Hodgkin's Lymphoma

Question 1

Basics

Answer 1

Malignant proliferation of lymphocytes (lymphatic system).
Characterised histologically by “Reed-Sternberg” cells - multinucleated giant cells and associated abnormal, smaller, mononuclear cells

Question 2

Classification

Answer 2

Classical (95%) - all treated same
- Nodular sclerosis
- Mixed cellularity
- Lymphocyte rich
- Lymphocyte depleted
Nodulcar lymphocytes predominant Hodgkin's lymphoma (NLPHL) (5%) - different

Question 3

Nodular sclerosing info

Answer 3

Most common (70%)
Good prognosis
More common in women.
Associated with lacunar cells

Question 4

Mixed cellularity info

Answer 4

20%
Good prognosis
Large number of Reed-Sternberg Cells

Question 5

Lymphocyte predominant

Answer 5

5%
Best prognosis
No Reed-Sternberg cells

Question 6

Lymphocytes depleted

Answer 6

Rare
Most common in immunodeficiency
More common in developing countries
Strong association with EBV

Question 7

Epidemiology/Risk factors

Answer 7

Peak incidence 20-34 and >70
M>F (slight)
EBV, PMH mononucleosis
HIV
Immunosuppression
Smoking

Question 8

Presentation

Answer 8

Painless enlarged lymph node - typically lower neck/supraclavicular
Mediastinal mass on CXR
Chest discomfort/cough/dyspnoea
“B symptoms” (25%): Drenching night sweats, unexplained fever >38, weight loss >10%
Alcohol induced pain at nodes (10%)
Lymphadenopathy, hepato/splenomegaly, SVC syndrome
Paraneoplastic syndromes: cerebellar degeneration, neuropathy, Guillain-Barre

Question 9

Bloods

Answer 9

Blood film
FBC: leukaemia, mononucleosis, other causes lymphadenopathy
ESR: >70 = poor prognosis
LFTs and serum protein: rise in LDH/fall in lactate prognostic significance
HIV/HCV/HBV
TSH: staging (?)

Question 10

Imaging

Answer 10

CXR: mediastinal mass
CT abdo thorax for staging
Note: also do biopsy

Question 11

Staging

Answer 11

Stage I: one lymph-node region or lymphoid structure (eg spleen, thymus)
Stage II: two or more lymph-node regions on same side of diaphragm
Stage III: LNs on both sides of the diaphragm
Stage IV: involvement of extranodal sides excluding Modifying E features

Question 12

Modifying features of staging

Answer 12

A: No symptoms
B: fever, drenching night sweats, weight loss >10% in 6months
X: bulky disease - greater than a third widening of mediastinum or greater than 10 cm maximum diameter of nodal mass.
E: involvement of single, contiguous, or proximal extranodal site.

Question 13

Management: prior to starting treatment

Answer 13

Assess for risk of short and long term complications
Cardiac and pulmonary function tests + consult with ENT
Reproductive counseling as treatment may compromise fertility - can cryopreserve semen, woman should be offered consultation with fertility specialist.

Question 14

Treatment options

Answer 14

Chemo, radio or combined therapy (both carry risk of solid tumours)
Vaccination - pneumococcal, flu, men C, Hib
Stem cell transplant being explored

Question 15

Chemo

Answer 15

Effective
Increases risk of leukaemia (peak 5 years after starting chemo. Highest risk in splenectomy/advanced disease)
Give prophylactic abx if severe neutropenia
+/- radiotherapy
(Options: ABVD: doxorubicin (used to be called Adriamycin®), bleomycin, vinblastine and dacarbazine.
BEACOPP: consists of bleomycin, etoposide, doxorubicin (Adriamycin®), cyclophosphamide, vincristine (Oncovin®), procarbazine and prednisolone.)

Question 16

Relapse treatment

Answer 16

Stem cell transplant

Question 17

Follow up

Answer 17

For 2-5 years
Counsel on increased risk of CVS and pulmonary disease, infertility and further cancers
Regular lifestyle advice to avoid above, including no smoking and management of CVS risk factors
Regular cancer screening
If radiotherapy to neck: regular TFTs. Hypothyroidism can occur up to 30 years later
Patient should receive irradiated blood products only for rest of life

Question 18

Complications

Answer 18

Leukaemia if chemo
Solid tumours (esp colon, lung, bone, breast, thyroid) of radio.
Also increased risk of melanoma, non-Hodgkin’s lymphoma, soft-tissue sarcoma, salivary gland cancers and pancreatic cancers.
Hypothyroidism and CVS disease (related to radiation)
Infertility (both genders)

Question 19

Prognosis

Answer 19

Generally good/curative
B symptoms indicate poor prognosis
As do male sex, age >45 years, stage IV disease, leukocytosis, lymphocytopenia, low haemoglobin and low serum albumin
5 year survival 81% (increased mortality mostly due to disease)
Causes of increased long term morbidity/mortality include second neoplasms, cardiac disease, pulmonary disease and infections