- 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

Hodgkin Lymphoma Flashcards by Ned Jones

subtypes of classical hodgkin lymphoma

1) nodular sclerosis
2) mixed cellularity
3) lymphocyte rich
4) lymphocyte depleted

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demographics of HL

bimodal (first peak around 20, second around 65)

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how staging generally work

lymph node distribution

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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

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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

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cell of origin

B-cell lymphoma

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staging workup

CT and ***PET/CT

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diagnosis of HL

Excisional lymph node biopsy w/ Reed-Sternberg cells

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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.

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treatment in general and regimen for limited stage

ABVD chemo followed by XRT

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ABVD regimen

doxorubicin/bleomycin/vinblastine/dacarbazine

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Standard of care for relapsed/refractory HL

high-dose chemotherapy (ICE) followed by autologous HSCT w/ brentuximab consolidation

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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

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Clinical course

Generally slow progression but tempo is variable

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2 major subtypes of HL

Classic HL

- Nodular lymphocyte predominant HL

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Lymph node appearance in patients with cHL

nontender, firm, rubbery

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How is weight loss defined as a b symptom

Unexplained loss of greater than 10% of body weight over 6 months

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Fever features in Hodgkin’s

more noticeable in the evening

- gradually becomes more severe and continuous with time

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less common presentations of hodgkin’s

alcohol-associated pain (uncommon but highly specific for HL)
liver disease
skin lesions
bone involvement

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laboratory presentation of HL

hypercalcemia (increased cailcitriol production)
anemia (multifactorial)
eosinophilia

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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