Medical Archive

Hodkin Lymphoma

Introduction

Epidemiology and etiology

15~34?? 50?? ???? Bimodal peak. Nodular sclerosis type? ????? ????? ? ??.

WHO classification

  • Nodular lymphocyte predominant Hodgkin�s lymphoma 
  • Classical Hodgkin�s lymphoma
    • Nodular sclerosis (50%)
      • Enlarging cervical or mediastinal lymph node in a young adult, usually female.
      • Lymph node is divided by bands of sclerosis; RS cells are present in lake-like spaces
    • Lymphocyte-rich (15%, ?? ?? ??)
    • Mixed cellularity (40%)
      • Often associated with abundant eosinophils (RS cells produce IL-5)
    • Lymphocyte-depleted (<10%, ?? ?? ??)

Approach to the patient

Clinical features

  • B symptom; fever, chills and night sweats
  • Pel-Epstein fever
    • ??~??? ?? ??? ????…
  • Pain in areas of lymphadenopathy following exposure to small quantities of alcohol
    • May be d/t vasodilation in the LN following alcohol exposure causing capsular distension.

Lab findings

  • ?LDH
  • Eosinophilia
    • Tumor cells secrete cytokines that generate eosinophils
  • Peripheral blood smear (PBS)
    • Neoplastic proliferation of Reed-Sternberg (RS) cells, which are large B cells with multi-lobed nuclei and prominent nucleoli (‘owl-eyed nuclei’)

RS(Reed-Sternberg) cell 

CD15+, CD30+ B cell origin.
Secrete cytokines;
Attract reactive lymphocytes, plasma cells, macrophages, and eosinophils
May lead to fibrosis

Imaging

  • PET scan with 18-FDG
    • Imaging test of choice.

Classification

Risk factors

Unfavorable prognostic factors for limited-stage HL

  • High ESR, high LDH, B symptoms
  • Involvement of >3 LN areas or ≥1 extranodal site
  • Bulky disease
  • Age ≥ 50 years

International prognostic score (IPS) for advanced-stage HL

  • Hypoalbuminemia (<4g/dL)
  • Hb <10.5g/dL
  • Male sex
  • Age ≥45 years
  • Lugano classification stage IV
  • WBC ≥ 15,000/mm3
  • Lymphopenia: lymphocyte count <8% or absolute lymphocyte count <600 cells/mm3

Treatment

Classic Hodgkin’s lymphoma

Early stage disease

Localized or good-Px disease: brief course CTx + followed RTx to involved node site

  • ABVD
    • Adriamycin(doxorubicin)
    • Bleomycin
    • Vinbalstine
    • Dacarbazine
  • MOPP
    • Mechlorethamine(nitrogen mustad)
      • S/E: Infertility
    • Oncovin (Vincristine)
    • Procabazine
    • Prednisone

Advanced stage disease

Relapsed disease

Survivorship

Combination of CTx and RTx cures >75% of cases.
More patients died from late complications of therapy than from HL itself, particularly with localized disease.

Long-term complications

  • Second malignancies
    • Acute leukemia in the first 10 yrs
      • Risk: MOPP-like, BEACOPP-like > ABVD
    • Solid organ carcinomas ?10 years after treatment
      • Associated with use of radiotherapy
  • Cardiac injury
    • Risk of coronary artery disease, valve damage, peripheral. vascular disease, and cardiomyopathy
  • Pulmonary disease
    • Radiation-induced fibrosis
      • 4-24 months after therapy
      • Dyspnea, nonproductive cough, and chest pain
      • Chest x-ray: volume loss with coarse opacities
    • Bronchiectasis
  • Hypothyroidism
  • Neuropathy
    • d/t chemotherapy

Nodular lymphocyte-predominant Hodgkin lymphoma

Prognosis

Overall, good prognosis with a 5ySR 80-90% (in children, >95%)

  • Lymphocyte-rich cHL (LRHL) – best prognosis
  • Nodular lymphocyte predominant HL (NLPHL) – good prognosis
  • Lymphocyte-depleted HL (LDHL) – poor prognosis

There is an increased risk for treatment-related second malignancies. (e.g., breast, lung, colorectal).