Hodgkin  lymphoma
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Hodgkin lymphoma

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Hodgkin  lymphoma Hodgkin lymphoma Presentation Transcript

  • بسم الله الرحمن الرحيم
  • HODGKIN LYMPHOMA
  • 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
  • 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
  • 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
  • 1—Classical HL
    2-Nodular lymphocyte predominance
  • Characteristic differint CHL &NLPHL
    Classical 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 _
  • 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 children
    Numerous 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
  • Lymphocyte depletion [L D H L ] ;-less than 5% ;- more RS cells with
    Less lymphocytes , common in elderly ; can be associated with HIV has
    ,associated with B symptoms .poor prognosis
  • 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 cxray
    Or as symptoms of compression [repiratory difficulty ]
    B symptoms ;- fever temp of 38 c or higher for multiple reading
    Un explainded weight loss more than 10% over 6 months .drenching
  • night sweats
    Usally patients with B symptoms have worse prognosis
    other commonly observed symptoms;-pel-Ebstein fever -- alcohol induced
    Pain --- bone pain ----abd pain --- neuro pain
    Signs ;-hepatosplenomagaly --- present of effusions --- evidence of neuotherapys
    Signs 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 evaluation
    Of NPH …OPH &hypopharynx by endoscopy
  • work up
    After take we complete H& P
    Lab-tests;-CBC with differential --- LFTS ----BUN --Cr --ESR
    Chemistries;- alkaline phosphatase-- LDH ---Alumen --pregnance
    Test ---HIV [ risk ]
    Pathologyp- excisional LN s biopsy ;- mandatry to diagnosis &
    to start of treatment
    Bone marrow biopsy ;-inducated in Bsymptoms --- bulky disease –stage
    3-4 & Recurrent disease
  • Imaging studies ;- chest xray PA & LAT
    CT scan ;-thorax --- abd ---& plevis for staging & evauation of the bulk
    Of the disease and determining the extent of the radiation treatment
    CT scan in the neck area in the cervical & mediastinal disease ==M M W
    Divided by M TD = or greater than 1|3 on BA cxray. [GHSG] . M M greater
    Than 1o cm in standford .
    Bone scan ;- for patients of high alkaline phosphatase or cO bone
    Pain
    PET scan ;- is used to evaluate equivocal disease seen in CT , to differentiating
    Active versus uninvolved nodes [ accuracy 95% ]
    Oophoropexy;- for women to preserve ovarian function
    Dental evaluation if go to treat the neck
    Pretreatment dental for neck treatment . Staging laprotomyno longer being
    do
  • staging
    Involvement of single lymphatic site;-nodal region, waldeyer ring
    Thymus --spleen or single extralymphatic organ
    Involvement of 2 or more lymph node region on the same side of the
    Diaphragm or extralymphatic organ or site in association with regional
    LNs on the same side of the diaphragm
    Involvement of LNs regions of both side of the diaphragm which also
    Associated with extralymphatic extension in aassociation with adjacent
    Lymph nodes or spleen
  • Diffuse involvement of one or more extralymphatic organs with or with out
    Assciated LNs involvement or isolated rxtralymphatic organ involvement
    In the absence of LNs involvement but in conjection with disease in distant
    Sites [any involvement of the liver –bone marrow -lunge -cerebrospinal
    Bsymptoms ;-fever ---- wt loss ---night sweat
    x= Bulky disease
  • prognosis
    Staging;- the most important prognosis factors . H L divided in to two ;
    -
    1] early stage;- treated with chemo-RT , 5yrs f ff 95 % & O S more
    Than 95 % [inculed stage 1 &2 ] adverse factors inculed ESR more
    Than 50 - more nodal sites -- bulky mediastinal mass more than
    33 % of thoracic diameter or more than 10 cms --extranodalsites
    2]Advanced stage ;- poor prognostic factors inculed male gender --age
    More than 45 yrs ---stage 4 --HGB more than 10,5 -- WBC more
    Than 15 ---lymphocyte less than 0,6 x 10 -- albumin less than 40 gl
    --
    * Less than 3 factors 5 yrs f fp 70 % . More than 3 factors is 50 %
  • B symptoms in all stage present of B symptoms is poorer
    Prognosis
    Histopathology ;- is independent prognosic variable [ apart
    From stage ] is less clearly defined than past
    Independent adverse prognostic factor for NSHL
    Include eosinophilia -- lymphocyte depletion -- RS cell
  • treatment
    Chemo agents ;- MOPP ;-mechlorethamine , oncovin , procarbazine
    prednisone
    . ABVD ;- Adriamycin , bleomycin , vinblastine , dacarbazine
    BEACOPP ;- bleomycin , etoposide , adriamycin , cyclophosphamide
    Oncovin , prednisone , procarbazine
    Standfor v ;-mechlorethamine , vincristine , prednisone , doxorubicin
    Bleomycin , vinblastine , etoposide .
  • 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 clinical
    Alternative 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 disease
    Then 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 gy
    10 Yrs FFP 82 % OS 90 %
  • 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 ,-6
    Then 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 & areas
    Yrs ffp stage 3 75% stage 4 65 % os stage 3 80 % stage 4 75 %
    10 Yrs ffp 85 % os 90 %