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Hodgkin lymphoma

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Page 1: Hodgkin  lymphoma

الرحمن الله بسمالرحيم

Page 2: Hodgkin  lymphoma

HODGKIN LYMPHOMA

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EPIDEMIOLOGY

H L IS common lymphoid malignancy of young

Hodgkin l ymphoma r epresent about 11% of all lymphoma

Incidence of HL is 3.2 per 100.000

:1

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Sex;- HL affects males slightly more than female 1.3 ; 1

Age group;- bimodal peak 25—30 & over 55

Associated with EBV & HIV

1st degree relatives of PTS have 5 fold increase in risk

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HISTOLOGY

Hall mark is Reed Sternberg cell [binucleate CD 15 – CD30

Derived from monoclonal population of B CELL

HL is classified in to two main categories and sub types

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1—Classical HL

2-Nodular lymphocyte predominance

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Characteristic differint CHL &NLPHLClassical HL NLPHL

1-Reed stern berg cell

CD15 + CD30 +

CD20 + _ CD45 _EMA _EBV + in 50%

1-Lymphocytic &histiocytic cell

CD15 _ CD30 _

CD20 + CD 45 +

EMA + EBV _

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Classical H L has four sub types;-

• Nodular sclerosis [ NSHL ] ;- 70 % more common in adolescents &Young adults. Frequent mediastinal involvement & peripheral nodes Nodular growth with fibrous bands

• mixed cellularity [MCHL ] ;-20% more common in young childrenNumerous R S & in flammatory back ground . associated with EBV &HIV

• Lymphocyte rich [ LRCH ] ;- 10 % , more lymphocytes , common in elderly •Can be associated with HIV poor prognosis

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Lymphocyte depletion [L D H L ] ;-less than 5% ;- more RS cells withLess lymphocytes , common in elderly ; can be associated with HIV has ,associated with B symptoms .poor prognosis

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clinical presenton

Cervical lymphadenopathy ;- more common presention about 80% of the Cases [pain less palpable cervical masses ]Although any group of lymph nodes can be affected

Mediastinal disease ;- about 50% of the cases, appears as opecity in cxrayOr as symptoms of compression [repiratory difficulty ]

B symptoms ;- fever temp of 38 c or higher for multiple readingUn explainded weight loss more than 10% over 6 months .drenching

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night sweatsUsally patients with B symptoms have worse prognosis

other commonly observed symptoms;- pel-Ebstein fever -- alcohol induced Pain --- bone pain ----abd pain --- neuro painSigns ;-hepatosplenomagaly --- present of effusions --- evidence of neuotherapysSigns of obs- [extremity edema ----superior vena cava syndrome ---spinal Cord compression lymph nodes examination ;- sub mental – supraclavicular --infrsclavicular -Epitrochlear --iliac --- femoral ---&politeal

Tonsil &oropharynx ;- waldeyer ring involvement mandate comp lety evaluationOf NPH …OPH &hypopharynx by endoscopy

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work up

After take we complete H& P

Lab-tests;- CBC with differential --- LFTS ----BUN --Cr --ESRChemistries;- alkaline phosphatase -- LDH ---Alumen --pregnanceTest ---HIV [ risk ]

Pathologyp- excisional LN s biopsy ;- mandatry to diagnosis &to start of treatmentBone marrow biopsy ;- inducated in Bsymptoms --- bulky disease –stage 3-4 & Recurrent disease

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Imaging studies ;- chest xray PA & LATCT scan ;-thorax --- abd ---& plevis for staging & evauation of the bulkOf the disease and determining the extent of the radiation treatmentCT scan in the neck area in the cervical & mediastinal disease ==M M WDivided by M TD = or greater than 1|3 on BA cxray. [GHSG] . M M greaterThan 1o cm in standford .Bone scan ;- for patients of high alkaline phosphatase or c\O bonePainPET scan ;- is used to evaluate equivocal disease seen in CT , to differentiatingActive versus uninvolved nodes [ accuracy 95% ]Oophoropexy ;- for women to preserve ovarian functionDental evaluation if go to treat the neck

Pretreatment dental for neck treatment . Staging laprotomy no longer beingdo

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staging

I. Involvement of single lymphatic site;-nodal region, waldeyer ringThymus --spleen or single extralymphatic organ

Involvement of 2 or more lymph node region on the same side of theDiaphragm or extralymphatic organ or site in association with regionalLNs on the same side of the diaphragm

Involvement of LNs regions of both side of the diaphragm which alsoAssociated with extralymphatic extension in aassociation with adjacentLymph nodes or spleen

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Diffuse involvement of one or more extralymphatic organs with or with outAssciated LNs involvement or isolated rxtralymphatic organ involvementIn the absence of LNs involvement but in conjection with disease in distantSites [any involvement of the liver –bone marrow -lunge -cerebrospinal

x= Bulky disease

Bsymptoms ;-fever ---- wt loss ---night sweat

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prognosis

Staging;- the most important prognosis factors . H L divided in to two ;-

1] early stage;- treated with chemo-RT , 5yrs f f f 95 % & O S moreThan 95 % [inculed stage 1 &2 ] adverse factors inculed ESR moreThan 50 - more nodal sites -- bulky mediastinal mass more than33 % of thoracic diameter or more than 10 cms --extranodal sites

2]Advanced stage ;- poor prognostic factors inculed male gender --age More than 45 yrs ---stage 4 --HGB more than 10,5 -- WBC moreThan 15 ---lymphocyte less than 0,6 x 10 -- albumin less than 40 g\l

* Less than 3 factors 5 yrs f fp 70 % . More than 3 factors is 50 %

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B symptoms in all stage present of B symptoms is poorer PrognosisHistopathology ;- is independent prognosic variable [ apartFrom stage ] is less clearly defined than past Independent adverse prognostic factor for NSHLInclude eosinophilia -- lymphocyte depletion -- RS cell

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treatment

Chemo agents ;- MOPP ;-mechlorethamine , oncovin , procarbazineprednisone . ABVD ;- Adriamycin , bleomycin , vinblastine , dacarbazine

BEACOPP ;- bleomycin , etoposide , adriamycin , cyclophosphamide Oncovin , prednisone , procarbazine

Standfor v ;-mechlorethamine , vincristine , prednisone , doxorubicinBleomycin , vinblastine , etoposide .

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Treatment recommendation

Stage 1A & 2 A [ favorable no bulky disease - -less than 3 sites ESR less than 50 ];- ABVD X 4 --IFRT [30 GY [subclinical ] 36 clinicalAlternative chemo = 8 week standford v &IFRT [30 GY ] for lp 1 A may give IFRT 30 GY or regional RT alone 30 –36 gy . stage 1 &2 A IFRT 30 then boost to 36 for residual diseaseThen PET \CT if CR chemo –[ ABVD R , CHOP R ] Preliminary stage 2 data support Rituximab . 10 yrs EFS \OS 85-90 %Unfavorable ;- ABVD x 4—6 then [30—36 ]GY subclinical 36 GY CLINICAL [ bulky disease – more than 3sites or ESR more than 50 ]Alternative -12 week standford v IFRT 36 to any node more than 5 cm

If refuse chemo STNI [mantle –PA –splenic ] or mantle alone . 36- 44 gy10 Yrs FFP 82 % OS 90 %

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Stage 3 &4 ;- 4- ABVD then restage with PET \CT if CR . ABVD X2 &IFRT 20-30 GY to bulky sites \ optional \ . If PR ABVD X 2—4C ,-6Then IFRT 30-36 GY to bulky sites \optional \

Alternative ; 12 weeks stanford v & IFTR 36 GY [to any nodes more than 5 cms and residual PET & sites . Or , dose escalated BEACOPP with IFRT 30 GY to initial sites more than 5 cm . 40 GY to residual PET & areas10 Yrs ffp stage 3 75% stage 4 65 % os stage 3 80 % stage 4 75 %10 Yrs ffp 85 % os 90 %

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