Hodgkin Lymphoma Flashcards
subtypes of classical hodgkin lymphoma
1) nodular sclerosis
2) mixed cellularity
3) lymphocyte rich
4) lymphocyte depleted
demographics of HL
bimodal (first peak around 20, second around 65)
how staging generally work
lymph node distribution
typical presentation
- asymptomatic LAD OR incidental mediastinal mass picked up on CXR (which can cause chest discomfort or respiratory symptoms if large)
- LAD, fatigue, and/or pruritus often recognized to have begun weeks to months before patient is evaluated for cHL
- b symptoms in 40% of patients
pattern of disease involvement? How common is marrow involvement?
- cervical nodes most commonly affected followed by mediastinal nodes
- spread to adjacent lymph nodes
- marrow involvement rare
cell of origin
B-cell lymphoma
staging workup
CT and ***PET/CT
diagnosis of HL
Excisional lymph node biopsy w/ Reed-Sternberg cells
prognosis
Survival rates = Good. Cure obtained in 80% of all patients. 5-year survival of >90% in early, and 75% in advanced-stage disease.
Hodgkin lymphoma is a highly curable disease.
treatment in general and regimen for limited stage
ABVD chemo followed by XRT
ABVD regimen
doxorubicin/bleomycin/vinblastine/dacarbazine
Standard of care for relapsed/refractory HL
high-dose chemotherapy (ICE) followed by autologous HSCT w/ brentuximab consolidation
Definition of bulky disease
Tumors in the chest that are at least ⅓ as wide as the chest, or tumors in other areas that are at least 10 centimeters (about 4 inches) across
Clinical course
Generally slow progression but tempo is variable
2 major subtypes of HL
- Classic HL
- Nodular lymphocyte predominant HL
Lymph node appearance in patients with cHL
- nontender, firm, rubbery
How is weight loss defined as a b symptom
Unexplained loss of greater than 10% of body weight over 6 months
Fever features in Hodgkin’s
- more noticeable in the evening
- gradually becomes more severe and continuous with time
less common presentations of hodgkin’s
- alcohol-associated pain (uncommon but highly specific for HL)
- liver disease
- skin lesions
- bone involvement
laboratory presentation of HL
- hypercalcemia (increased cailcitriol production)
- anemia (multifactorial)
- eosinophilia
Systemic exertion intolerance disease treatment
Regularly scheduled office visits
CBT
Graded exercise therapy
sleep hygiene education
First-line treatment of acute low back pain
Nonpharmacologic therapy (eg acupuncture, massage, spinal manipulation, superficial heat) (most patients will improve over time, regardless of treatment)
Boards recommendation on patient that is really nonadherent
send warning letter that relationship may be terminated (assuming patient is medically stable and alternative care is available)
immunophenotype of classical HL
CD15 and CD30
- usually CD20 negative
primary general goal of HL treatment
HL is highly curable so goal is to balance risk of recurrence with toxicity of treatment (toxicity is becoming leading cause of cancer related mortality)
Limitation of CT for evaluating disease burden in HL
- can’t detect residual disease after treatment
- can’t distinguish between necrosis and/or fibrosis and active disease
Stage I HL
involvement of a single lymph node
Stage II HL
involvement of 2 or more lymph node regions
Major distinction in categorization of limited stage HL
Favorable and unfavorable prognosis
2 most commonly used definitions of favorable disease
- European Organization for Research and Treatment of cancer (EORTC)
- German Hodgkin Study Group (GHSG)
Limited stage favorable definition per EORTC
patients age 50 or under; without large mediastinal adenopathy; with an erythrocyte sedimentation rate (ESR) of less than 50 mm/h and no B symptoms (or with an ESR of less than 30 mm/h in those who have B symptoms); and disease limited to three or fewer regions of involvement
Limited stage favorable definition per GHSG
no more than two sites of disease; no extranodal extension; no mediastinal mass measuring one-third the maximum thoracic diameter or greater; and ESR less than 50 mm/h (less than 30 mm/h if B symptoms present)
distinction in management between unfavorable and favorable limited stage disease
Less chemo and less intense radiation
Advanced stage HL refers to
Stage III and IV disease
stage III definition
Nodal involvement on both sides of the diaphragm
stage IV definition
Diffuse or disseminated involvement of 1 or more extranodal organs or tissues
Stage IV management
Induction chemo +/- consolidation radiotherapy (controversial)
Definition of primary refractory disease
Patients who don’t attain a complete remission after initial therapy
Management of relapsed disease
Conventional chemoRT OR high dose chemo and autologous HCT
What management of relapsed disease depends on
How far out relapse occurs
HCT usually if early relapse
Score used for advanced stage stratification
International prognostic score (IPS)
Advanced stage management in general
Main treatment is combination chemotherapy, radiation therapy may be used for selected patients as consolidation
Therapy-related complications to know in general for HL
Delayed complications presenting years after treatment secondary malignancies, cardiac disease, radiation-induced hypothyroidism
Distinctive Morphologic feature of reed sternberg cells
- bilobed nucleus (sometimes multinucleated)
scoring system used for response assessment
Deauville
immunophenotype
CD20-, CD15+, CD30+
Reed sternberg cell immunophenotype
CD15 and CD30 positive
Evidence for radiation in unfavorable early stage classic HL
PFS benefit but no OS
Management of patient on ABVD with interim PET of 4 or 5
Escalate to BEACOPP
Is CHF from doxorubicin a concern for patients without CHF?
No. Cumulative exposure for ABVD is well below threshold that puts people at risk for CHF.
What is the biggest mortality risk for Hodgkin’s patients who have achieved a cure?
Nonhematologic secondary malignancies (related to an underlying deficiency in their immune systems)
Early stage Hodgkin lymphoma management
2 cycles of ABVD followed by radiation
