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Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
Hodgkin  lymphoma
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Hodgkin lymphoma

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  1. بسم الله الرحمن الرحيم<br />
  2. HODGKIN LYMPHOMA<br />
  3. EPIDEMIOLOGY<br />H L IS common lymphoid malignancy of young<br />Hodgkin l ymphoma r epresent about 11% of all lymphoma<br />Incidence of HL is 3.2 per 100.000<br />:1<br />
  4. Sex;- HL affects males slightly more than female 1.3 ; 1<br />Age group;- bimodal peak 25—30 & over 55<br />Associated with EBV & HIV<br />1st degree relatives of PTS have 5 fold increase in<br /> risk<br />
  5. HISTOLOGY<br />Hall mark is Reed Sternberg cell [binucleate CD<br /> 15 – CD30<br />Derived from monoclonal population of B CELL<br />HL is classified in to two main categories and <br />sub types<br />
  6. 1—Classical HL<br />2-Nodular lymphocyte predominance<br />
  7. Characteristic differint CHL &NLPHL<br />Classical HL<br /> NLPHL<br />1-Reed stern berg <br /> cell <br />CD15 + CD30 + <br />CD20 + _ CD45 _<br />EMA _<br />EBV + in 50%<br />1-Lymphocytic &histiocytic cell <br />CD15 _ CD30 _<br />CD20 + CD 45 +<br />EMA + <br /> EBV _<br />
  8. Classical H L has four sub types;-<br /><ul><li> Nodular sclerosis [ NSHL ] ;- 70 % more common in adolescents &</li></ul>Young adults. Frequent mediastinal involvement & peripheral nodes <br />Nodular growth with fibrous bands<br /><ul><li> mixed cellularity[MCHL ] ;-20% more common in young children</li></ul>Numerous R S & in flammatory back ground . associated with EBV &<br />HIV<br /><ul><li> Lymphocyte rich [ LRCH ] ;- 10 % , more lymphocytes , common in elderly
  9. Can be associated with HIV poor prognosis</li></li></ul><li>Lymphocyte depletion [L D H L ] ;-less than 5% ;- more RS cells with<br />Less lymphocytes , common in elderly ; can be associated with HIV has<br /> ,associated with B symptoms .poor prognosis<br />
  10. clinical presenton<br />Cervical lymphadenopathy;- more common presention about 80% of the <br />Cases [pain less palpable cervical masses ]<br />Although any group of lymph nodes can be affected<br />Mediastinal disease ;- about 50% of the cases, appears as opecity in cxray<br />Or as symptoms of compression [repiratory difficulty ]<br />B symptoms ;- fever temp of 38 c or higher for multiple reading<br />Un explainded weight loss more than 10% over 6 months .drenching<br />
  11. night sweats<br />Usally patients with B symptoms have worse prognosis <br />other commonly observed symptoms;-pel-Ebstein fever -- alcohol induced <br />Pain --- bone pain ----abd pain --- neuro pain<br />Signs ;-hepatosplenomagaly --- present of effusions --- evidence of neuotherapys<br />Signs of obs- [extremity edema ----superior vena cava syndrome ---spinal <br />Cord compression<br /> lymph nodes examination ;- sub mental – supraclavicular --infrsclavicular -<br />Epitrochlear --iliac --- femoral ---&politeal<br />Tonsil &oropharynx ;- waldeyer ring involvement mandate comp lety evaluation<br />Of NPH …OPH &hypopharynx by endoscopy<br />
  12. work up<br />After take we complete H& P<br />Lab-tests;-CBC with differential --- LFTS ----BUN --Cr --ESR<br />Chemistries;- alkaline phosphatase-- LDH ---Alumen --pregnance<br />Test ---HIV [ risk ]<br />Pathologyp- excisional LN s biopsy ;- mandatry to diagnosis &<br />to start of treatment<br />Bone marrow biopsy ;-inducated in Bsymptoms --- bulky disease –stage <br />3-4 & Recurrent disease<br />
  13. Imaging studies ;- chest xray PA & LAT<br />CT scan ;-thorax --- abd ---& plevis for staging & evauation of the bulk<br />Of the disease and determining the extent of the radiation treatment<br />CT scan in the neck area in the cervical & mediastinal disease ==M M W<br />Divided by M TD = or greater than 1|3 on BA cxray. [GHSG] . M M greater<br />Than 1o cm in standford .<br />Bone scan ;- for patients of high alkaline phosphatase or cO bone<br />Pain<br />PET scan ;- is used to evaluate equivocal disease seen in CT , to differentiating<br />Active versus uninvolved nodes [ accuracy 95% ]<br />Oophoropexy;- for women to preserve ovarian function<br />Dental evaluation if go to treat the neck<br />Pretreatment dental for neck treatment . Staging laprotomyno longer being<br />do<br />
  14. staging<br />Involvement of single lymphatic site;-nodal region, waldeyer ring<br />Thymus --spleen or single extralymphatic organ<br />Involvement of 2 or more lymph node region on the same side of the<br />Diaphragm or extralymphatic organ or site in association with regional<br />LNs on the same side of the diaphragm<br />Involvement of LNs regions of both side of the diaphragm which also<br />Associated with extralymphatic extension in aassociation with adjacent<br />Lymph nodes or spleen<br />
  15. Diffuse involvement of one or more extralymphatic organs with or with out<br />Assciated LNs involvement or isolated rxtralymphatic organ involvement<br />In the absence of LNs involvement but in conjection with disease in distant<br />Sites [any involvement of the liver –bone marrow -lunge -cerebrospinal<br />Bsymptoms ;-fever ---- wt loss ---night sweat<br /> x= Bulky disease<br />
  16. prognosis<br />Staging;- the most important prognosis factors . H L divided in to two ;<br />-<br />1] early stage;- treated with chemo-RT , 5yrs f ff 95 % & O S more<br />Than 95 % [inculed stage 1 &2 ] adverse factors inculed ESR more<br />Than 50 - more nodal sites -- bulky mediastinal mass more than<br />33 % of thoracic diameter or more than 10 cms --extranodalsites<br />2]Advanced stage ;- poor prognostic factors inculed male gender --age <br />More than 45 yrs ---stage 4 --HGB more than 10,5 -- WBC more<br />Than 15 ---lymphocyte less than 0,6 x 10 -- albumin less than 40 gl<br />--<br />* Less than 3 factors 5 yrs f fp 70 % . More than 3 factors is 50 %<br />
  17. B symptoms in all stage present of B symptoms is poorer <br />Prognosis<br />Histopathology ;- is independent prognosic variable [ apart<br />From stage ] is less clearly defined than past <br />Independent adverse prognostic factor for NSHL<br />Include eosinophilia -- lymphocyte depletion -- RS cell<br />
  18. treatment<br />Chemo agents ;- MOPP ;-mechlorethamine , oncovin , procarbazine<br />prednisone<br /> . ABVD ;- Adriamycin , bleomycin , vinblastine , dacarbazine<br />BEACOPP ;- bleomycin , etoposide , adriamycin , cyclophosphamide<br />Oncovin , prednisone , procarbazine<br />Standfor v ;-mechlorethamine , vincristine , prednisone , doxorubicin<br />Bleomycin , vinblastine , etoposide . <br />
  19. Treatment recommendation<br />Stage 1A & 2 A [ favorable no bulky disease - -less than 3 sites ESR<br /> less than 50 ];- ABVD X 4 --IFRT [30 GY [subclinical ] 36 clinical<br />Alternative chemo = 8 week standford v &IFRT [30 GY ]<br /> for lp 1 A may give IFRT 30 GY or regional RT alone 30 –<br />36 gy . stage 1 &2 A IFRT 30 then boost to 36 for residual disease<br />Then PET CT if CR chemo –[ ABVD R , CHOP R ] <br />Preliminary stage 2 data support Rituximab . 10 yrs EFS OS 85-90 %<br />Unfavorable ;- ABVD x 4—6 then [30—36 ]GY subclinical 36 GY <br />CLINICAL [ bulky disease – more than 3sites or ESR more than 50 ]<br />Alternative -12 week standford v IFRT 36 to any node more than <br />5 cm<br />If refuse chemo STNI [mantle –PA –splenic ] or mantle alone . 36- 44 gy<br />10 Yrs FFP 82 % OS 90 %<br />
  20. Stage 3 &4 ;- 4- ABVD then restage with PET CT if CR . ABVD X2 &<br />IFRT 20-30 GY to bulky sites optional . If PR ABVD X 2—4C ,-6<br />Then IFRT 30-36 GY to bulky sites optional <br />Alternative ; 12 weeks stanford v & IFTR 36 GY [to any nodes more than <br />5 cms and residual PET & sites . Or , dose escalated BEACOPP with IFRT <br />30 GY to initial sites more than 5 cm . 40 GY to residual PET & areas<br />Yrs ffp stage 3 75% stage 4 65 % os stage 3 80 % stage 4 75 %<br />10 Yrs ffp 85 % os 90 %<br />

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