Hodgkin's Lymphoma Flashcards
What are lymphomas?
Disorders caused by malignant proliferations of lymphocytes, which accumulate in lymph nodes or other organs.
(Solid tumours of the immune system)
How are lymphomas histological classified?
Hodgkin’s
Non-Hodgkin’s
Hodgkin’s lymphoma is characterised by the presence of…
Reed-Sternberg cells
Have mirror image nuclei - looks like an owl
Almost always have CD15 and CD30 antigens expressed
What is the peak incidence?
Young adults (HL is commonest malignancy in 15-25 yr olds) Second peak: 50-70
Male:female = 2:1
What risk factors are there?
An affected sibling
Mononucleosis infections - EBV
What is the most common classification of HL?
Nodular sclerosing - accounts for 70%
Most common in young women
In particular involves lymph nodes of the mediastinum and neck
Many fibrotic bands present
Good prognosis
Other than nodular sclerosing type, what others are there?
Mixed cellularity 20-25%
Lymphocyte rich 5%
Lymphocyte depleted <1%
Describe the mixed cellularity type
Mixed infiltrate of lymphocytes, eosinophils, neutrophils, hisyocytes
Reed-Sternberg cells present but not fibrotic bands
More common in elderly
Associated with B symptoms
Describe lymphocyte depleted type
Lack of infiltrate, but Reed-Sternberg cells present
Cells called popcorn cells - tend not to express CD30 and express other antigens
Very poor prognosis
Associated with HIV
Describe the pathogenesis
Not fully clear, but several factors involved:
B cells become Reed-Sternberg and stop expressing surface antibodies
Resistance to apoptosis
Development of self regulation
Environmental factors - possibly due to late exposure to common pathogens e.g EBV
Main point: B cells no longer express IgG and they no longer undergo apoptosis, so they become large cells that no longer perform original function
What symptoms and signs occur?
Enlarged lymph nodes - non tender and rubbery, 60-70% = cervical, also axillary or inguinal
Node size may fluctuate and they can become matted
B symptoms - fever, night sweats, weight loss
Other vague symptoms - pruritis, fatigue, anorexia
Mediastinal lymph node involvement may cause mass effect - bronchial or SVC obstruction
Splenomegaly or hepatomegaly
What can induce lymph node pain?
Alcohol
What is required for definitive diagnosis?
Lymph node biopsy - gives full histology (unlike FNA)
What can the bloods show?
FBC - normocytic, normochromic anaemia, may be lymphocytopaenia
ESR raised
LFTs - usually normal
LDH - raised level is a bad prognostic indicator, suggests increased cell turnover
Uric acid
What imaging should be done?
CXR - mediastinal widening
CT CAP -will show involvement of intrathoracic nodes in 70% cases
What staging system is used?
Ann Arbor system - influences treatment and prognosis
Describe the Ann Arbor staging system
SI - confined to a single lymph node region
SII - two separate regions - an affected node/ lymph organ plus a second affected area. Both on same side of diaphragm
SIII - involvement of node regions on both sides of diaphragm
SIV - involvement of 1 or more extralymphatic organs e.g liver or bone marrow, and may also be in lymph nodes
A = no symptoms other than pruritis B = presence of B symptoms E = localised extranodal extension (does not advance stage) X = bulky disease e.g widening of mediastinum
What are the B symptoms?
Weight loss > 10% in last 6 months
Unexplained fever > 38
Night sweats - need change of clothes
B indicates worse disease
What is the treatment for early stages (IA and IIA)?
Radiotherapy plus short courses of chemotherapy
Short targeted burst of RT
70% cured this way
Usually women’s fertility preserved
What treatment is used for more advanced disease IIA-IVB?
Long courses of chemotherapy ABVD Adriamycin Bleomycin Vinblastine Dacarbazine
Typically 4 week cycles, outpatient procedure, given IV on days 1 and 15
ABVD relatively non toxic compared to that used for other cancers
Cures approx 80%
What complications of radiotherapy treatment can occur?
Increased risk of second malignancies - solid tumours especially breast and lung Cardiac disease Hypothyroidism Lung fibrosis Can affect fertility
What ABVD side effects can occur?
Alopecia
N&V
Myelosuppression - occurs 50% of time, monitor for signs of infection
Allergic reaction to bleomycin or long term pulmonary toxicity
Neuropathy to peripheries
Describe how it spreads
Contagious spread ie from one node to nearby node
