Hodgkin Lymphoma

Question 1

From what cell does Hodgkin lymphoma (HL) arise?

Answer 1

B lymphocytes

Question 2

Name and describe two cell types present in Hodgkin lymphoma (HL).

Answer 2

• large, multi-nucleated giant cells called ‘Reed-Sternberg’ cells
• large, mono-nucleated cells called malignant ‘Hodgkin cells’.

Question 3

Name the 4 subtypes of Classical Hodgkin lymphoma (HL).

Answer 3

Nodular Sclerosis
Mixed Cellularity
Lymphocyte-rich
Lymphocyte-depleted

Question 4

What type of classical Hodgkin lymphoma (HL) is most common?

Answer 4

Nodular Sclerosis

Question 5

Name some risk factors of developing Hodgkin lymphoma (HL).

Answer 5

• Epstein-Barr virus (EBV): it is estimated that around 40% of Hodgkin lymphoma cases in the UK are related to EBV infection. However, most people who have glandular fever will not develop cancer as a result.
• Human immunodeficiency virus (HIV): it is estimated that the risk of developing Hodgkin lymphoma is 11 times higher than that of the general population
• Immunosuppression: immunosuppressant drugs and certain autoimmune conditions such as rheumatoid arthritis increase the risk of developing HL
• Previous history of non-Hodgkin lymphoma (NHL)
• First-degree relative family history of Hodgkin lymphoma, non-Hodgkin lymphoma (NHL) or chronic lymphocytic leukaemia (CLL)
• Cigarette smoking

Question 6

Describe how a patient with Hodgkin lymphoma (HL) would present.

Answer 6

The most common symptom of Hodgkin lymphoma (HL) is a painless, rubbery, enlarged lymph node/nodes, typically in the cervical or supraclavicular region.

Question 7

Name some B symptoms of Hodgkin lymphoma (HL).

Answer 7

fever >38°C, drenching night sweats and unintentional weight loss of >10% within the last 6 months.

Question 8

What clinical findings may be present on examination of a patient with HL?

Answer 8

Lymphadenopathy
Hepatomegaly
Splenomegaly
Superior vena cava (SVC) syndrome: a mediastinal mass may cause SVC obstruction
Paraneoplastic syndromes such as cerebellar degeneration, neuropathy or Guillain-Barré syndrome

Question 9

Describe the relevant investigations carried out in suspected HL and their inferences on the patient’s prognosis.

Answer 9

FBC: to investigate for leukaemia, infectious mononucleosis and other causes of lymphadenopathy
U&Es: to provide a baseline measurement before treatment
LFTs: reduced albumin levels are associated with a poorer prognosis
LDH: increased levels are associated with a poorer prognosis
ESR: increased levels are associated with a poorer prognosis

Question 10

What is the gold standard for imaging in HL?

Answer 10

Positron emission tomography CT (PET-CT)

Question 11

Using immunochemistry what antigens are positively expressed on Reed-Sternberg cells?

Answer 11

CD15 CD30

Question 12

What is observed in stage one of HL?

Answer 12

Involvement of one lymph-node region or lymphoid structure (e.g. spleen or thymus).

Question 13

What is observed in stage two of HL?

Answer 13

Two or more lymph node regions on the same side of the diaphragm.

Question 14

What is observed in stage three of HL?

Answer 14

Lymph nodes on both sides of the diaphragm.

Question 15

What is observed in stage four of HL?

Answer 15

Involvement of extranodal site(s)

Question 16

Due to the increased risk of opportunistic infections following chemotherapy, patients with HL are also usually vaccinated with what?

Answer 16

Polyvalent pneumococcal vaccine
Influenza vaccine
Meningococcal group C conjugate vaccine
Haemophilus influenzae type b vaccine

Question 17

Describe two commonly used chemotherapy combination regimes in patients with HL.

Answer 17

• ABVD: Doxorubicin (used to be called Adriamycin®), Bleomycin, Vinblastine and Dacarbazine
• BEACOPP: Bleomycin, Etoposide, Doxorubicin (Adriamycin®), Cyclophosphamide, Vincristine (Oncovin®), Procarbazine, Prednisolone

Question 18

How is relapsing HL treated?

Answer 18

Regardless of stage, relapsed disease is usually treated with high dose chemotherapy (HDCT) followed by autologous stem cell transplant (ASCT).

Question 19

If a transfusion of blood products is required, patients with or treated for Hodgkin lymphoma (at any stage of the disease) must only receive what types of products?

Answer 19

Irradiated blood products are used to reduce the risk of transfusion-associated graft-versus-host disease.