Paraneoplastic synromes are non-metastatic distant manifestation of a cancer. The paraneoplastic manufestations of lymphoma aredescribed below.
Hypecalcaemia: About 4% of Hodgkin’s Lymphoma and about 1% of the patinets with non-Hodgkin’s lymphoma (NHL) have hypercalcaemia. The NHLs associated with high prevelance hypercalcaemia include high grade B-cell neoplasms and adult T cell lymphoma/leukaemia. Paraneoplastic hypercalcaemia may be caused by PTHrP or 1, 25-dihydroxy vitamin D3. Hypercalcaemia in almost all the patients of HL results from overproduction in 1,25-dihydroxy vitamin D. This mechanism is analogous of hypercalcaemia of tuberculosis and sarcoidosis, is believed to be a result of increased activity of 1α-hydroxylase in macrophages and is responsive to corticosteroids.
Among the HNLs the lymphoma with the highest incidence of hypecalcaemia is adult T-cell leukaemia/lymphoma. About one fifth to half thr patirnts have hypercalcaemia. Both PTHrP and calcetrol have been associated with hypercalcaemia.
Syndrome of Inappropriate ADH Secertion (SIADH): Paraneoplastic SIADH is most commonly associated with small cell lung cancer but has been described in patients with lymphoma. When the syndrome developes in patients with lymphoma on treatment vinca alkaloids may be the culprit.
Paraneoplastic Cerebellar Degeration (PCD): PCD has been reported in HL as well as NHL but the syndrome associated with HL is better characterized as HL is one of the commonest malignancies associated with PCD. HL associated PCD may occur even when the patient is in remission and there appers to be no relation of PCD and stage of HL. PCD is an immune disease that is associated with anti-Hu in cases of PCD associated with small cell lung cancer and anti-Yo antibodies in gynecological cancers. PCD associated with HL is charcterized by the presence of anti-TR antibodies that are distinct from the antibodies mentioned above. PCD associated with HL appeares to have a better outcome. Spontaneous recovery has been reported in 15% of patients and recovery following therapy has been reported. Immunosupressive therapy has not been shown to be of benefit.
Other Central Nervous System Manifestations: Limbic encephalitis that reverses with treatment, a chloroform disorders, a paraneoplastic myelopathy have been described with HL.
Motor Neuron Disease (MND): Paraneoplastic MND associated with lymphoma is charcterized by upper and lower motor neuron involvement. These patients often have paraproteinaemia. They may may benefit from chemotherapy but the benefit of immunotherapy and plasmapheresis is less clear.
Peripheral Nerve Involvement
Acute polyradiculoneuropathy (APN): APN resembles Guillian-Barre syndrome and is seen with HL. No specific antibodies have been associated with this syndrome. Treatment of HL does not appear to alter it’s course. Plasmaphersis and intravenous gamma globin may control the manifestations. Patients with relapsing and remiting forms have been described.
Polyneuropathy of Paraproteinaemia: Lymphplasmacytic lymphoma is associated with a peripheral neuropathy (sensory, motor or both) in 5-10% of the patients. The pathogenesis of these neuropathies is diverse and include
- Demyelination resulting from IgM monoclonal band being directed against neuronal components
- Axonopathies due to endoneural granulofibrilar IgM diposits lacking activity against neuronal components.
- Rarely amyloid deposition may cause neuropathy
Neuropathy due to Paraneoplatic Vasculitis: painful mononeuritis multiplex may occur in patinets with lymphoma. In some of these patinets the vasculitis may be limited to the nerves. Patients may respond to treatment if the primary, immunosupression or plasmapheresis.
Neuromuscular Dysfunction: Rarely patients with lymphoma may develop Eaton-Lambert stndrome or myasthenia gravis
Cutaneous Paraneoplastic Syndromes
The cutaneous paraneoplastic syndromes associated with lymphoma include acanthosis nigracans, Sweet’s syndrome (neutrophila, fever, papular rash), paraneoplastic pemphigus (most commonly asociated with CLL and NHL) and lichen planus with low grade lymphomas.
Haematological Paraneoplastic Syndromes
Sixty three pecent of the patients of lymphoma have an abnormal haemoram. Anaemia is the commonest abnormality. Warm antibody type autoimmune haemolytic anaemia has been described NHL particularly angioimmunoblastic T cell lymphoma and chronic lymphocytic leukaemia (CLL). AIHA occurs with an incidence of 2-3% in other NHLs and HL. Immune thrombocytopenia is less common than AIHA. It is most commonly seen in CLL but may be seen with other lymphomas. Low grad B cell lymphomas may be associated with cold antibody type of AIHA. Pure red cell aplasia may be seen with T cell lymphomas. Eosinophila is more common in HL and T cell lymphomas but may be seen in B cell lymphomas. Lymphoma may be a cause of secondary thrombocytosis.
Renal Paraneoplastic Syndrome
About 10% patinets with idiopathic nephrotic syndrome have an underlying maligancy. Most of these patinets have membranoproliferative glomerulonephritis. HL is associated with minimal change disease. Membranous and membranoproliferative glomerulonephritis may be seen with CLL and other NHLs. A few patients with NHLs have been reported to have minimal change disease.