Hodgkin lymphoma

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Hodgkin lymphoma

  1. 1. بسم الله الرحمن الرحيم<br />
  2. 2. HODGKIN LYMPHOMA<br />
  3. 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. 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. 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. 6. 1—Classical HL<br />2-Nodular lymphocyte predominance<br />
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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