A.15 Hodgkin's Lymphoma

Question 1

A.15 Hodgkin’s Lymphoma
Epidemiology

Answer 1

Age: Bimodal distribution:
- 1st peak: 25-30 years
- 2nd peak: 50-70 years
Higher incidence in males (especially notable in pediatric cases)
Exeption: nodular sclerosing HL shows a more balanced distribution, with roughly equal rates of diagnosis in males and females.

Question 2

A.15 Hodgkin’s Lymphoma

Answer 2

In Hodgkin’s lymphoma, characteristic cells with mirror-image nuclei are found, called Reed–Sternberg cells.
Hodgkin’s lymphoma (HL) is a malignancy of mature B lymphocytes.
It represents ~10% of all lymphomas diagnosed each year.
The majority of HL diagnoses are classical HL (cHL), but there is a second subtype of HL, nodular lymphocyte-predominant HL (NLPHL).

Question 3

A.15 Hodgkin’s Lymphoma
Etiology

Answer 3

Risk Factors:
* Association with Epstein-Barr virus (EBV)
* Immunodeficiency (e.g., organ transplant recipients, HIV infection)
* Autoimmune diseases (e.g., RA, sarcoidosis)

Question 4

A.15 Hodgkin’s Lymphoma
Clinical Features

Answer 4

1. Painless Lymphadenopathy:
   * Cervical Lymph Nodes: Affected in 60-70% of patients.
   * Axillary Lymph Nodes: Involved in 25-35% of cases.
   * Inguinal Lymph Nodes: Affected in 8-15% of patients.
   * Mediastinal Lymph Nodes: Can cause chest pain, dry cough, and shortness of breath.
2. Systemic Symptoms (B Symptoms):
   * Night sweats, unexplained weight loss (>10% in 6 months), and fever (>38°C), which may overlap with other diseases.
3. Other Symptoms:
   * Alcohol-Induced Pain: Pain in lymph nodes after consuming alcohol.
   * Pruritus: Itching that may be localized or generalized.
4. Characteristics of Lymphadenopathy:
   * Lymph nodes may show rapid growth, be painless, hard/ coarse, and fixed to surrounding tissues, indicating possible malignancy.

Question 5

A.15 Hodgkin’s Lymphoma
Staging (Ann Arbor System)

Answer 5

• Stage I: Confined to a single lymph node region.
• Stage II: Involvement of two or more nodal areas on the same side of the diaphragm.
• Stage III: Involvement of lymph nodes on both sides of the diaphragm.
• Stage IV: Spread beyond the lymph nodes to the liver or bone marrow.

Each stage can be classified as either
‘A’—without systemic symptoms other than pruritus, or
‘B’—presence of B symptoms: weight loss >10% in the last 6 months, unexplained fever >38°C, or night sweats.
Stage ‘B’ indicates worse disease.
Localized extranodal extension does not change the stage but is noted with a subscript, e.g., I-AE.

The staging of Hodgkin’s lymphoma influences treatment options and prognosis. It is determined through imaging and, if B symptoms or stage III–IV disease are present, a marrow biopsy.

Question 6

A.15 Hodgkin’s Lymphoma
Diagnostics

Answer 6

Diagnosis of Hodgkin’s lymphoma is primarily based on medical history and clinical features (B symptoms, localization of lymph node involvement) and is confirmed with a lymph node biopsy (excisional).

Blood Tests
* Complete Blood Count (CBC): May show elevated or decreased white blood cell count, anemia, or eosinophilia.
* Serum Chemistry: Elevated LDH; hypercalcemia (potentially due to paraneoplastic syndromes).
* Vitamin D Levels: Check for deficiencies.
Histology
* Obligatory Diagnostic Step: Lymph node biopsy is essential.
* Reed-Sternberg Cells (RSCs): Characteristic cells originating from B cells; positive for CD15/CD30 markers.
Imaging
* Chest X-ray or CT Scan: Used to detect and measure masses and enlarged lymph nodes.
* Bone Scintigraphy or PET-CT: Conducted prior to treatment to assess disease spread.

Question 7

A.15 Hodgkin’s Lymphoma
Pathology

Answer 7

• Nodular Sclerosis: Most common subtype.
• Lymphocyte Predominance: Associated with the best prognosis.
• Mixed Cellularity: Often shows eosinophilia; seen in immunocompromised patients.
• Lymphocyte Depletion: Typically seen in immunocompromised individuals.

Question 8

A.15 Hodgkin’s Lymphoma
Differential Diagnosis of Lymphadenopathy

Answer 8

Generalized lymphadenopathy can indicate systemic illnesses such as HIV, mycobacterial infections, or lymphoma (including Hodgkin’s lymphoma).
Symptoms may include tender, mobile, and erythematous lymphadenopathy.

Question 9

A.15 Hodgkin’s Lymphoma
Treatment

Answer 9

Early Stage (I and II):
Combination of chemotherapy and radiation therapy.
Chemotherapy Regimen: ABVD (Adriamycin, bleomycin, vinblastine, dacarbazine).

Advanced Stage (III and IV, often with bulky disease):
Combination chemotherapy with radiation therapy in select cases.
Chemotherapy Regimens:
ABVD
BEACOPP (bleomycin, etoposide, Adriamycin, cyclophosphamide, oncovin, procarbazine, prednisone).

Additional Options: Anti-CD30 antibodies and autologous stem cell transplantation.