Hodgkin's Lymphoma

Hodgkin’s Lymphoma

Overview

Hodgkin’s lymphoma is a malignancy arising in the lymphoid tissues (mainly lymph nodes). The cell of origin is the “B” lymphocyte.

Etiology: Epstein-Barr virus is thought to play a major role in most cases.

Epidemiology

Hodgkin’s lymphoma has a peak incidence in two age groups (bimodal):

• Young adulthood (in the 20s)
• Above 50

Signs and Symptoms

1. Lymph Node Enlargement:

   • Commonest Feature
   • Most common is enlargement of axillary, cervical, supraclavicular & inguinal nodes
   • Nodes are painless and rubbery
   • Nodes become acutely painful after alcohol intake (2-3% of patients)

2. Systemic Features (B Symptoms):

   • Low-grade fever
   • Night sweats
   • Weight loss (at least 10% of body weight in less than 6 months)
   • Note: B Symptoms may or may not be present.
   • Pruritus

3. Other Findings:

   • Splenomegaly (often seen)
   • Hepatomegaly (possible but not very common)
   • Features of nephrotic syndrome (pathology in the glomerulus is minimal change disease)Z

Pel-Ebstein Fever

• A cyclic pattern of fever, rarely seen in Hodgkin’s patients
• Fever present for a few days, then absent for a few days (cycle continues)

Diagnostic Feature

The diagnostic feature is the presence of malignant Reed-Sternberg cells (R-S cells), seen on lymph node biopsy.

• Large cell with two nuclei, looking like “owl eyes”

Classification of Hodgkin’s Lymphoma

1. Classic Hodgkin’s Lymphoma (Most Cases):

   • Lymphocyte-rich: RS cells + excess lymphos.
   • Lymphocyte-depleted: RS cells plus very few lymphos
   • Mixed cellularity: Almost equal number of RS cells and lymphos
   • Nodular sclerosis: RS cells plus lymphos plus fibrous tissue

2. Nodular Lymphocyte Predominant Hodgkin’s Lymphoma (Only 10% of Cases)

Diagnosis & Workup

• Diagnosis: Confirmed by lymph node biopsy showing R-S cells. - After diagnosis, workup is done for staging the lymphoma, so that treatment options can be decided
• Workup:
  • Routine blood tests (CBC, electrolytes, etc.)
  • Imaging:
    • Whole body imaging (CT, MRI, or PET scan) to determine affected lymph nodes.

Stages of Hodgkin’s Lymphoma

Based on which lymph node regions are affected:

• Stage 1: Involvement of only one lymph node region
• Stage 2: Involvement of two or more lymph node regions on the same side of the diaphragm.
• Stage 3: Involvement of two or more lymph node regions on both sides of the diaphragm.
• Stage 4: Disseminated disease (involvement of other organs like the liver).

A/B Designation:

• A: No systemic symptoms (B symptoms)

• B: Presence of systemic symptoms (B symptoms)

• Stage 1 A, or 1 B

• Stage 2 A, or 2 B

• Stage 3 A, or 3 B

• Stage 4 A or 4 B

Differential Diagnosis

• Non-Hodgkin’s lymphoma
• Metastases from other cancers
• Infection in the nodes (lymphadenitis); painful

Treatment

• Radiotherapy: Used alone or with chemotherapy.

  • Mantle field (neck, chest, and axilla)
  • Inverted Y field (abdomen, spleen, and pelvis)

• Chemotherapy:

  • ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine): Standard initial treatment in the U.S.
  • Other regimens: MOPP, Stanford V(5), BEACOPP

1. MOPP:

• Mustargen, Oncovin, Prednisone, Procarbazine
• Was used in the past. Rarely used now( only in relapse)

2. ABVD:

• Adriamycin, Bleomycin, Vinblastine, Dacarbazine
• Standard initial treatment in the U.S.

3. Stanford V: Contains multiple drugs Used in some countries

4. BEACOPP Contains multiple drugs Used mainly in Europe

Prognosis

Prognosis of HD depends on many factors but overall, it’s a curable cancer in many patients

• Overall 5-year survival rate is 85-90%.
• Poor Prognostic Factors:
  • Old age
  • Advanced disease (Stage 4)
  • Presence of B symptoms
  • Large intrathoracic tumor mass