymphoma may also have systemic symptoms, including general wasting symptoms such as anemia, weight loss, weakness, and may also have special "B" symptoms (with Hodgkin's lymphoma, including fever, night sweats) And weight loss). However, in general, the systemic symptoms of non-Hodgkin's lymphoma are less common than Hodgkin's lymphoma, and more common in the later stages of the disease. In fact, fever, night sweats, and weight loss, which are common in the late stages of the disease, are sometimes difficult to distinguish between clinical manifestations of the disease, long-term treatment (chemotherapy, radiotherapy), or co-infection due to impaired advanced immune function. .

1. The diagnosis of this disease depends on histological biopsy (including immunohistochemistry and molecular cytogenetics). These histological, immunological, and cytogenetic tests not only confirm NHL, but also make a type of diagnosis, which is critical to understanding the malignancy of the disease, estimating the prognosis, and choosing the right treatment.

Any lymph node with no obvious infection should be considered in this disease. If the swollen lymph nodes are full, tough and so on, the disease should be considered. Sometimes swollen lymph nodes can be temporarily reduced due to anti-inflammatory measures, and then grow up again; some patients have superficial lymph nodes, but have symptoms such as fever, night sweats, and weight loss over a long period of time. Adrenal lymph nodes and other conditions.

2. The staging is the same as the HD staging.

Must be associated with Hodgkin's disease, reactive follicular hyperplasia, acute and chronic leukemia, infectious mononucleosis, cat paw disease, malignant melanoma, tuberculosis (especially primary tuberculosis with hilar lymphadenopathy) And other diseases that cause lymphadenopathy include the differentiation of pseudolymphoma caused by phenytoin. The diagnosis of NHL relies on biopsy of diseased lymph nodes or related tissues. Pathological diagnosis should include at least two parts, namely histological typing and immunophenotype of tumor cells, and if necessary, immunoglobulin and T cell receptor gene rearrangement analysis, as well as cytogenetic testing. The usual diagnostic criteria for histology is that the structure of the normal lymph nodes is destroyed, and the envelope and adjacent fat are invaded by typical tumor cells. Phenotypic examination can determine the source of the cells and their subtypes, help to determine the prognosis, and The treatment regimen may also be valuable (see below). The presence of leukocyte common antigen (CD45) is determined by immunoperoxidase assay (usually used for the differential diagnosis of undifferentiated malignancies), and metastatic cancer is excluded. This method can be used on fixed tissues. Used to determine leukocyte public antigens. Most surface markers can also be examined on fixed tissues using the immunoperoxidase method.

diagnosis:

It is difficult to make a definitive diagnosis based on clinical judgment alone. Many normal healthy people can also touch certain lymph nodes in the neck or groin. The enlargement of lymph nodes can also be seen in bacterial, tuberculosis or protozoal infections and certain viral infections. It also needs to be differentiated from lymph node metastasis. The specific identification is as follows:

1. Chronic lymphadenitis Generally, chronic lymphadenitis has multiple infections. In the acute phase of infection, such as foot and ankle infection, it can cause ipsilateral inguinal lymphadenopathy, or with acute manifestations such as redness, swelling, heat, pain, or only lymphadenopathy with pain. After the acute phase, the lymph nodes shrink and the pain disappears. Generally, the lymph nodes of chronic lymphadenitis are small, about 0.5-1.0 cm, the texture is soft, flat, and more active, while the lymph node enlargement of malignant lymphoma is characterized by large, full, and toughness, and biopsy is performed if necessary.

2. In addition to different degrees of fever, acute suppurative tonsillitis, the tonsils are mostly bilateral swelling, red, swollen, pain, and attached with pus moss, the texture of the sputum is soft, after the inflammation control, the tonsils can be reduced . Malignant lymphoma invades the tonsils, which can be bilaterally or unilaterally. It can be asymmetrically swollen. The texture of the sputum is hard and tough. Later, it involves the surrounding tissue. When suspicious, it can be performed by tonsillectomy or biopsy. an examination.

3. Lymph node tuberculosis is a special type of chronic lymphadenitis, swollen lymph nodes are more common in the neck, more with tuberculosis, if accompanied by tuberculous systemic symptoms, such as low fever, night sweats, weight loss, etc., it is not easy to distinguish from malignant lymphoma Lymph node tuberculosis lymph nodes, hard, uneven surface, uneven texture, or cystic due to caseous necrosis, or adhesion to the skin, poor mobility, PPD test was positive.

However, it should be noted that patients with malignant lymphoma may have tuberculosis, which may be due to long-term anti-tumor treatment, decreased immunity, and tuberculosis. Therefore, it should be vigilant in clinical practice. Whenever the condition changes, it should be obtained again. Pathological or cytological evidence to avoid misdiagnosis and mistreatment.

4. Sarcoidosis is more common in adolescents and middle-aged people. It can invade lymph nodes and can be swollen with multiple lymph nodes. It is common in the lymph node symmetry enlargement, or in the paratracheal and supraclavicular lymph nodes. The lymph nodes are more than 2cm in diameter. The texture is generally hard, and can also be accompanied by long-term low heat. The diagnosis of sarcoidosis requires biopsy, epithelioid nodules can be found, Kvein test is 90% positive in sarcoidosis, and angiotensin-converting enzyme is elevated in lymph nodes and serum of patients with sarcoidosis.

5. Histiocytic necrotizing lymphadenitis The disease is more common in China, mostly young and middle-aged, and the clinical manifestations are persistently high fever, but the number of peripheral white blood cells is not high, and it is ineffective with antibiotics, which is similar to malignant reticulosis. The lymph nodes of histiocytic necrotizing lymphadenitis are more common in the neck, and the diameter is more than 1 to 2 cm. Quality or soft. Unlike lymph nodes of malignant lymphoma. A lymph node biopsy is required for the diagnosis, and the disease is cured after a few weeks.

6. Central lung cancer invading the mediastinum, thymus tumor can sometimes be confused with malignant lymphoma, the diagnosis depends on the mass biopsy.

7. Identification of Hodgkin's lymphoma The clinical manifestations of non-Hodgkin's lymphoma are very similar to those of Hodgkin's lymphoma. Actually. It is difficult to make a clear differential diagnosis from clinical manifestations. Only histopathological examination can clearly distinguish the two. However, there are some different manifestations in the clinic.

Must also be associated with Hodgkin's disease, reactive follicular hyperplasia, acute and chronic leukemia, infectious mononucleosis, cat paw disease, malignant melanoma, tuberculosis (especially primary tuberculosis with hilar lymphadenopathy) ), as well as other diseases that cause lymphadenopathy, including the differentiation of pseudolymphoma caused by phenytoin.

complication:

Organ infiltration is more extensive, bone marrow and peripheral blood can be affected. The more frequently invaded sites are Wei's pharyngeal ring, gastrointestinal tract, testis and intra-abdominal lymphoid tissue, and often invade bone marrow tissue and leukemia-like blood changes. The most common complications are infection, fever, chest tightness, chest pain, shortness of cough, shortness of breath, obstruction of swallowing, difficulty breathing, abdominal cramps, intestinal obstruction, jaundice, ascites, cirrhosis, renal pelvis and stagnant water, uremia, anemia, headache, vision Obstacles and so on.

treatment:

(a) treatment

1. Principles and strategies of treatment The treatment of NHL depends to a large extent on the classification. In particular, the NHL derived from B cells is sensitive to chemotherapy and radiotherapy except for high malignancy. The remission period is longer and the cure rate is higher. In addition to low malignancy, T cell-derived NHL is sensitive to chemoradiotherapy, but it is difficult to control for a long time, and the survival rate is low. However, this is only because of the current conventional treatment, because of the high proliferation of highly malignant NHL, it is also sensitive to chemoradiation. If it can be transplanted through bone marrow or hematopoietic stem cells and colony-stimulating factor, intensive treatment can be cured. Improve on.

We can summarize the treatment process as follows: (1) remove the tumor as much as possible in the first stage; 2 then enter the second stage to focus on the recovery of all aspects of the physical strength of the disease, especially the immune and bone marrow function; 3 then intensive treatment according to the situation; 4 treatment After that, it is still necessary to continuously improve the patient's immune status. While treating tumors, that is, stagnation, it is also important to protect the patient's body, especially immune and bone marrow function, liver and kidney function.

The main reasons for treatment failure: 1 local treatment is not complete, or local recurrence after unsuccessful treatment; 2 extensive violation of important organs; 3 severe damage to the body's immune function to create favorable conditions for recurrence and dissemination.

2.NHL treatment

(1) For more limited tumors: especially extranodal NHL originating from certain organs, surgery and/or regional radiotherapy may be performed first, and chemotherapy or biological therapy may be added according to the situation. A high cure rate can be achieved for most of the I and II stage B cell lymphomas and stage I T cell lymphomas.

(2) It is advantageous to have prior disseminated III:IV stage B cell lymphoma or stage I and II stage T cell lymphoma with obvious dissemination tendency. After the dissemination tendency is controlled, take necessary Surgical or radiotherapy enhances local or regional control. For patients with large lumps (generally referred to as tumor diameter ≥ 10cm or mediastinal mass exceeding 1/3 of the transverse diameter of the chest) or cavity organ such as stomach, intestine and other chemotherapy after radiotherapy or surgery can significantly reduce recurrence and perforation, bleeding, Opportunities such as obstruction are often the key to success.

(3) For patients who fail after the first treatment or relapse after treatment: intensive treatment plus bone marrow or hematopoietic stem cell transplantation should be considered. In these cases, only intensive treatment (high-dose chemotherapy plus total lymph node irradiation) is likely to seek a cure.

(4) Biotherapy has a certain status in the treatment of NHL: recent data indicate that moderate malignant NHL is added in 8-week CHOP chemotherapy.Interferon alpha-2aCan significantly improve the cure rate of 5 years. In China, Fuzheng Chinese medicine combined with radiotherapy has also improved the long-term cure rate to some extent. The monoclonal antibody rituximab (Rituximab) has a prominent effect on CD20-positive B lymphoma, either alone or in combination with the CHOP regimen. It is one of the important advances in the treatment of B lymphoma in recent years.

(5) In some patients with systemic low-grade malignant NHL: the body's immunity and tumors are in a relatively fragile equilibrium. Excessive treatment can not only improve the cure rate, but also damage the immune function of the body. under these circumstances. Careful observation and waiting for the tumor to develop when re-treatment, the so-called watch and wait, can allow patients to survive for a long time.

3. The comprehensive treatment plan of NHL is based on the principle and scheme of comprehensive treatment of low, medium and high grade malignant NHL with lymph node invasion.

(1) Low-grade lymphoma: Low-grade malignant NHL occurs mostly in elderly patients. Typical representatives are follicular small cell types, with more than half progressing slowly.

Patients with stage I and II chemotherapy and/or radiotherapy can receive better results. However, for patients with stage IV, especially those with bone marrow involvement, many scholars advocate observation and wait until the disease develops, and then start treatment. These patients have a relatively long time (about half of the 1-3 years, 10% can be more than 5 years), the body and the disease are in a relatively balanced state. But observation and waiting does not mean that it is negative and does not deal with anything. For such patients, on the one hand, to minimize the stimulation of the lymphatic system (such as chronic infection, drinking, etc.); on the other hand, attention should be paid to protecting or improving the patient's immune function (such as avoiding overwork, not inhibiting immune function) Hormones, etc., appropriate exercise to take Fuzheng Chinese medicine and other immune promoters). Experts at home and abroad have experience to keep a considerable number of patients stable, about 30% can be partially or even completely relieved.

1 treatment method:

A. Radiation therapy: Irradiation of the affected lymphatic area, usually 35 ~ 50Gy, such as with systemic chemotherapy can achieve radical effect.

B. Chemotherapy: It is mainly based on the fact that low-grade malignant NHL can be converted into a more malignant type within a certain period of time, such as a large cell or an immunoblast cell type. Half of these transformations can occur in 6 years after diagnosis, and autopsy data show that 90% of cases have some lesions converted to other types. Therefore, appropriate chemotherapy should be given when the disease progresses.

The available chemotherapy regimen is COP, COPP, and CHOP if necessary, with an effective rate of 60% to 90%. A considerable number of patients with localized radiation can survive for a long time. Most of the patients with stage I and II have been mentioned before.

Can be cured by comprehensive treatment. The 5-year survival rate of stage III patients is 70% to 75%, the 5- to 10-year survival rate is 60%, and the median survival period is 7 to 8 years. Patients with stage IV have a poor prognosis. There is currently no sufficient data to prove that the survival rate can be further improved by chemotherapy, but in the development of the disease, in order to relieve the symptoms, chemotherapy and other necessary treatment should be given as soon as possible.

C. Interferon andAldileukin (interleukin-2): There is information that interferon alpha and aldesleukin (interleukin-2) are effective for low-grade malignant NHL, and may be preferred or used in the case of chemotherapy failure. Because some studies have shown that interferon has the functions of promoting differentiation and cytotoxicity in addition to immune regulation, it can also be used in combination with chemotherapy.

D. Auxiliary applicationMonoclonal antibodies: The monoclonal antibody rituximab (Rituximab) developed on the surface of B lymphoma cells CD20 has been clinically tested in various countries including China, and has achieved encouraging results. We applied in 30 cases of CD20 NHLRituximab(Merrohua) 375mg/m2, instilled once a week, after 4 weeks, 14 cases of PR, the effective rate was 46%. In foreign countries, rituximab (Rituximab) and CHOP were used together, and the efficiency was more than 96% in 166 patients with lymphoma, and the survival time was also prolonged. The newly developed monoclonal antibody zevalin is even more effective than rituximab (Rituximab) and is currently undergoing clinical trials.

2 treatment effect: As mentioned above, different experts on low-grade lymphoma have different opinions on treatment. Rosenberg believes that any treatment of this type of patient is difficult to achieve a complete cure. However, most scholars advocate that radiotherapy should be used first in the early stage (I and II). In the stage I, the affected lymph node area was irradiated, and the second stage was used for total lymph node irradiation. The cure rate in 10 years was 83%. Stanford University's report on the treatment of stage III patients is also highly valued. They underwent careful staging of the patients (half of the laparotomy) and further divided the patients into three limited stages (no B symptoms, less than 5 violation sites, maximum mass <10 cm) and extensive periods. Through a total lymph node irradiation and partial patient whole body irradiation + autologous bone marrow transplantation, the 15-year disease-free survival rate of patients with limited disease reached 88%. It is based on the fact that recurrent patients often occur in the lymph node area, so total lymph node irradiation can cure the patient. However, the 15-year survival rate for the extensive phase III is only 30%.

Bitran et al applied CPP treatment in 34 cases, and 50% achieved complete remission. The CHOP regimen also performed well in this class of patients, and Mekelvey et al. initially reported a complete response rate of 76% for nodular poorly differentiated lymphocytes and 78% for nodular mixed cell types. The results of the CHOP program were 71% and 64%, respectively. Cabanillias et al reported that the results of MD Aaderson Hospital in the United States, the 5-year disease-free survival rate of patients with CHOP-induced remission and consolidation therapy was 67%, and that stronger combination chemotherapy was better than single drug or other conservative treatment. CHOP chemotherapy plus radiotherapy, the 5-year survival rate was 64%, and only 37% of single radiotherapy.

Patients in the advanced stage (stage III and IV) have accumulated a lot of experience in the past 20 years. This group of patients should be based on chemotherapy, and a large number of patients can be cured by intense chemotherapy, but with appropriate radiotherapy, especially with large masses. The patient is still one of the keys to success. The preferred option for NCI in the United States is Pro-MACE/MOPP, which then applies 24 Gy to the total lymph node in patients with complete remission (CR), and 78% of patients have CR. The 4-year disease-free survival rate of patients with CR was 86%, but 14% had recurrence. C-MOPP is also a commonly used regimen. For patients with follicular mixed cell type, the CR rate is 72%, and the median remission period is about 7 years. The CR rate of stage III patients who were first irradiated to the affected lymph node area after CHOP-B was 74%, and the stage IV was 57%. The 4-year survival rate was 64% in stage III patients and 48% in stage IV. M-BACOD is also effective in the treatment of advanced follicular small cell types, with a 5-year survival rate of 40%.

Some new drugs have been effective in low-grade lymphoma in recent years. Others such as Hainsworth et al reported oral etoposide (Etoposide, VP-16) 50mg/m2, once a day, with an effective rate of 67% for 21 days and a median remission period of 8 months. The use of oral anthracycline idarubicin (4-demethoxydaunorubicin) in the treatment of low-grade malignant lymphoma has received attention, and can be used when it is resistant to common chemotherapeutic drugs.

(2) Moderate malignant lymphoma: moderately malignant lymphoma can account for 60% of NHL, and the typical representative is diffuse large cell lymphoma. Most Western countries are B-cell sources, but 20% are T-cell sources. These patients are sometimes referred to as "peripheral T-cell lymphomas." The source of T and B in this group of patients is not the main factor determining the prognosis. Most scholars believe that the important factors affecting the prognosis of progressive NHL are: the general condition of the patient, whether the mass exceeds 10cm (especially the NHL of the digestive tract), and multiple (such as 2 to 3) extranodal organs are invaded and B symptoms ( Refers to fever, night sweats and weight loss) and serum lactate dehydrogenase over 4 μmol (SL). Age is also a prognostic factor and may be related to tolerance to treatment.

Traditionally, patients with limited period of time are first given radiotherapy (35 to 40 Gy / 4 to 5 weeks), but the authoritative units of the United Kingdom and the United States believe that even if the irradiation is 45 to 50 Gy, there will still be a considerable number of patients recurring in the irradiation field. For patients with clinical stage I and IE, the 5-year survival rate for radiotherapy is 65; for patients with II and IIE, only 25%. After a CT examination or a laparotomy, patients with stage I have a cure rate of 75% to 100%. At present, most scholars agree that this group of patients is mainly based on comprehensive treatment, and radiotherapy plus chemotherapy can improve the cure rate to a considerable extent.

1 Radiation therapy: In the improved staging of NCL in the middle and high-grade lymphoma, stage I patients have an important role in radical radiotherapy. The so-called radical irradiation means that the irradiation dose of the area where the tumor is located reaches 45 to 50 Gy, and the prophylactic irradiation of the next lymphatic area is 35 to 40 Gy. For patients with stage II and III, they should be treated as consolidation therapy after chemotherapy or as a rescue treatment when chemotherapy fails.

2 chemotherapy:

A. Moderately malignant NHL chemotherapy regimen: the general complete response rate is 50% to 80%.

It is related to the patient's illness, past treatment and various subtypes. For diffuse tissue cell types, CHOP, COMA, or COMLA regimens are more effective. Other programs such as ProMACE-MOPP and CVP-ABP are not used interchangeably, and BACOP has good effects.

Other programs, such as the so-called "third-generation chemotherapy program" - m-BACOD, COP-BLAM, MACOP-B and Pro-MAC/CytaBOM are also quite positive. However, there are quite a few reports that the long-term results of these new programs are not necessarily better than CHOP and BACOP. In recent years, many research units have conducted comparative studies on the short- and long-term results of various chemotherapy regimens.

For patients with advanced stage (III, IV), there has been a great improvement in the treatment for more than ten years, and more than 50% of them can be cured through active treatment. Commonly used programs are C-MOPP, BACOP and COMLA (or ACOMLA). In the treatment strategy, cell cycle non-specific drugs should be used to induce remission, and then cell cycle-specific anti-metabolites can be added to remove residual tumor cells in the bone marrow, which can make patients complete long-term complete remission (CR). A newer chemotherapy regimen still has HOAP-bleo (cytarabine,VincristineDoxorubicin (doxorubicin),PrednisoneAnd bleomycin), mainly for patients who cannot reach CR after CHOP treatment, can also switch to IMVP16 after CHOP and HOAP-bleoCyclophosphamide,Methotrexate,Etoposide(Ghost scorpion)) to further consolidate and eliminate residual tumor cells.

B. Dose intensity of chemotherapy: In recent years, the dose intensity of chemotherapy, that is, the relationship between the total dose given by body surface area and the therapeutic effect in a certain period of time, has been discussed. Fisher et al. conducted a randomized comparative study of several chemotherapy regimens CHOP, M-BACOD, MACOF, and ProMACE-CytaBOM, suggesting that these regimens have little effect on moderate malignant lymphoma. However, Meyer et al. reviewed the results of a large number of literature reports in 14 groups of 2300 cases of lymphoma treatment, and concluded that the dose intensity of chemotherapy drugs is the most important determinant and is related to long-term survival. Similarly, Kwak et al reviewed 115 patients treated with CHOP, M-BACOP or MACOP-B at Stanford University, and noted that the dose intensity of doxorubicin in the first 12 weeks was associated with efficacy and long-term survival. Autologous bone marrow and hematopoietic stem cell transplantation have certain indications for the treatment of moderate malignant lymphoma. It usually works best after the first induction reaches complete remission. Patients can get high-dose intensity chemotherapy and total lymph node irradiation or whole body irradiation to improve the cure rate. For patients with relapse or complete remission after treatment, high-dose chemotherapy and total lymph node irradiation can also be given by autologous bone marrow transplantation or hematopoietic stem cell infusion to achieve better curative effect. The widespread use of colony stimulating factors is also quite beneficial for increasing dose strength.

C. Auxiliary application of interferon: Another important study is the application of CHOP plus interferon alpha 2a by Smalley et al (1992) (6 million U/m2, 1 time/d on day 22 of CHOP per 28 days) In the comparative study of advanced moderate malignant NHL, the complete response rate was 29% for CHOP and 32% for I-CHOP. The 2-year survival rate was 46%, and the efficacy was related to long-term survival. For patients with relapse or complete remission after treatment, high-dose chemotherapy and total lymph node irradiation can be given by autologous bone marrow transplantation or hematopoietic stem cell infusion to achieve better therapeutic effect. The percentage of colony stimulating factor, I-CHOP was 71%; the overall survival rate was 79%, and the I-CHOP was 87%. To a certain extent, the addition of interferon is beneficial for short-term and long-term effects, but further observation is needed.

D. Surgical treatment: For moderately malignant lymphoma of the digestive tract and genitourinary system, surgery may still be advocated if possible. On the one hand, it can eliminate large tumors and reduce tumor burden, which is conducive to further chemotherapy; on the other hand, it can avoid complications such as perforation, hemorrhage and hyperuricemia.

(3) Highly malignant lymphoma:

1 chemotherapy: high-grade lymphoma is mainly chemotherapy. Longo et al compared the results of Pro MACE-MOPP and ProMACE-CytaBOM in the treatment of advanced diffuse progressive NHL, and concluded that the short-term and long-term results of Pro MACE-CytaBOM were better than the former. Carde et al compared CHVmP plus radiotherapy and CHVmP-OB plus radiotherapy to treat stage III and IV moderate and high-grade malignant NHL. The latter had a higher rate of complete remission, but there was no difference in survival. Fisher's multicenter comparative study showed that the efficacy of the third-generation chemotherapy regimen was not significantly superior to that of CHOP. In the international work classification, I. Lymphocyte type and J. small non-cleavable cell type are currently difficult to treat. Most patients are already in Phase II and III at the time of the visit. Treatment should be based on chemotherapy, such as the third-generation chemotherapy program ProMACE-CytaBOM, CHOMP, APO and so on. Most of the lymphoblastic type will be combined with acute lymphoblastic leukemia early or late, and should be treated according to acute lymphoblastic leukemia, using the LSA2-L2 regimen.

Because of the high degree of malignant NHL associated with central nervous system invasion, attention should be paid to preventive intrathecal injection or total cranial plus spinal cord irradiation. Autologous bone marrow transplantation and hematopoietic stem cell infusion can also be carried out under conditions, which improves the long-term cure rate to some extent.

Adult high-grade lymphoma is quite difficult to treat, but chemotherapy is effective in children, with an effective rate of 85% to 95%, mostly recurring within 1 year. The current better solution is LSA2-L2, which can make 90% long-term survival for patients with relatively limited, and 60% to 80% long-term survival for a wide range. In another program, APO has a good effect, and the 2-year survival rate can reach 82%. However, the efficacy of adult patients is far less than that of children. The APO regimen allows 95% to 98% of patients to achieve CR and 60% to 75% of long-term disease-free survival. Levine et al. made appropriate improvements to the LSA2-L2 regimen, with a CR rate of 73% in adult lymphoblastic lymphoma patients, but 36% of CR patients had recurrence with a median survival of 3.5 years. Irradiation of the affected lymph node area after chemotherapy is also being studied, with a 3-year survival rate of 56%.

Most of the lymphoblastic lymphomas are T-cell lymphomas, which often occur in adolescents and young adults. In the course of the disease, bone marrow is invaded earlier and develops rapidly. Often there are large mediastinal masses and central nervous system invasion. The treatment should be treated according to the prognosis of acute lymphoblastic leukemia (pro-lymphocyte type), that is, the induction of chemotherapy is relieved, and a large mass is given to the local irradiation; afterwards, the chemotherapy is consolidated several times in 2 to 3 years to strive for and maintain Complete remission, and preferably given prophylactic cranial irradiation or intracerebroventricular methotrexate treatment. For example, Weinstein et al. first induced remission with vincristine, doxorubicin (doxorubicin), prednisone, and then administered vincristine, doxorubicin (doxorubicin), prednisone every 3 weeks.mercaptopurine(6-mercaptopurine),AsparaginaseIntrathecal methotrexate was used as a consolidation therapy until complete remission, which lasted for 24 months. They also gave the cranial irradiation at the same time. In 19 cases, 18 cases achieved complete remission, and 8 cases had undergone mediastinal irradiation. The follow-up period was as short as 20 months and the longest was 72 months. Only 3 cases of central nervous system recurrence. The estimated 2- to 6-year survival rate is 63%.

Burkitt's lymphoma was originally found in Africa and is currently sporadic around the world. Most of the patients are children, and it is easy to invade the face, neck and ovary, bone and bone marrow, and intestines. The course of the disease is rapid and can be fatal if not treated. Burkitt lymphoma belongs to B cell lymphoma. The best treatment for both early and late is chemotherapy. The more prominent solutions are the COM and COMP solutions. Localized radiation should be given if there is an abdominal mass. Ziegler et al reported a complete response rate of 95%, more than half of which can be cured.

Diffuse small crack-free lymphoma (non-Burkitt) is also highly malignant, accounting for a few percent of diffuse lymphoma. The National Cancer Institute is mainly treated with the ProMACE regimen, with a complete remission of 84%, 14% of which relapsed later, with a long-term survival rate of 67%. However, this small non-split lymphoma and Burkitt are difficult to distinguish in pathology. The main point is that Burkitt's lymphoma cells are highly uniform, and this is not uniform. Both clinical progress is faster and the proportion of proliferation is large. Molecular biological examination can further identify that Burkitt's lymphoma is mostly (17/18) recombination of the myc gene, but not Burkitt's small non-split lymphoma (0/11).

The treatment of cutaneous T-cell lymphoma has also made some progress recently. Winkler and Bunn have evaluated the efficacy of various monotherapy and combination chemotherapy regimens for these tumors. But the differences between the different types are great.

At present, it is considered that local application of nitrogen mustard and electron beam treatment for local lesions can achieve good results, but systemic chemotherapy and necessary radiation therapy should be given to patients with severe skin lesions or lymph nodes and visceral invasion. In the US NCI, the local nitrogen mustard was applied to the I-II stage (10 mg of nitrogen mustard dissolved in 50 ml of water and applied to the affected area) or irradiated with electron beam for a total of 3200 cGy. Electron beam irradiation and CAPO chemotherapy were given for stage III-IV lesions. The hospital's program is similar, I and II lesions were given topical nitrogen mustard, 1 time / d, 1 year later changed to once every other day. If complete remission is given, only Chinese medicine will be given. If only partial remission is achieved, continue to apply the drug, if the disease progresses, give COPP chemotherapy. The treatment of stage III-IV patients was 6 cycles of topical nitrogen mustard plus COPP chemotherapy. For patients with complete remission, only Chinese medicine is given to the right, and some patients with remission continue to receive COPP treatment. China's anti-cancer drug, pyrimidine, 520, pyrimidine, mustard has a good effect on cutaneous T-cell lymphoma. Local and systemic administration can achieve complete remission in more than half of patients. Glyphosate mustard (M-25) is also effective in this disease and is currently under further observation.

Although highly malignant lymphoma is sensitive to chemotherapy, some have long-term adverse effects. The treatment of the large cell immunoblast cell type is generally considered to be the same as the treatment of the aforementioned diffuse histological cell type (diffuse large cell type), and the therapeutic effect is also good. As many scholars believe that they should be moved into the moderate malignant group.

Lymphoma originating in the central nervous system accounts for about 2% of brain tumors and 2% of all lymphomas. Lymphomas associated with immune deficiency are more likely to invade the central nervous system, including lymphoma caused by AIDS, which should be classified as highly malignant. Most central nervous system lymphomas are B-cell sources, often invading the frontal or deep brain tissue, and can be multiple. The main clinical manifestations are headache, visual impairment (indistinct vision, double vision, etc.), memory loss, nausea and vomiting, convulsions and so on. Examination of visible optic disc edema, weakness on one side, visual field defects and cranial nerve disorders. Cerebrospinal fluid protein is elevated, but the cells are normal, and CT or magnetic resonance can show the lesion. The best treatment is 40Gy for whole cranial irradiation, plus 15Gy in the primary lesion. Because the chance of spinal cord invasion is only 4%, most scholars do not advocate preventive irradiation of the spinal cord. But can add systemic chemotherapy such as CHOP, high dose methotrexate, DHAP (DexamethasoneHigh dose cytarabine, cisplatin)HydroxyureaProcarbaMethyl benzamidine), lomustine (CCNU) and prednisone.

2 Radiation therapy: At present, it is generally advocated to implement radiation therapy according to the following principles.

A. Patients occurring in the nasopharynx and tonsils: the entire pharyngeal lymphatic ring and the double-neck lymphatic area should be irradiated. Nasopharyngeal malignant lymphoma should also include the skull base. If the middle and lower neck are invaded, the ipsilateral or bilateral axillary lymphatic drainage area is added. The total dose is 5 to 6 Gy for 5 to 6 weeks. About one-third of malignant lymphomas in the pharyngeal lymphatic ring may have intra-abdominal lymph nodes invaded; the Institute of Cancer Prevention and Treatment, Chinese Academy of Medical Sciences, counts 100 cases of NHL invading the pharyngeal lymphatic ring, and 34% of the abdominal cavity is invaded. Therefore, it is necessary to add abdominal irradiation or chemotherapy to such patients.

B. A small number of malignant lymphomas that occur in the digestive tract, urinary tract or spleen, and can also be irradiated to the local, spleen and adjacent lymphatic areas after surgical resection. The efficacy of surgery alone is very poor, chemotherapy and radiotherapy should be added.

C. Tumors that occur in the mediastinum are often prone to invasion of the lung tissue. The chest should be first explored to determine the extent of the invasion and the type of pathology, and to remove the tumor as much as possible. In addition to the area where the tumor is located, the irradiation field should also include a part of the surrounding lung tissue. After the tumor has shrunk, the irradiation field should be appropriately reduced.

D. Malignant lymphoma that occurs in the bone, whether single or multiple, can be treated with radiation. The field of illumination includes the full length of the invaded bone, but does not exceed the articular surface.

E. Malignant lymphoma that occurs in the nervous system should be explored first to determine the extent of the lesion and to perform decompression. Later, according to the affected part, it usually has little chance of outward transfer, and it can not be irradiated by lymphatic drainage area.

F. Sputum fungal disease application of high-energy electron flow system is also very good, generally choose 4Me (2 ~ 6Mev), source skin distance of 3m, subcutaneous 0.5cm is the highest energy zone, energy can be completely absorbed within 1cm. The irradiation dose is 30-40 Gy every 4 to 5 weeks, and it is divided into the front and back fields and the two side fields. The daily dose can start from 0.5 Gy and is added to 2 Gy according to the reaction. When the patient is standing, the heel is raised, and important parts of the body such as crystals and nails are protected with a 1 mm thick lead cover. After the whole body irradiation, the skin folds such as underarms, groin, female breast area, finger joints, buttocks and skin folds may be slightly lower, and the air volume of the 100kV X-ray machine can be used for 5~6Gy.

3 surgical treatment: Regardless of the degree of patient acceptance and long-term results, radiation and drug treatment are more important in the treatment of malignant lymphoma, but there are still some indications for surgical treatment, especially the digestive tract and Lymphoma in the chest. Other extranodal malignant lymphomas such as bone, brain, spinal cord, and breast can be treated surgically when necessary and possible. After the larger lymph nodes are reduced to a certain extent by radiation or chemotherapy, due to the formation of a large number of fibrous tissues, poor blood supply, and lack of oxygen in the center, it is difficult to continue to shrink, and can be surgically removed after a certain period of observation.

4. Some special cases that may occur in NHL and their treatment

(1) superior vena cava compression syndrome: occurs mostly in the mediastinal NHL. Acute superior vena cava compression should be treated as an emergency, except for oxygen inhalation, diuretics andHydrocortisoneIn addition, it is preferred to give a fast-acting periodic non-specific drug such as nitrogen mustard, nicardine (cannon), cyclophosphamide or doxorubicin (doxorubicin). It is best not to do radiotherapy first, because radiotherapy may cause congestion and edema, resulting in increased respiratory pressure. However, it is best to use radiotherapy after chemotherapy is relieved. Injection chemotherapy drugs are best rushed into the lower limbs to avoid extensive endocarditis due to poor venous return of the upper extremities.

(2) intraspinal compression: can be used as the first symptom, but also during the course of treatment. Acute compression of the spinal cord should be treated as an emergency. A spinal epidural malignant lymphoma with or without bone involvement or a paravertebral mass. Most of the patients felt back pain, numbness of the limbs, weakness of the limbs, and incontinence. Lumbar puncture can have oppressive performance and can be clearly located by CT, MRI or myelography.

Generally, laminectomy should be performed immediately, and a biopsy should be taken to relieve the compression of the spinal cord and strive for functional recovery. Radiotherapy is given 35 to 40 Gy every 4 weeks. If unconditional surgery, a larger dose of nitrogen mustard or cyclophosphamide can be given, and then radiotherapy will be performed later.

(3) Infection: Many patients are in advanced stage, their immune status is low, and many anti-tumor drugs and hormones are immunosuppressive drugs. Radiotherapy also has immunosuppressive effects, especially when irradiating the lungs, the local tissue resistance is low, because Very easy to concomitantly infected. More important is the general bacterial infection, fungal infections, especially the common Candida albicans and Cryptococcus neoformans, the main predilection sites are the lung and meninges. Followed by viral infections, especially in young patients is prone to herpes zoster.

The principle of treatment is first of all to pay attention to the treatment of righting and the hygiene of the skin, respiratory tract and digestive tract. Once it occurs, it should be treated in a timely manner. The general infection of the respiratory tract is usually given to the traditional Chinese medicine wild chrysanthemum, honeysuckle, mint decoction inhalation, taking or injecting appropriate antibiotics according to the pathogen. For fungal infections, fluconazole or ketoconazole should be given. Herpes zoster is generally mainly to prevent secondary infections. Recently, it has been reported that interferon and cytarabine have antiviral effects, and also have inhibitory effects on lymphoma, and also have a good effect on herpes zoster complicated by malignant lymphoma. Therapeutic effect.

(4) Fever: The fever of malignant lymphoma is sometimes difficult to identify. Whether it is one of the systemic symptoms or a co-infection requires a comprehensive examination (including careful examination and routine examination, blood and urine culture). , chest X-ray, abdominal CT, liver function, anti-streptolysin "O" agglutination test, cellular immunological examination, etc.) and observation can be affirmed.

For long-term unexplained fever, many units try to use broad-spectrum antibiotics and hydrocortisone intravenous infusion for 3 to 5 days to protect patients from excessive consumption. Low-dose antiallergic and antipyretic drugs such as promethazine (phenazone), chlorpheniramine (chlorpheniramine),Indomethacin(Indomethacin), Pregnancy (anti-inflammatory pine), etc. can also achieve the purpose of fever. But these treatments can often mask contradictions, so they can only be applied temporarily. Chinese herbal medicine for clearing away heat and detoxifying and nourishing yin and cooling blood has a certain effect on fever.

(5) anemia: severe anemia of malignant lymphoma, often a poor prognosis. In addition to the blood transfusion, the treatment should be ascertained as to whether there are bone marrow invasion, hemolysis and other factors, and treatment according to the situation. When the bone marrow is invaded, combined chemotherapy can be used, but the dose should be low. Adrenal corticosteroids can be given when there is a hemolysis factor. If there is hypersplenism, surgery should be considered. Fuzheng Chinese medicine and testosterone are beneficial for correcting chronic anemia in patients, but the fundamental treatment is to fully control the tumor, thus promoting the patient's anemia to be corrected. If necessary, erythropoietin (EPO) can be used to correct the anemia of cancer patients.

(6) elevated blood uric acid, uric acid crystallization: malignant lymphoma may have elevated blood uric acid and increased urine output in the late stage or after effective treatment, and even crystallization in the urinary system leads to obstruction and no urine.

Renal function, blood uric acid and urine routine should be routinely examined before treatment. For patients with extensive lesions or high blood uric acid, allopurinol 100 mg, 4 times/d should be taken before and during treatment, and sufficient fluid intake is ensured. Taking alkaline drugs can also help prevent uric acid crystallization.

(7) Perforation, hemorrhage: Gastrointestinal malignant lymphoma may undergo perforation and hemorrhage during the development and treatment of the disease. Therefore, we should be alert and prevent this possibility. General treatment should be carried out slowly without giving impact treatment to promote the repair of the body to keep up with the disintegration of the tumor. For patients with positive occult blood before treatment, hemostatic drugs can be given appropriately, and treatment should be more cautious. Once perforation or bleeding occurs, surgery should be performed as soon as possible.

(8) Pregnancy and childbirth: Patients with long-term remission after good general treatment have little effect. It was counted that 3,212 patients (58% of whom were female) had a long-term survival of 3,687 live births, and 3.7% were defective. And no adverse effects on the condition and treatment. Many of our children have been cured, married and matured in adulthood, and their children are normal.

However, in patients who are still unstable or are being treated, pregnancy often imposes an excessive burden on the patient and even causes the disease to deteriorate rapidly. Considering the specific circumstances of the patient, such as malignant lymphoma in early pregnancy should induce labor, because radiation and chemotherapy may have an impact on the fetus; if observed in the late pregnancy, the condition is aggravated and induced. After treatment, contraception should be considered for at least 2 years before considering fertility problems. Male patients may have sperm deficiency after radiation and a large number of chemotherapy, and it is best to have at least 1 to 2 years of contraception, but still have normal fertility.

(9) pleural cavity and pericardial effusion: tumor development invaded by pleural or pericardial effusion should be given chemotherapy, some patients can be controlled by systemic medication, and some patients need to inject nitrous acid as much as possible after injection of nitrogen mustard, more Resorcin (doxorubicin), cisplatin or aldesleukin (interleukin-2). The dose should generally be based on the amount of fluid, the time of occurrence and the absorption of the serosa, usually higher than the usual intravenous dose. Most of the control can be achieved by 2 to 4 intraluminal injections. Some patients with serosal effusion are due to larger tumors in adjacent tissues, it is best to add radiotherapy after effusion control.

Some patients have fluid accumulation due to obstruction of lymphatic drainage after radiation or adjacent tissue compression, usually leakage, and should be differentiated from exudate caused by tumor invasion.

The international non-Hodgkin's lymphoma prognostic index helps guide the selection of treatment options and assessment of prognosis. Intensive combination chemotherapy can be selected for high-risk cases.

(two) prognosis

Because of the different disease types and biological behaviors of HD and NHL, the Ann Arbor staging method does not accurately reflect the prognosis of NHL patients. Many clinical features of NHL before treatment are closely related to the patient's survival, such as age at diagnosis, systemic (B) symptoms, physical strength, serum LDH, serum B2 microglobulin, number of lymph node and extranodal involvement sites, tumor burden, and The limitation period is still the progress period. The clinical features of response to tumor growth and invasion include LDH, B2 microglobulin, staging, mass size, number of lymph nodes and extranodal sites, bone marrow infiltration, etc.; physical and B symptoms indicate the patient's response to the tumor; Tolerance indicators include physical strength, bone marrow infiltration, and age. The above factors before clinical treatment include the tumor volume and tumor infiltration at the time of treatment, which can be a prognostic factor for patients.

International indicators: International NHL prognostic factors studies in the United States, Europe, and Canada show that clinical characteristics associated with survival include age, LDH, physical strength, staging, and number of extranodal lesions.

The international prognostic indicators are based on the above characteristics, and patients with different risk factors for death are divided into different subgroups (low, low, medium, high). The 5-year 5-year survival rates are expected to be 73%, 51%, 43%, and 26%, respectively. Because young and old patients may vary in the intensity of treatment options, 60-year-old or younger patients may be selected for a more aggressive treatment group, so an age-corrected model is established for patients 60 years of age or younger (age correction international) index). Among young patients, only stage, LDH, physical strength and prognosis are related. Patients under 60 years old are divided into 4 risk groups. The 5-year survival rates are expected to be 83%, 69%, 46%, and 32%, respectively. International prognostic indicators are not only applicable to invasive NHL, but also to indolent lymphoma.

In recent years, cytological and molecular properties of tumor cell proliferation, immunophenotype, adhesion molecule expression, and eukaryotic cell abnormalities have been found to be associated with survival. This newly identified biological indicator is expected to eventually replace clinical features and guide the basic treatment of specific subgroups.

The molecular biology of NHL is characterized by Ign and TCR gene rearrangements as well as specific chromosomal translocations. The sensitivity of PCR to detect specific gene rearrangements or chromosomal translocations can reach 1 in 1 million, so it can be used to further evaluate minimal residual disease (MDR) in lymphoid tumors and to help determine early recurrence. MD Anderson Cancer Center used PCR technology to study blood samples from patients with follicular lymphoma, and found that patients with negative t(14;18) within 3 to 5 months of treatment had significantly higher survival rates than positive patients [5 years FFS, PCR (-) was 90%, PCR (+) was 40%, P = 0.008). For more than 200 patients who underwent autologous bone marrow transplantation to purify bone marrow in vitro, bone marrow samples were taken for PCR analysis before and after purification. 114 cases had t(14;18) translocation, and the 114 bone marrow samples were positive for PCR before purification. After purification, 57 cases were negative for PCR, and only 4 cases (7%) relapsed. Of the 51 patients who were positive for PCR after bone marrow purification, 26 (46%) relapsed.

Although the molecular biology of MRD is not yet used for staging and treatment, it is likely to affect treatment strategies in the future.

prevention:

Because the cause of lymphoma patients is not very clear, the prevention methods are: 1 minimize infection, avoid exposure to radiation and other harmful substances, especially drugs that have an inhibitory effect on immune function; 2 exercise properly, enhance physical fitness, Improve your disease resistance.

Mainly for the prevention of various factors that may lead to malignant lymphoma. It is currently believed that the loss of normal immune surveillance function, the tumorigenic effect of immunosuppressants, the activity of latent viruses and the long-term application of certain physical (such as radiation), chemical (such as anti-epileptic drugs, adrenocortical hormone) substances, Lead to the proliferation of lymphatic network, and eventually malignant lymphoma. Therefore, pay attention to personal and environmental hygiene, avoid drug abuse, and pay attention to personal protection when working in a harmful environment.