Hodgkin’s Lymphoma Flashcards
Lymphomas are broadly divided into _____ and ______
Hodgkin and Non hodgkin
• Hodgkin lymphoma is a incurable lymphoma with distinct histology, biologic behavior, and clinical characteristics.
T/F
F
potentially curable lymphoma
Thomas Hodgkin first described the disorder in 1832 in his paper titled “ ________________________ ”
some morbid appearances of the absorbent glands and spleen
Hodgkin lymphoma:
a (benign or malignant?) lymphoid neoplasm characterised by the presence of neoplastic _________ cells or its variants ( _____________ ) in a background of _________ ————— cell infilterates comprising lymphocytes, eosinophils, histiocytes, plasma cells and neutrophils
Malignant
Reed-sternberg
Hodgkin cell
non-neoplastic inflammatory
REED-STERNBERG CELL
• Neoplastic giant cells derived from ______ centre or _______ centre ___ cells.
germinal
post germinal
B
REED-STERNBERG CELL
___lobed nucleus with prominent ______ nucleoli separated by a _______
Bi
eosinophilic
clear space.
REED-STERNBERG CELL
Account of ___-___% of cell population
1-2
HODGKIN CELLS
_____nuclear variants: ______nucleus with (small or large?) nucleolus.
Mono
single
Large
HODGKIN CELLS
Lacunar cells : folded _____lobed nuclei with (scanty or abundant?) cytoplasm.
multilobed
Abundant
HODGKIN CELLS
_________ variant(L&H cells or _______ cells): _________nuclei,( conspicuous or inconspicuous?) nucleoli and (mild or moderately?) abundant cytoplasm.
Lymphohistocytic
popcorn
polypoid
inconspicuous
moderately
HODGKIN CELLS
•__________ variants
•___________ cells
•___________ variant or ______ cells
Mononuclear variants
Lacunar cells
Lymphohistocytic
popcorn
AETIOLOGY of Hodgkin’s lymphoma
Main
• Largely (known or unknown?)
• Strong association with the ________ VIRUS
Unknown
EPSTEIN BARR
AETIOLOGY of Hodgkin’s lymphoma
Other risk factors
• (Low or High?) socio economic status particularly in the young adults.
• Family history of ________ disease.
•_________
• ____
• Infectious ___________
High
autoimmune
Identical twin
HIV
mononucleosis
HISTOLOGIC CLASSIFICATION
Hodgkin lymphoma is classified into 2 main types:
1)___________ HODGKIN LYMPHOMA
2) _______________ HODGKIN LYMPHOMA.
CLASSICAL
NODULAR LYMPHOCYTE PREDOMINANT
CLASSICAL HODGKIN LYMPHOMA
• Characterised by large ____________ cells or ____________ cells.
• The cells are CD___+,CD___+,CD20-,CD45-,CD____+,CD79a-,PAX5+
mononuclear hodgkin
binucleate reed- sternberg
30, 15; 75
CLASSICAL HODGKIN LYMPHOMA
• Comprises of 4 subtypes.
• __________
•___________
•____________
• ____________
NODULAR SCLEROSIS
MIXED CELLULARITY
LYMPHOCYTE DEPLETED
LYMPHOCYTE RICH
NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA
• A unique subtype constitutes _____% of cases.
• Reed-sternberg cells are (frequent or infrequent?) or (absent or present?) .
5-10
infrequent
absent
NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA
• _____________________ cells are seen in a background of _______ ————— cells.
Lymphocytic and histiocytic cells or popcorn
benign inflammatory
NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA
It is associated with EBV infection
T/F
F
not
NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA
• Unlike reed-sternberg cells they are positive for B cell antigen such as CD__,CD___,CD___,CD___,CD79a,BCL-6 and negative for CD____,CD__,CD__
19; 20; 45; 75;
30;15
NODULAR LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA
• majority of patients are young adult (male or female?) (4;1) with _______ or _________
• Prognosis is (good or bad?).
Male
cervical or axillary lymphadenopathy.
Good
CLINICAL FEATURES of HL
• Presentation commonly with (painful or painless?) ‘_______ ’ ____________ lymph node enlargement: frequently ____ gland(s).
• Initial mode of spread occurs predictably to ___________. Often involves _______ and ________ glands and other sites.
painless;rubbery
supradiaphragmatic; cervical
contiguous nodal chains
supraclavicular and axillary
CLINICAL FEATURES
•_____________ involvement is rare and suggests a diagnosis of _______.
•______________ in HL may wax and wane during observation.
Waldeyer’s ring; NHL
Lymphadenopathy
CLINICAL FEATURES
• Abdominal lymphadenopathy may occur with ______ involvement.
splenic
CLINICAL FEATURES of HL
• Bulky ________ and _______ lymphadenopathy may produce local symptoms(e.g. _____ or ______ ) or direct extension (e.g. to _____,_____,______, or _______ ).
mediastinal and hilar
bronchial or SVC compression
lung, pericardium, pleura or rib
CLINICAL FEATURES of HL
• Extranodal spread may also occur via ______ (e.g. to _____,_______, or _______ ).
Presence of disseminated extranodal disease is generally accompanied by _________________.
bloodstream
bone marrow, lung or liver
generalised lymphadenopathy
CLINICAL FEATURES of HL
• ~33% patients have ≥1 associated constitutional __________ at presentation:
•weight loss >____% body weight during the previous ________
•unexplained ________ or ____________.
•_______,__________, and __________ -induced lymph node pain.
‘B’ symptoms
10; 6 months
fever or drenching night sweats
‘B’ symptoms, pruritus and alcohol
CLINICAL FEATURES of HL
• A defect in ______ immunity has been documented in patients with HL rendering them more susceptible to TB, fungal, protozoal and viral infections including Pneumocystis carinii and HZV.
cellular
CLINICAL FEATURES of HL
•___________ fever
Pel-ebstein
DIAGNOSTIC WORK UP to be done to check for HL
•_______
•_______
•_________
Blood studies
Biopsy
Imaging
Blood studies of HL
• FBC: may show _____chromic _____cytic anaemia, reactive leuco____ and/or a reactive mild thrombo_______.
• ESR is (elevated or depressed?)
• LDH is (elevated or depressed?)
normo; normo
cytosis; cytosis
Elevated
Elevated
Blood studies of HL
• elevated ESR may (help or worsen?) prognosis.
• elevated LDH is correlating with ________
Worsen
bulk of disease
Blood studies of HL
•Elevations of ESR and LDH are seen in ____,_____.
• ____glycemia due to _________
•_____ screening.
CRP, ALP
Hypo
insulin auto antibodies
HIV
BIOPSY of HL
• Bone marrow biopsy especially in the (youth or elderly?) ,(early or advanced?) stage disease, (local or systemic?) symptoms as well as ____ involvement.
Elderly ; advanced; systemic; liver
BIOPSY in HL
• Sampling of pleural fluid by _______
• CNS evaluation by _________
thoracocentesis
lumbar puncture
A histologic diagnosis is always required with excisional lymph node biopsy.
T/F
T
MRI is done for HL if __________________
rare CNS symptoms are present.
IMAGING in HL
• AP and LATERAL CXR to assess _________
• CT scan of _____,_______, and ________
bulk of mediastinal mass.
chest,abdomen,pelvis
IMAGING in HL
•________________(PET) scan now considered essential in the ________ of hodgkin lymphoma as well as in _______
Positron emission tomography
initial staging
assessing treatment.
STAGING OF HODGKIN LYMPHOMA
• ____ stage __________ classification is used.
• It is a _______ and ______ staging system.
4 stage ann-arbour
clinical and pathological
STAGING OF HODGKIN LYMPHOMA
• It is a clinical and pathological staging system.
• The clinical stage is the result of _____,_______,________, and ________
• Pathological staging refers to the use of ________ or __________
history, physical examination,imaging and laboratory investigation.
biopsy procedures or staging laparotomies.
STAGING OF HODGKIN LYMPHOMA
Presence or absence of ______________ further modifies the staging system.
constitutional symptoms
ANN ARBOUR STAGING SYSTEM
Stage 1: Involvement of _________ region(I) or __________________
single lymph node
a single extralymphatic organ or site(Ie)
ANN ARBOUR STAGING SYSTEM
STAGE II: Involvement of ________________ regions on ______________ or with involvement of ______________________(IIe)
two or more lymph node
the same side of the diaphragm alone(II)
limited contiguos extralymphatic organ or tissue
ANN ARBOUR STAGING SYSTEM
STAGE III: Involvement of ________________ ,which may include the ________ or limited _____________ or _______
lymph node regions on both side of the diaphragm III
spleen IIIs
contiguos extralymphatic organ or site IIIe or both IIIes.
ANN ARBOUR STAGING SYSTEM
STAGE IV: _______________ of involvement of _____________________ with ___________________
Multiple or disseminated foci
one or more extralymphatic organ or tissues
or without associated lymph node involvement.
Modifying features in HL
• A. ____________
• B. ____________
• X. ________:mass>___cm,.__:__mediastinal:mass ratio
• E.Involvement of a ________,______ or ________
• Spread is via __________,________, or ___________
ASYMPTOMATIC
B symptoms
Bulky disease; 10; 1:3
single,contiguos or proximal extranodal site
lymphatics,hematogenous or direct extension.
PROGNOSTIC FACTORS(EORTC)
Favourable
• Clinical stage ________
• Maximum of _____ nodal areas involved
• Age < ___ years
• ESR < ____mm/hour without ———— or ESR < ____mm/hour with __________
• Mediastinal/thoracic ratio < ____
I and II
three
50
50 ; ‘ B ’ symptoms
30 ; ‘ B ’ symptoms
0.35
UNFAVOURABLE PROGNOSTIC FACTORS
• ________ disease
• An ESR of _____ mm/h or higher, if the patient is otherwise asymptomatic
• More than ___ sites of disease involvement
Bulky
50
3
UNFAVOURABLE PROGNOSTIC FACTORS
• The presence of _____ symptoms
• The presence of ______ disease
B; extranodal
Bulky disease is defined as a ________ mass >___rd of the intrathoracic diameter on a chest radiograph or greater than ____% of the thoracic diameter at vertebral level ____-____
mediastinal
1/3
33
T5-6.
UNFAVOURABLE FACTORS:ADVANCED DISEASE
• Serum albumin less than ___g/dL
• Hemoglobin less than ______ g/dL
• (Male or female ?) sex
4
10.5
Male
UNFAVOURABLE FACTORS:ADVANCED DISEASE
• Stage —— disease
• Age ____ years or older
• White blood cell (WBC) count greater than _______/μL
IV
45
15,000
UNFAVOURABLE FACTORS:ADVANCED DISEASE
• Lymphocyte count less than _____/μL or less than ___% of the total WBC count
600
8
Advanced disease refers to stage ___/___ disease or early stage disease with ______ or ______
iii/iv
systemic symptoms or bulky disease.
• Treatment of Hodgkin lymphoma is tailored to disease type, disease stage, and an assessment of the risk of resistant disease.
T/F
T
TREATMENT of HL
• It is potentially curable but significant ___________ can arise from therapy.
long term toxicity
TREATMENT of HL
•____________ therapy (______ therapy and _________ ) is frequently the preferred approach.
Combined-modality
radiation
chemotherapy
TREATMENT of HL
• In patients with advanced Hodgkin lymphoma, involved-field radiotherapy can be used for sites of persistent disease following chemotherapy(Stanford V)
TREATMENT of HL
• In patients with advanced Hodgkin lymphoma, _________ ———-therapy can be used for sites of persistent disease following ———therapy(Stanford V)
involved-field radio
chemo
TREATMENT of HL
many cases of Hodgkin lymphoma do not relapse
T/F
F
Despite the high rate of cure for this disease, many cases Hodgkin lymphoma do relapse.
TREATMENT of HL
• In most of these relapse cases, _____ chemotherapy followed by _______ chemotherapy (HDC) with _______________ support is indicated.
salvage
high-dose
autologous hematopoietic stem cell
GOAL OF THERAPY
The primary goal of therapy is to induce __________, which is defined as the _____________, as evaluated by ______ scanning, physical examination, and _______ examination.
a complete remission (CR)
disappearance of all evidence of disease
PET/CT
bone marrow
GOAL OF THERAPY
• A partial remission (PR) is defined as “ __________________________ “ of disease.
regression of measurable disease and no new sites
For treatment of classic Hodgkin lymphoma, ______ therapy is generally administered in combination with ______therapy
radiation
chemo
RADIATION THERAPY
• Radiation fields and doses are selected to minimize _____________, and maximize ________________
the potential side effects of therapy
the potential for long-term disease- free survival.
RADIATION THERAPY
• Involved-field therapy encompasses __________________.
• Regional-field therapy ______________________________
only the areas of observed disease
extends the involved field to include adjacent lymph regions
RADIATION THERAPY
Other fields that have been used historically and may be used in exceptional clinical circumstances include:
the _______ field
__________ field
____________ irradiation
mantle
inverted Y
Subtotal nodal
Radiation therapy
1)the mantle field, covering the ____,______ and ,_________ nodes and avoiding the _________
mediastinal, cervical, and axillary
heart and lungs
Radiation therapy
•inverted Y field, covering the _____,______. And _____ nodes
•Subtotal nodal irradiation involves the ________ plus _________
para-aortic, pelvic, and inguinal
mantle field
the para-aortic nodes.
In Radiation therapy
Careful avoidance of the ________ can reduce the risk of _______.
spinal cord
myelitis
In radiation therapy,
__________________________________________________ are important during the reproductive years
Shielding the testes and oophoropexy (temporary surgical suspension of the ovaries [eg, outside of a radiation field])
In radiation therapy ,
Doses used in combined modality therapy are 30-36 Gy for _________ sites and 20-30 Gy for ______ sites.
bulky disease
nonbulky disease
In radiation therapy,
When radiation therapy is used alone, doses may range from ___-___ Gy.
30-44
INDUCTION CHEMOTHERAPY REGIMEN
____________ was the first effective combination chemotherapy for Hodgkin
lymphoma.
MOPP (mechlorethamine, vincristine, procarbazine, prednisolone)
INDUCTION CHEMOTHERAPY REGIMEN
• 1)MOPP
• It is a ____-drug regimen developed by ___________ and colleagues at the National Cancer Institute in the mid _____s and is primarily of historical importance.
• It has a high incidence of _________ and ____________
4; Vincent DeVita
1960
sterility and secondary leukaemia.
INDUCTION CHEMOTHERAPY REGIMEN
___________ combination has now become the standard chemotherapy regimen for Hodgkin lymphoma.
ABVD regimen
MOPP (______,________,________,_______)
mechlorethamine, vincristine, procarbazine, prednisolone
ABVD (_______,________,_________,__________)
Adriamycin [doxorubicin], bleomycin, vinblastine, dacarbazine
ABVD
The ABVD regimen was designed in Italy by ______________ and his colleagues in the early _____s.
Gianni Bonadonna
1970
OTHER INDUCTION CHEMOTHERAPY REGIMENS
•_____________
•_____________
Stanford V
BEACOPP
SALVAGE CHEMOTHERAPY
• When _______ chemotherapy fails, or patients experience _______, salvage chemotherapy is generally given.
induction
relapse
SALVAGE CHEMOTHERAPY
• Salvage regimens incorporate drugs that are _______________________________________.
complementary to those that failed during induction therapy
SALVAGE CHEMOTHERAPY
Some salvage protocols include
• -____
• -______
• -_______- regimen
ICE
DHAP
EPOCH
RESPONSE ASSESSMENT
• Assessment of disease response requires _________ and, if infiltrated on staging investigations, repeat __________
• The utility of _____ is increasingly well understood.
repeat imaging
bone marrow biopsy.
PET
RESPONSE ASSESSMENT
PET can help differentiate between _______ and ________
active disease and fibrotic material.
Response to treatment has been graded as follows.
• Complete remission CR: ———————
• PARTIAL REMISSION PR: ___________________ and ________________
DISSAPEARANCE OF ALL EVIDENCE OF
DISEASE
REGRESSION OF MEASURABLE DISEASE AND NO NEW SITES.
Response to treatment has been graded as follows.
• STABLE DISEASE SD: ___________________
• RELAPSED DISEASE OR PROGRESSIVE DISEASE PD: ________ OR ______________
FAILURE TO ATTAIN CR/PR OR PD
ANY NEW LESION
INCREASE BY >50% OF PREVIOUSLY INVOLVED SITES.
Response to treatment has been graded as follows.
• Complete remission CR: DISSAPEARANCE OF ALL EVIDENCE OF
DISEASE
• PARTIAL REMISSION PR:REGRESSION OF MEASURABLE DISEASE AND NO NEW SITES.
• STABLE DISEASE SD:FAILURE TO ATTAIN CR/PR OR PD
• RELAPSED DISEASE OR PROGRESSIVE DISEASE PD:ANY NEW LESION OR INCREASE BY >50% OF PREVIOUSLY INVOLVED SITES.
