Case Presentation
報告者 : 黃順祥指導者 : 謝宏仁醫師
Basic Data
姓 名 : 謝承翰病歷號 : 34316795
年 齡 : 025
性 別 : M
Chief Complaint
Cough with sputum for 5 months
Present IllnessGouty arthritis noted for about 1 year with diet control Cough with sputum since 94/12 Mild dyspnea on exertion in recent 4 monthsBody weight loss 13 kg within recent 1.5 years 新竹馬偕
chest CT scan:multiple enlarged lymph nodes over anterior mediastinum, and a 4X4 cm sized irregular tumor with cavitation over RUL.
Bronchoscopy performed on 95/4/13 showed incomplete obstruction due to external compression over RML and RLL orifice
Lab DataSMAC: UA 11.7
LDH 417 ALK-P 188 G-GT 15 I.P. 5.1
WBC 30800 /CUMM HGB 12.3 g/dl HCT 37.1 % MCV 80.6 fl PLT 665000 /CUMM BAND 0.0 SEG 88.2LYMP 3.8 MONO 2.6 EOS 5.1 BASO 0.3
Lab Datatumor marker:AFP 2.98
CEA 1.91
CA-125 44.46
SCC 4.10
CA-199 2.49
AChRAb 0.51 (0.5)
Beta-HCG 0.05(<10)
IG G: 1950IG A: 354 IG M: 166 Negative:HBsAg-EIA, HBsAb-EIA, H
CV-EIA ANTI-HIV TEST-EIA(NHI) EB VCA IGG, IGM, IGA
Lab Data
First-pass EF and wall motion: 1. LVEF: 62 % (normal range: > 50%). RVEF: 45 % (normal range: > 40%). 2. Wall motion: Normal. 3. Poor venous return is noted in the morning on Apr. 28, 2006, but not so obvious in the study perfomed in the afternoon. SVC symdrome is impressed.
SPIROMETRY PRED ACTUAL %PREDFVC 4.74 1.90 40 FEV1 4.03 1.60 40 FEV1/FVC 86 84
The pulmonary function test shows severely restrictive ventilatory impairment
PRED ACTUAL %PREDDLCO 35.8 18.4 51
The DLCO indicates moderate reduction of gas exchange
ImageCXR
A 8.5cm soft tissue mass noted in RML with consolidation of right lung, in favor of tumor growth with obstruction pneumonitis.
Abdominal CT
1. Small lymph nodes noted at bilateral inguinal regions
2. Splenomegaly
3. Increased soft tissue density at paraaortic region of retroperitoneum
Nuclear MedicineWBBS:
No definite evidence of distant bone metastasis
tumor survey: 1. There is a huge
and irregular mass of heterogeneous
uptake in the right lung, which is compatible with tumor
involvement in this region.
PathologyLung, "anterior mediastinal tumor," CT-guided biopsy---Classical Hodgkin lymphoma Cytology (mediastinal)---Positive for malignant cells, lymphoma is favoredSurgical pathology, bone marrow---hypercellularityCytogenetics-bone marrow ---pending report
Hospital Course4/21: CT guided biopsy: classical Hodgkin lymphoma
4/27: BM biopsy : hypercellularity
4/27: port-A implantation
04-28 : C/T with ABVD
05/03 : discharged
Adriamycin inj 46 MG IVA cardiac toxicity
Bleocin inj 18.5 MG IVA pulmonary fibrosis
Vinblastine inj 11 MG IVA
Dacarbazine inj 693 MG IVA
Hodgkin’s Disease
EtiologyMalignancy of lymphoid tissue , presence of Reed-Sternberg (RS) cell
characteristic way—contiguous spread from lymph node to lymph node, central distribution (mediastinum, neck, etc)
Role of Epstein-Barr virus is suspected
EpidemiologyBimodal distribution of peak incidence: young adults (ages 15-35) (this patient:25) and adults >age 50More prevalent in males, especially young-onset HDRisk in monozygotic twins increases nearly 100-fold
Signs/symptomsMajority are asymptomaticLocalized lymphadenopathy
Central structures: mediastinum, neck/supraclavicularFirm, freely movable, nontender (this patient)may be detected on routine CXR
constitutional symptoms (B symptoms) (this patient)fever >38℃night sweatsweight loss > 10% in 6 months
nonspecific symptoms: rash, cough, chest pain, SOB, bone pain, GI discomfort, fatigue, malaise, pruritismay have disulfuram-like reaction (flushing with alcohol ingestion)
Diagnosisgold standard: lymph node biopsy demonstrating RS cells (large cell with bilobed/multilobed nucleus with prominent nucleoli) in appropriate cellular backgroundflow cytometry: CD15+ and CD30+ on RS cellstaging evaluation after pathologic diagnosis
physical exam with emphasis on lymph nodes, spleen sizepresence of B symptomsLabs: CBC, LFTs, renal function tests, uric acid, ESRChest X-rayCT of thorax, abdomen, and pelvis to document lymphadenopathyBilateral bone marrow biopsy/aspiration to assess for marrow involvementLymphangiograms have generally been replaced by Gallium scans, MRI, and PET scans
Treatment Depends on staging
Stage I: 1 lymphatic structure involvedStage II: >1 lymphatic structure involved, on same side of diaphragmStage III: lymphatic involvement on both sides of diaphragmStage IV: disseminated/marrow involvementB = presence of B symptoms; E = Extralymphatic spreadLocalized disease (stages I-II): radiation therapy
Advanced disease (stages IIB-IV): chemotherapyStandard therapy is ABVD(adriamycin, bleomycin, vincristine, dacarbazine)Salvage therapy for recurrence: MOPP (mechlorethamine, vincristine, procarbazine, prednisone)
Consider autologus bone marrow transplant
Prognosis/clinical courseFour types of HD
Nodular sclerosis(classical): most common; more common in females usually at anterior mediastinum Mixed cellularity: 2nd most common prognosisLymphocyte predominant: uncommon; best prognosisLymphocyte depleted: least common
HD is a curable disease (85% curable with treatment)Post-treatment complications: patients may develop myelodysplasia or myelotenous leukemia 10-15 years following treatment