LLA

 Patients with acute lymphoblastic leukemia (ALL) present with either (1) symptoms relating to direct
infiltration of the marrow or other organs by leukemic cells or (2) symptoms relating to the decreased
production of normal marrow elements.
 Fever is one of the most common symptoms of acute lymphoblastic leukemia (ALL).
 Patients with acute lymphoblastic leukemia (ALL) often have decreased neutrophil counts, regardless of
whether their total white blood cell (WBC) count is low, normal, or elevated. As a result, they are at
increased risk of infection. The prevalence and severity of infections are inversely correlated with the
absolute neutrophil count (ANC), which is defined as the number of mature neutrophils plus bands per
unit of volume. Infections are common when the absolute neutrophil count is less than 500/µL, and they are
especially severe when it is less than 100/µL.
 Patients with acute lymphoblastic leukemia (ALL) often have fever without any other evidence of
infection. However, in these patients, one must assume that all fevers are from infections until proven
otherwise, because a failure to treat infections promptly and aggressively can be fatal. Infections are still
the most common cause of death in patients undergoing treatment for ALL.
 Symptoms of anemia are common and include fatigue, dizziness, palpitations, and dyspnea upon even mild
exertion.
 Other patients present with signs of bleeding. Bleeding can be the result of thrombocytopenia due to
marrow replacement. Additionally, approximately 10% of patients with acute lymphoblastic leukemia
(ALL) have disseminated intravascular coagulation (DIC) at the time of diagnosis. These patients may
present with hemorrhagic or thrombotic complications.
 Some patients present with palpable lymphadenopathy. Others, particularly those with T-cell ALL, present
with symptoms related to a large mediastinal mass, such as shortness of breath.
 Infiltration of the marrow by massive numbers of leukemic cells frequently manifests as bone pain. This
pain can be severe and is often atypical in distribution.
 Uncommonly (10-20%), patients may present with left upper quadrant fullness and early satiety due to
splenomegaly.
 Although patients may present with symptoms of leukostasis (eg, respiratory distress, altered mental status)
because of the presence of large numbers of lymphoblasts in the peripheral circulation, leukostasis is much
less common in people with ALL than those with AML, and it occurs only in patients with the highest
WBC counts (ie, several hundred thousand per μL).
 Patients with a high tumor burden, particularly those with severe hyperuricemia, can present in renal
failure.

Physical

 Patients with acute lymphoblastic leukemia (ALL) commonly have physical signs of anemia, including
pallor and a cardiac flow murmur.
 Fever and other signs of infection, including lung findings of pneumonia, can occur. Fever should be
interpreted as evidence of infection, even in the absence of other signs.
 Patients with thrombocytopenia usually demonstrate petechiae, particularly on the lower extremities. A
large number of ecchymoses is usually an indicator of a coexistent coagulation disorder such as DIC.
 Signs relating to organ infiltration with leukemic cells and, to a lesser degree, lymphadenopathy may be
present.
 Occasionally, patients have rashes that result from infiltration of the skin with leukemic cells.

Limfona non hodgkin

In general, the clinical manifestations of patients with NHL depend on various factors such as the location of the
lymphomatous process, the rate of tumor growth, and the function of the organ being compromised or displaced by
the malignant process.
The Working Formulation classification groups the subtypes of non-Hodgkin lymphoma (NHL) by clinical
behavior, that is, low-grade, intermediate-grade, and high-grade. Because the Working Formulation is limited to
classification based upon morphology, it cannot encompass the complex spectrum of NHL disease, excluding
important subtypes such as mantle cell lymphoma or T/NK lymphomas. However, it continues to serve as a basis for
understanding the clinical behavior of groups of NHLs.

 Low-grade lymphomas
o Peripheral adenopathy that is painless and slowly progressive is the most common clinical
presentation in these patients.
o Spontaneous regression of enlarged lymph nodes can occur in low-grade lymphoma, potentially
causing confusion with an infectious condition.
o Primary extranodal involvement and B symptoms (ie, temperature >38°C, night sweats, weight
loss >10% from baseline within 6 mo) are not common at presentation, but they are common in
patients with advanced, malignant transformation (ie, evolution from a low-grade to an
intermediate- or high-grade lymphoma) or end-stage disease.
o Bone marrow is frequently involved and may be associated with cytopenia or cytopenias. 1
o Fatigue and weakness are more common in patients with advanced-stage disease.
 Intermediate- and high-grade lymphomas
o These types of lymphomas cause a more varied clinical presentation.
o Most patients present with adenopathy.
o More than one third of patients present with extranodal involvement; the most common sites are
the GI tract (including the Waldeyer ring), skin, bone marrow, sinuses, genitourinary (GU) tract,
thyroid, and CNS.
o B-symptoms are more common, occurring in approximately 30-40% of patients.
o Lymphoblastic lymphoma, a high-grade lymphoma, often manifests with an anterior-superior
mediastinal mass, superior vena cava (SVC) syndrome, and leptomeningeal disease with cranial
nerve palsies.
o Patients with Burkitt lymphoma (occurring in the United States) often present with a large
abdominal mass and symptoms of bowel obstruction.
o Obstructive hydronephrosis secondary to bulky retroperitoneal lymphadenopathy obstructing the
ureters can also be observed in these patients.
o Primary CNS lymphomas are high-grade neoplasms of B-cell origin. Most lymphomas originating
in the CNS are large cell lymphomas or immunoblastomas, and they account for 1% of all
intracranial neoplasms. These lymphomas are more commonly observed in patients who are
immunodeficient because of conditions such as Wiskott-Aldrich syndrome, transplantation, or
AIDS.2

Physical

 Low-grade lymphomas o Large abdominal mass: This

o Peripheral adenopathy usually occurs in Burkitt
o Splenomegaly: Splenomegaly is lymphoma.
observed in approximately 40% of o Testicular mass
patients; the spleen is rarely the o Skin lesions: Lesions are associated
only involved site at presentation. with cutaneous T-cell lymphoma
o Hepatomegaly (mycosis fungoides), anaplastic
 Intermediate- and high-grade lymphomas large-cell lymphoma, and
o Rapidly growing and bulky angioimmunoblastic lymphoma.3
lymphadenopathy o Chest radiograph: The chest
o Splenomegaly radiograph may demonstrate a
o Hepatomegaly bulky mediastinal mass, which is
associated with primary
mediastinal large B-cell lymphoma
or lymphoblastic lymphoma.
Hodgkin disease (Hodgkin's lymphoma)

incidence rates in the United States vary by race and sex. The incidence in cases per 100,000 individuals is 3.3 for
white males, 2.7 for white females, 2.9 for black males, 2.3 for black females, 1.4 for Asian/Pacific Islander males,
and 1.0 for Asian/Pacific Islander females.

Overall, Hodgkin disease (Hodgkin's lymphoma) is somewhat more common in males than in females. The
observed male predominance is particularly evident in children, in whom 85% of the cases are in males.

Age-specific incidence rates of Hodgkin disease (Hodgkin's lymphoma) have a bimodal distribution in both sexes,
peaking in young adults (aged 15-34 y) and older individuals (>55 y). In the United States, young adults typically
have NSHD, whereas children (aged 0-14 y) and older individuals more commonly have the MCHD subtype.

Clinical history features of Hodgkin disease (Hodgkin's lymphoma)

 Asymptomatic lymphadenopathy may be present (above the diaphragm in 80% of patients).

 Constitutional symptoms (eg, unexplained weight loss, fever, night sweats) are present in 40% of patients.
Collectively, these are known as "B symptoms."
 Intermittent fever is observed in approximately 35% of cases. Infrequently, the classic Pel-Ebstein fever is
observed (high fever for 1-2 wk followed by an afebrile period of 1-2 wk).
 Chest pain, cough, shortness of breath, or a combination of these things may be present due to a large
mediastinal mass or lung involvement. Rarely, hemoptysis is observed.
 Patients may present with pruritus.
 Alcohol-induced pain at sites of nodal disease is specific for Hodgkin disease (Hodgkin's lymphoma) and
occurs in less than 10% of patients.
 Back or bone pain occurs rarely.

Physical examination findings in Hodgkin disease (Hodgkin's lymphoma) 

 Palpable painless lymphadenopathy occurs in the cervical area (60-80%), axilla (6-20%), and, less
commonly, in the inguinal area (6-20%). It is described as rubbery adenopathy.
 Involvement of the Waldeyer ring or occipital or epitrochlear areas is infrequently observed.
 Splenomegaly may be present.
 Patients may have hepatomegaly.
 Superior vena cava syndrome resulting from massive mediastinal lymphadenopathy can also be seen.
 Central nervous system (CNS) symptoms or signs may be due to paraneoplastic syndromes, including
cerebellar degeneration, neuropathy, Guillain-Barre syndrome, or multifocal leukoencephalopathy.

The etiology of Hodgkin disease (Hodgkin's lymphoma) is unknown.

 Infectious agents, particularly EBV, may be involved in the pathogenesis of Hodgkin disease (Hodgkin's
lymphoma).
 In as many as 50% of Hodgkin disease (Hodgkin's lymphoma) cases, the tumor cells are EBV-positive; EBV
positivity is higher with MCHD (60-70%) than with NSHD (15-30%). Almost 100% of HIV-
associated Hodgkin disease (Hodgkin's lymphoma) cases are EBV-positive.
 An epidemiologic study from Denmark and Sweden showed an increased risk of EBV-positive Hodgkin
disease (Hodgkin's lymphoma) in patients with a self-reported history of infectious mononucleosis (IM) in
adolescence.6 The average incubation time from IM to symptoms of Hodgkin disease (Hodgkin's
lymphoma) was 2.9 years.
 Patients with HIV infection have a higher incidence of Hodgkin disease (Hodgkin's
lymphoma) compared with the population without HIV infection. However, Hodgkin disease (Hodgkin's
lymphoma) is not considered an acquired immunodeficiency syndrome (AIDS)-defining neoplasm.
 Genetic predisposition may play a role in the pathogenesis of Hodgkin disease (Hodgkin's lymphoma).
Approximately 1% of patients with Hodgkin disease (Hodgkin's lymphoma) have a family history of the
disease. Siblings of an affected individual have a 3- to 7-fold increased risk for developing Hodgkin disease
(Hodgkin's lymphoma). This risk is higher in monozygotic twins.
 Human leukocyte antigen (HLA)-DP alleles are more common in Hodgkin disease (Hodgkin's lymphom