Lecture 10: Hodgkin's Lymphoma

Question 1

Are lymphomas the same as leukaemias?

Answer 1

No, because a lymphoma is a solid tumour ** of leukocytes in lymphatics and reticuloendothelial system.

Leukemias are

Question 2

What was Hodgkin’s Lymphoma named after?

Answer 2

It was named after Dr Thomas Hodgkin.

Question 3

Who was Dr Thomas Hodgkin?

Answer 3

A british pathologist that lived from 1798-1866. He published a paper in 1832, which describes lymphoma.

He did a study analysing patients of TB with swollen lymph nodes, and found that some patients had swollen lymph nodes due to an overproduction of lymphocytes rather than

Question 4

What is Hodgkin’s Lymphoma?

Answer 4

It is a haematological disease of B-lymphocytes.

It comprises of a range of sub-types.

It is responsible for around 15% of all lymphoma cases.

Question 5

What do Hodgkin’s diseases have in common?

Answer 5

There a Reed-Sternberg cells.

Question 6

What are Reed-Sternberg cells?

Answer 6

Abnormal cells derived from B-lymphocytes, of which do not express antibodies.

They are very large cells (around 50 microns)

They can present as bi-nucleated, or multinucleated cells.

They are CD30 and CD15 positive.

Can be quite rare in tumours (>5%)

Question 7

What is the difference between Hodgkin’s and non-Hodgkin’s lymphoma?

Answer 7

Hodgkin’s can only arise from B-lymphocyte lineages, whereas non-Hodgkin’s lymphoma can arise from any lineage.

Question 8

What are Reed-Sternberg cells named after?

Answer 8

They were named after Dorothy-Reed and Carl Sternberg.

Question 9

Who was Dorothy-Reed?

Answer 9

A woman who was a paediatrician and pathologist who discovered that lymphoma was not due to TB infection in 1901. She identified that Reed-Sternberg cells were a pathological presence in Hodgkin’s lymphoma and produced the first definitive microscopic descriptions.

Question 10

Who was Carl Sternberg?

Answer 10

An Austrian pathologist who was working on the discovery of the Reed-Sternberg cells around the same time as Dorothy-Reed, and published a paper in German around the same time.

Question 11

How are Reed-Sternberg cells formed?

Question 12

How do Reed-Sternberg cells contribute to cancer?

Question 13

What are the clinical symptoms of Hodgkin’s Lymphoma?

Answer 13

Lymphadenopathy (swelling of lymph nodes)

Night sweats

Weight loss

Question 14

What is the epidemiology of Hodgkin’s Lymphoma?

Answer 14

There is a geological difference in prevalence. For example it is rare in East Asia but more common in West Asia.

Question 15

What is the aetiology of Hodgkin’s Lymphoma?

Answer 15

Epstein-Barr virus is highly associated with Hodgkin’s lymphoma. Around 90% of HD cases are positive for EBV.
All cases of HD in HIV patients are EBV positive.

Question 16

What EBV genes are associated with malignancy?

Answer 16

LMP1
LMP2a
EBNA1

Question 17

How can Hodgkin’s Lymphoma be tested for?

Answer 17

There are non-specific tests:

-A full blood count can be performed,
although this means the lymphoma
must have progressed quite a lot.

• Liver function tests
• Serum lactate dehydrogenase (when tumour cells die, lactate dehydrogenase is released)

There are also specific tests:

• Lymph node biopsy
• Immunohistochemistry (looking at
  CD30 and CD15)

Question 18

Why do tumour cells die often enough to release large amounts of lactate dehydrogenase?

Question 19

Side Fact: How can testicular cancer be tested for?

Answer 19

A blood test looking for AFP and human chorionic gonadotropin. Since these are not normally produced in significant amounts in adults males, but tumour cells will produce them.

Question 20

How many diseases come under the umbrella term Hodgkin’s Lymphoma? Name them.

Answer 20

5 classifications exist, according to WHO:

• Nodular lymphocyte predominant
  Hodgkin’s lymphoma (NLPHL)
• Classical Hodgkin’s lymphoma (CHL)
• Nodular sclerosis Hodgkin’s
  lymphoma.
• Lymphocyte rich classical Hodgkin’s
  lymphoma.
• Mixed cellularity Hodgkin’s
  lymphoma.
• Lymphocyte depletion Hodgkin’s
  lymphoma.

Question 21

What is Nodular sclerosis Hodgkin’s lymphoma?

Answer 21

Around 60-80% of HL falls into this category.

Question 22

What is Mixed cellularity classical Hodgkin’s lymphoma?

Answer 22

This accounts for 15-30% of HD.

Question 23

What staging system is used for the prognosis of Hodgkin’s Lymphoma?

Answer 23

The Ann Arbor system is used, it consists of four stages. Beyond the four stages, they can be subdivided by adding letters:

• B, presence of B symptoms (fever,
  nights sweats, weight loss).
• S, meaning splenic involvement.
• E, meaning tissue other than
  lymphatics involved.
• X, meaning a large tumour (>10cm).

Question 24

What is skin involvement in HL?

Question 25

How will a biopsy of HL look?

Question 26

What is paraneoplastic syndrome in HL?

Question 27

What does IPFP stand for and what is it used for?

Question 28

How can HL be managed?

Answer 28

Treatment of early stage HL involves the use of ABVD.
Large tumours can be removed by surgery.

Advanced HL can be treated by using BEACOPP.

Question 29

What is ABVD?

Question 30

What is BEACOPP?

Question 31

What therapeutic role does G-CSF play?

Answer 31

It aids in the proliferation of neutrophils in immunocompromised individuals undergoing ABVD and BEACOPP treatment.

Question 32

What other supportive therapies are provided next to ABVD and BEACOPP.

Question 33

What can be done about refractive lymphomas?

Answer 33

Checkpoint Inhibitors, such as pembrolizumab and nivolumab, which target checkpoint protein PD-L1. PD1 is overexpressed in Reed-Sternberg cells.