Hodgkin's Lymphoma

Question 1

What are lymphomas?

Answer 1

Disorders caused by malignant proliferations of lymphocytes, which accumulate in lymph nodes or other organs.

(Solid tumours of the immune system)

Question 2

How are lymphomas histological classified?

Answer 2

Hodgkin’s

Non-Hodgkin’s

Question 3

Hodgkin’s lymphoma is characterised by the presence of…

Answer 3

Reed-Sternberg cells
Have mirror image nuclei - looks like an owl
Almost always have CD15 and CD30 antigens expressed

Question 4

What is the peak incidence?

Answer 4

Young adults (HL is commonest malignancy in 15-25 yr olds) 
Second peak: 50-70 

Male:female = 2:1

Question 5

What risk factors are there?

Answer 5

An affected sibling

Mononucleosis infections - EBV

Question 6

What is the most common classification of HL?

Answer 6

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

Question 7

Other than nodular sclerosing type, what others are there?

Answer 7

Mixed cellularity 20-25%
Lymphocyte rich 5%
Lymphocyte depleted <1%

Question 8

Describe the mixed cellularity type

Answer 8

Mixed infiltrate of lymphocytes, eosinophils, neutrophils, hisyocytes
Reed-Sternberg cells present but not fibrotic bands
More common in elderly
Associated with B symptoms

Question 9

Describe lymphocyte depleted type

Answer 9

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

Question 10

Describe the pathogenesis

Answer 10

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

Question 11

What symptoms and signs occur?

Answer 11

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

Question 12

What can induce lymph node pain?

Answer 12

Alcohol

Question 13

What is required for definitive diagnosis?

Answer 13

Lymph node biopsy - gives full histology (unlike FNA)

Question 14

What can the bloods show?

Answer 14

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

Question 15

What imaging should be done?

Answer 15

CXR - mediastinal widening

CT CAP -will show involvement of intrathoracic nodes in 70% cases

Question 16

What staging system is used?

Answer 16

Ann Arbor system - influences treatment and prognosis

Question 17

Describe the Ann Arbor staging system

Answer 17

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

Question 18

What are the B symptoms?

Answer 18

Weight loss > 10% in last 6 months
Unexplained fever > 38
Night sweats - need change of clothes

B indicates worse disease

Question 19

What is the treatment for early stages (IA and IIA)?

Answer 19

Radiotherapy plus short courses of chemotherapy
Short targeted burst of RT

70% cured this way
Usually women’s fertility preserved

Question 20

What treatment is used for more advanced disease IIA-IVB?

Answer 20

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%

Question 21

What complications of radiotherapy treatment can occur?

Answer 21

Increased risk of second malignancies - solid tumours especially breast and lung 
Cardiac disease
Hypothyroidism 
Lung fibrosis 
Can affect fertility

Question 22

What ABVD side effects can occur?

Answer 22

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

Question 23

Describe how it spreads

Answer 23

Contagious spread ie from one node to nearby node