Local clinical manifestations of lymphoma

Non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL) have in common that lymphoma cell proliferation causes lymph node enlargement and compression symptoms, and invasion of tissues and organs causes symptoms of various systems. However, due to the different pathological histological changes of the two, they have different clinical characteristics.

Clinically, most cases first invade superficial and/or mediastinal, retroperitoneal, and mesenteric lymph nodes, and a few first invade extranodal organs. Superficial lymph nodes are invaded in 60%-80%.

(1) Superficial lymphadenopathy: Painless, progressive enlargement of superficial lymph nodes is often the first manifestation of malignant lymphoma, especially in the cervical lymph nodes, followed by axillary lymph nodes, and less commonly in the groin or trochlear lymph nodes. 60% to 70% of HL first presents in the cervical lymph nodes. The enlarged lymph nodes may be movable, or may adhere to each other and fuse into lumps, with a cartilage-like feel when palpated. A small number of patients only have deep lymphadenopathy. 56% of NHL presents with superficial lymphadenopathy, half of which occur in the neck, but are more likely to involve the pharyngeal lymph ring, mesentery, and groin. Lymph node enlargement can compress nearby organs, such as nerve compression, which can cause pain; mediastinal lymph node enlargement can cause cough, chest tightness, shortness of breath, atelectasis, cervical sympathetic nerve paralysis syndrome, superior vena cava compression syndrome and other symptoms; hilar lymph node enlargement compressing the common bile duct can cause jaundice and liver enlargement; retroperitoneal lymph node enlargement can cause back pain and edema of the lower limbs, perineum or scrotum, and compress the ureter to cause hydronephrosis

(2) Pharyngeal lymphatic ring lesions: The oropharynx, tongue root, tonsils and nasopharynx form the pharyngeal lymphatic ring, also known as the Waldeyer ring. Its mucosa and submucosal areas are rich in lymphatic tissue and are a common site for malignant lymphoma. Pharyngeal lymphatic ring lymphoma accounts for about 1/3 of extra-nodal NHL. Tonsillar lymphoma is often accompanied by enlarged cervical lymph nodes. Sometimes tonsillar masses can block the entire oropharynx, affecting eating and breathing; tonsillar lymphoma can also be combined with gastrointestinal invasion at the same time or successively.

(3) Nasal lesions: The vast majority of primary nasal lymphomas are NHL. Patients often have a long history of runny nose, nasal congestion, or allergic rhinitis, which may lead to nosebleeds, and even lumps in the nasal cavity, affecting breathing. Nasopharyngeal lymphomas are more prominent with symptoms such as tinnitus and hearing loss.

(4) Chest lesions: The mediastinum is a common site for malignant lymphoma. It is commonly found in the anterior and middle mediastinum, paratracheal and tracheobronchial lymph nodes, and is more common in bilateral than unilateral lymph nodes. There are often no obvious symptoms in the early stages. When the tumor grows to a certain size, it compresses the surrounding tissues or organs and causes corresponding symptoms. Primary malignant lymphoma of the lung accounts for only 0.5% to 2% of NHL.

(5) Abdominal lesions: ① Gastrointestinal lesions: Primary gastric lymphoma is more common, and the vast majority are NHL. The small intestine, especially the duodenum, ileum and ileocecal region, is the most common in the intestine. There are no symptoms in the early stage, but as the lesion progresses, nonspecific symptoms such as indigestion and upper abdominal discomfort may appear. Symptoms such as vomiting blood, black stools, upper abdominal mass, anemia, weight loss, intestinal perforation and intestinal obstruction may appear as the lesion progresses. ② Liver and spleen lesions: Primary malignant lymphoma of the liver and spleen is rare, but it is more common in liver and spleen invasion during the progression of the disease. Liver invasion of malignant lymphoma is mostly secondary to splenic palm or advanced patients. The lesions are mostly diffuse, and liver puncture biopsy is helpful for diagnosis. Invasion of the liver parenchyma causes hepatomegaly. Biopsy of 25%-50% of NHL has liver involvement. Splenic infiltration is mostly caused by the spread of abdominal lymph node lesions through lymphatic vessels. Splenomegaly is uncommon in the early stage of HL, but it increases as the disease progresses, generally around 10%. ③ Retroperitoneal, mesenteric and pelvic lymph node lesions: ML often involves retroperitoneal, mesenteric and iliac fossa lymph nodes. Swollen lymph nodes may fuse together to form masses, and masses or pain may be palpated in the abdomen. NHL with swollen retroperitoneal lymph nodes is prone to fever symptoms. Sometimes very few lymph nodes are involved and can only be seen during abdominal exploration. Involvement of abdominal lymph nodes often indicates a high degree of malignancy and a poor prognosis.

(6) Bone lesions: ML invasion of bones may cause local tenderness and pathological fractures. HL involves bones in 10% to 35% of cases, while NHL involves more bones, with the thoracic and lumbar vertebrae being the most frequently affected, followed by the femur, ribs, pelvis, and skull. Bone marrow invasion is usually in the late stage of the disease, manifested as bone marrow invasion or combined with leukemia.

(7) Skin lesions: Malignant lymphoma can invade the skin primarily or secondarily, which is more common in NHL. Specific skin lesions are more common in T-cell adult leukemia/lymphoma syndrome or mycosis fungoides, and their manifestations are diverse, including lumps, subcutaneous nodules, infiltrative plaques, ulcers, papules, etc., which are common in the head and neck. Herpes zoster can be seen in 5%-16% of HL patients.

(8) Nervous system lesions: Malignant lymphoma originating from the central nervous system is rare, generally accounting for about 1%. However, neurological complications caused by ML are relatively common, occurring in about 10% of NHL. In clinical practice, they are often taken seriously due to the occurrence of compression symptoms.

(9) Others: ML can also infiltrate the pancreas and cause malabsorption syndrome. It is very rare for ML to infiltrate tissues or organs such as the breast, thyroid, lacrimal gland, bladder, testicles, and ovaries and cause corresponding symptoms.