Hodgkins lymphoma Flashcards
History of lymphadenopathy
Duration
pAInful
changing
B symptoms
Immunosupression
Risk - HIV.TB
Cat contacts - cat scratch fever
Travel history
What is hodgkins lymphoma
Proliferation of B lymphocytes -> lymphadenopathy
Spleen and/or bone marrow can be effected
Physcial exam of nodes
Size, shape, surface, mobility, consistency
Exam of other lymph node areas
Check skin for brusing
Neuro exam if indicated eg headahces
Do you see changes in FBC w lymphoma
No - normally doesnt infiltrate bon marrow unless advanced disease
Referral criteria for lymphoma
Any patient >1cm for 6 weeks or more
Generalised lymphadenopathy eg two or more contigious areas
Supraclavicular nodes concerning
Initial investigation hodgkins lymphoma
FBC, U+Es, LFTs, ESR, LDH
Immunoglobulins (paraprotein ass)
Viral screen - HIV, hep B, EBV -
Why do viral screen
increased risk of developing lymphoma and also reactivation in chemo
LDH why can signla cancer
(non specific if high cell turnover)
Why do CXR in lymphoma
Widened mediastinum need other scans
What is diagnostic investigation of lymphoma
Biopsy of lymph node
Core biopsies via US or CT often adequate
If cant above then surgical excision biopsy
What cell is classical feature of hodgkins lympomha
Reed steinberg cell - owl eyes on film
What stain use in lymphoma
CD20 - marks B cells
Imaging for Staging of lymphoma
CT neck, chest, abdo and pelvis
PET required for some subtypes
MRI brain and spine for CNS lymphoma
What does PET scan show
Increased glycolytic acitivity of malignant tissues
How stage lymphoma
Ann arbor staing - above or below diaphragm
Stages of lymphoma
A - no B cell symtpoms, B = present
I - 1 nodal site one side of diaphragem
II - 2 nodal sites same side of diaphragm
III - if disease crosses diaphragm in nodal sites
IV - extranodal
What is high grade vs low grade lymphomas
Treat high grade
Watch and wait low grade
What type of lymphoma is hodgkins
High grade - needs treatment
Age distribution in hodgkins lymphoma
Bimodal - teenagers and young adults and then old adults
How often do bloods in tumour lysis syndrome
Twice daily bloods
Prognosis w hodgkins lymphoma
V good - 5 year survival 80-90% if early
40-80% if later stages
Peak incidence hodgkins lymphoma
20-30 years
BIMODAL DISTRIBUTION tho
Multifactorial causes of hodgkins lymphoma
EBV infection
Immunosupression - organ transplant, immunosupression, HIV
AI conditions - RA, SLE, sarcoidosis
Familial- same sex siblings 10 x more likely develop
What are reed steinberg cells
Histological feature hodgkins lymphoma - post germinal B lymphocytes transfomation intended for apoptosis but escape and unchecked proliferation
EBV prevents cytotoxic T cell detection
EBNA1 nad LMP1 proteins contribute
Cytokines and chemokines from inflam cells inhibit Th1 response -> immunosupress and prolif B lymphocytes by IL13
HLA class I ihibtis CD8 antigen presnetation
Hodgkin lymphoma types
Classical
Nodular lymphocyte predominant HL
Features of nodular lymphocyte-predominant hodgkins lymphoma
More common in males
Not ass w EBV
absence of RS cells - characterised by LP popcorn cells
Peripheral adenopathy presents
Affects mesenteric lymph nodes
Subtypes of classical HL
Nodular sclerosing
Mixed cellularity - EBV
Lymphocyte-rich - older age group
Lymphocyte -depeleted - EBV
Subtype w worst prognosis
Lymphocyte depleted
more common w HIV/EBV
Lymhpadenopathy in HL
Painless
ASymmetrical
Cervical nodes or mediastinal involvement
Usually upper body
Spreads continuously
Spleen, axillary, abdominal, hilar, inguino-femoral
Alxohol induced pain?
Classical features of hodgkins lymphoma
B-symtpoms 30% - fever night sweats, weight loss
Pruritis
Abdo pain if lymphadenopathy
Rare:
Clinical hepatosplenomegaly
Bone marrow involvement
Pel-ebstein fever
2 week wait vs urgent referral for HL
2 week wait in adults w unexplained lymphadenopathy considering ass symptoms
CHILDREN - URGENT 48 HRS REFERRAL
Significance of A/B, E, S and X staging HL
A/B = presence B cell symptoms or not
E = extranodal
S = spleen
X = bulky disease/large tumour mass
When is a mediastinal mass bulky and in need of radiotherapy
> 1/3 mediastinal mass ratio
When can do regular monitoring in HL
Stage III/IV nodular lymphocyte predominant hodgkins lymphoma
Unless rpaid progression or symptomatic then RCHOP
Treatment for stageI/II calssical HL
Chemo then radiotherapy
Chemo - ABVD (BEACOPP if unfavourable)
When is chemo alone used in HL
NOn bulky HL <1/3 mediastinal mass ration
Stage III/IV classical
When is radiotherapy alone used HL
Stage I/II nodular lymphcyte predom HL
ABVD chemotherapy drugs
Doxorubicin, bleomycin, vinblastine, dacrabazine
BEACOPP chrmo drugs and risk
Bleomycin, etoposie, doxorubicin, cyclophosphamide, vincristine, procabazine, prednisolone
Risk of secondary leukaemia higher
Treatment for relapsed or refractory HL
Chemo then autologous Stem cell transplant
Immunotherapeutic agents eg brentixumab vedotin, nivolumab
Pembrolizumab
Treatment related complications HL
Myelosupression -> infection, bleeding
Cardiotoxicity (anthracycline)
Secondary malignancies esp AML, NHL, solid tumours eg breast and lung cancer
Complications disease progression HL
Hyperviscosity syndrome
SVC syndrome
Lymph node compression of organs or structures eg trachea, oesophagus
Liver failure, bone marrow failure = end stage
Prognositc factors HL stage I/II
B symptoms
Extra nodal
High ESR
Prognositc factors HL stage III/IV
Male
>45 yrs
Lymphopenia
Low Hb
Low albumin, high ESR
