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Hodgkin’s Disease

Title

Ñ    Hodgkin’s Disease (Hodgkin’s lymphoma HL)

Definition

Ñ    Clinically and histologically distinct

Ñ    Malignant lymphoma

Ñ    Typically of B-cell origin

Pathogenesis

Causes

Ñ    EBV (Epstein-Barr virus) implicated

Pathological Process

Ñ    B lymphocytes that do not express immunoglobulin escape apoptosis

Ñ    Produce a clone of neoplastic cells

Ñ    Characteristic cell is the Reed-Sternberg cell which represents transformed cells

Classical HL

Nodular sclerosing HL

Ñ    Many fibrotic bands

Ñ    Young females, cervical mediastinal lymphadenopathy

Lymphocyte rich HL

Ñ    Many small lymphocytes and Reed-Sternberg cells

Ñ    Peripheral nodes, indolent disease

Mixed cellularity HL

Ñ    Lymphocytes, eosinophils, neutrophils, histiocytes, no fibrotic bands

Ñ    Men, B symptoms

Lymphocyte depleted HL

Ñ    Lack of cell infiltrate, numerous Reed-Sternberg cells

Ñ    Associated with HIV

In additional to classical

Nodular lymphocyte predominant HL

Ñ    Malignant lymphocytic and or histiocytic Reed-Sternberg cell variants

Clinical Features

History

Age

Ñ    Two peaks of incidence:

Young adults

Elderly patients

Sex

Ñ    Males > Females

E&M

Ñ    Fever

Ñ    Night sweats

Ñ    Weight loss

Ñ    Lethargy

IS

Ñ    Pruritus

HS

Ñ    Painless enlargement of lymph nodes

Ñ    Alcohol related pain in nodes:

Rare

Examination

E&M

Ñ    Cachexia

CVS

Ñ    Superior vena cava obstruction

HS

Ñ    Anaemia

Ñ    Lymphadenopathy

Ñ    Hepatosplenomegaly

Investigations

Fluids

Blood

Haematology

Ñ    Normocytic normochromic anaemia

Ñ    ESR:

Raised

Ñ    Neutrophilia:

Common

Ñ    Eosinophilia:

In 15%

Imaging

Chest x-ray

Ñ    Widening of the mediastinum

CT scan

Ñ    Enlarged intrathoracic, abdominal, pelvic nodes

Tissue Diagnosis

Lymph node biopsy

Ñ    Reed-Sternberg cells:

·          Characteristic bi-nucleate or multinucleate cells found in Hodgkin’s disease:

Owl’s eye nuclei or church plate nuclei

Staging

Modified Ann Arbor classification

Ñ    I:

Involvement of a single lymph node region (I) or a single extralymphatic site or organ (IE)

Ñ    II:

Involvement of two or more lymph node regions on the same side of the diaphragm:

II

Or

One or more lymph node regions plus an extralymphatic site (localised contiguous involvement):

IIE

Ñ    III:

·          Involvement of lymph nodes on both sides of the diaphragm:

The spleen is included in stage III

Ñ    IV:

·          Involvement of one or more extralymphatic organs:

Lung, liver, bone marrow, with or without lymph node involvement

Subclassification

Ñ    A:

Asymptomatic

Ñ    B:

·          Symptomatic:

Fever, night sweats, loss of > 10 % body weight

Ñ    E:

Extranodal disease

Ñ    X:

·          Bulky lymph nodes denoted by suffix X:

> 10 cms diameter or mediastinal mass greater than 1/3 of intrathoracic diameter

Management

Control/Cure

Drugs

Ñ    Chemotherapy:

·          MOPP:

Mustine, Oncovin, Procarbazine, Prednisolone

·          ABVD:

Adriamycin, Bleomycin, Vinblastine, Dacarbazine

·          MVPP:

Mustine, Vinblastine, Procarbazine, Prednisolone

·          ChlVPP:

Chlorambucil, Vinblastine, Procarbazine, Prednisolone

·          MOPP/ABV

Biological Agents

Ñ    Peripheral stem cell transplantation:

Allogenic or autologous

Radiotherapy

Ñ    I A

Ñ    IIA

Prognosis

Ñ    Good

Ñ    Curable in the majority

Ñ    Prognosis worse with advanced stage and if there is recurrence within a year of treatment

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