Hodgkin’s Disease (HD)

Hodgkin’s Di sease (HD)

A disease of lymp h nodes with a pr

edictable pattern of spread

Epidemiology• Age: bimodal peak age– Third decade– After 50

• Gender: male to female 13 10= . to .

Etiology and R isk Factors

•Unknown• Possible etiologic factor– 1) Familial factor– - 2) Viruses EBV

Signs and Symptoms

• - HD is a lymph node based malignancy• Common = asymptomatic lymphadenopathy• Systemic symptoms• Extranodal involvement

Location of Lymphadenopathy

• 80% LN above the diaphragm–AAAAAAAA AAAAAAAAAAA– AAAAAAAA, ,

Systemic Symptoms

• - 40% of patients > sAAAAAAA AAAAAAAA– - B symptom => Fever, N

ight sweat, Weight loss– Chronic pruritus

Extranodal Involvement

•“ E” lesion by direct invasion• Hematogenous metasta

sis (Stage IV): spleen, lu ngs, liver, bone marrow

Diagnosis•Biopsy• - Pathology : “Reed Sternberg Cell”– Diagnostic tumor cell– Must be identified– Large size, binucleated, large eo

sinophilic nucleoli

Histology• 1. Lymphocyte predominant (LP)

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tcommon, young adul t , f emal e• 3. ( ) =Mixed cellularity MC generali

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Staging : The Coltswold s Classification for HD• I: A single LN region or a lymphoid structure (eg., spleen

, thymus, Waldeyer’s ring)• II: Two or more LN regions on the same side of the diaphragm

• III: LN regions or structures on both sides of the diaphragm– 1: with/without involement of splenic, hilar, celiac, or portal

AAAAA– 2: , ,with involvement of paraaortic iliac or mesenteric nodes

• IV: Extranodal site(s) beyond that designated E ( a singl e extranodal site, contiguous or proximal to a known no

dal site)

Designations applicable to any disease stage

• A: No symptoms• B: Fever, drenching sweats, weight loss• X: Bulky disease– 13> / the width of the mediastinum– 10> cmmaximal dimension of nodal mass

• E: Involvement of a single extranodal site, contiguous or proximal to a know nodal sit

e

Prognostic Factors• Stage of disease: the most importa

nt prognostic factor• Number of sites of involvement• Bulky disease ( particularly in themediastinum)

• B symptoms•Age

Investigations• 1. Imaging : CT scan of the chest/ abd

AAAA• 2. : , ,Lab tests CBC ESR LDH• -3. :Bone marrow biopsy B symptoms• 4. :Staging laparotomy consist of– Splenectomy– LN sampling: celiac/splenic/hilar/paraaorti

c/paracaval/iliac nodes– Wedge/needle biopsy of the liver– open iliac crest Bone Marrow Biopsy– Oophoropexy

Treatment• - StageI I I = Radi ot her apy• - Stage III IV = Chemotherapy

Radiotherapy• Subtotal lymphoid irradiation =

Mantle + Paraaortic field• Mantle field = base of mandible

to diaphragm– - CoverLNabovediaphragm>submandibular, cervical, supr acl avi cul ar , i nf r ac

lavicular, axillary, mediastinum, hi l ar

• Dose = 3,600 cGy

Side Effects of Radiotherapy•Acute

– N/V, Dermatitis, Fatigue•Delay– Pneumonitis– Herpes zoster infection– Subclinical hypothyroidism– Infertility– Secondary malignancies

• secondary solid tumors ( lung, breast)• - chemotherapy > most common = leukemia

- Non Hodgkin’s Lymphoma

Heterogeneous grou p of lymphoprolifera

tive malignancies

Epidemiology

• The incidence has been increasing worldwide.

• This increase is more m arked for older persons.

Etiology and Ca usative Factors

• The origin is UNCERTAIN.• Causative factors with a predisposition–Immunosuppression– Infectious agents (EBV, HTL

- V 1, Herpes type 8, H.pylori)

NHL• Usually originates in lymphoidtissues• Can spread to other organs• Prognosis depends on the hist

ologic type, stage and extent o f disease, age, and treatment

Clinical Manifestations• Asymptomatic LN enlargement (most common

presentation)• 1) Location of lymphadenopathy– most common = neck, inguinal, and abdominal LNs

• 2) Systemic symptoms– fever, weight loss, night sweats ( usually heralding

more advanced disease)

• 3) Primary extranodal lymphoma– depend on the site of origin

Staging Evaluation• Pathologic diagnosed by an experie

nced hematopathologist.• Staging Evaluation includes:– History + Physical Exam– Lab : CBC, LDH– Bone marrow biopsy– -Chest X Ray– CT abdomen and pelvis/chest– Gallium scan

2Histology: prognooooo oooooo

• Indolent lymphoma• Aggressive lymphoma

Staging: Ann Arbor Sys tem (commonly used)

• I: A single nodal region (I) or single extralymp hatic site (IE)

• II: 2 or more nodal regions on the same side of diaphragm(II) or a single localized extralymph

atic site and its regional nodes on the same si de of diaphragm (IIE)

• III: Nodal regions on both sides of the diaphragm

• IV: Diffuse or disseminated involvement of 1 o r more extralymphatic organs with/without as

sociated nodal involvement

Designations applic able to any stage

• A: No symptoms• B: Weight loss, unexplained

fever, night sweats• E: Localized involvement of

extralymphatic tissue• S: Spleen involvement

Treatment• I ndol ent Lymphoma– Stage I + II = RT– Stage III + IV = Chemotherapy + RT

• Aggr essi ve Lymphoma– Stage I + II = combined modality (

Chemotherapy + RT)– Stage III + IV = Chemotherapy ( Do

xorubicin based)

oooooooooooo• - Involve field RT:– -Involved region + first ech

elon adjacent LN region

• Extended field RT:– -involve field + second ech

elon adjacent LN region

Example

Radiation Dose:

• Indolent: 2 ,5 0 0- 3,500cGy• Aggressive: 3 ,5 0

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Late effects of t reatment

• Normal tissue toxicity• Secondary cancers