Hodgkin s Disease HD A disease of lymph nodes

Hodgkin’s Disease (HD( A disease of lymph nodes with a predictable pattern

Epidemiology • Age: bimodal peak age –Third decade –After 50 • Gender: male to

Etiology and Risk Factors • Unknown • Possible etiologic factor – (1 Familial factor – (2 Viruses - EBV

Signs and Symptoms • HD is a lymph node-based malignancy • Common = asymptomatic lymphadenopathy • Systemic symptoms • Extranodal involvement

Location of Lymphadenopathy • 80% LN above the diaphragm –Anterior mediastinum –Cervical, supraclavicular,

Systemic Symptoms • 40% of patients -> systemic symptoms –B-symptom => Fever, Night sweat, Weight loss –Chronic pruritus

Extranodal Involvement • “E” lesion by direct invasion • Hematogenous metastasis (Stage IV): spleen, lungs,

Diagnosis • Biopsy • Pathology : “Reed Sternberg Cell” –Diagnostic tumor cell –Must be identified –Large size, binucleated, large

Histology • . 1 Lymphocyte predominant (LP) = few RS cells, good prognosis • . 2 Nodular sclerosis (NS) = the most common, young adult, female • . 3 Mixed cellularity (MC) = generalized lymphadenopathy • . 4 Lymphocyte depletion (LD) = numerous RS cells, poor

Staging : The Coltswolds Classification for HD • I: A single LN region or a lymphoid structure (eg. , spleen, thymus, Waldeyer’s ring( • II: Two or more LN regions on the same side of the diaphragm • III: LN regions or structures on both sides of the diaphragm – : 1 with/without involement of splenic, hilar, celiac, or portal nodes

Designations applicable to any disease stage • A: No symptoms • B: Fever, drenching sweats, weight loss • X: Bulky disease – 1/3

Prognostic Factors most • Stage of disease: the important prognostic factor • Number of sites of involvement • Bulky disease ( particularly in the mediastinum( • B symptoms • Age

Investigations • . 1 Imaging : CT scan of the chest/ abdomen • . 2 Lab tests: CBC, ESR, LDH • . 3 Bone marrow biopsy: B-symptoms • . 4 Staging laparotomy : consist of – Splenectomy – LN sampling: celiac/splenic/hilar/paraaortic/paracaval/ili ac nodes – Wedge/needle biopsy of the liver

Treatment • Stage I-II = Radiotherapy • Stage III-IV = Chemotherapy

Radiotherapy • Subtotal lymphoid irradiation = Mantle + Paraaortic field • Mantle field = base of mandible to diaphragm – Cover LN above diaphragm -> submandibular, cervical, supraclavicular, infraclavicular, axillary, mediastinum, hilar

Side Effects of • Acute Radiotherapy – N/V, Dermatitis, Fatigue • Delay – Pneumonitis – Herpes zoster infection – Subclinical hypothyroidism – Infertility – Secondary malignancies • secondary solid tumors ( lung, breast( • chemotherapy -> most common = leukemia

Non-Hodgkin’s Lymphoma Heterogeneous group of lymphoproliferative malignancies

Epidemiology • The incidence has been increasing worldwide. • This increase is more marked for older persons.

Etiology and Causative Factors • The origin is UNCERTAIN. • Causative factors with a predisposition –Immunosuppression –Infectious agents (EBV, HTLV -1, Herpes type 8, H. pylori(

NHL • Usually originates in lymphoid tissues • Can spread to other organs • Prognosis depends on the histologic type, stage and

Clinical Manifestations (most • Asymptomatic LN enlargement common presentation( • (1 Location of lymphadenopathy – most common = neck, inguinal, and abdominal LNs • (2 Systemic symptoms – fever, weight loss, night sweats ( usually heralding more advanced disease( • (3 Primary extranodal lymphoma

Staging Evaluation • Pathologic diagnosed by an experienced hematopathologist. • Staging Evaluation includes: – History + Physical Exam – Lab : CBC, LDH – Bone marrow biopsy – Chest X-Ray – CT abdomen and pelvis/chest – Gallium scan

Histology: 2 prognostic groups • Indolent lymphoma • Aggressive lymphoma

Staging: Ann Arbor System (commonly used( • I: A single nodal region (I) or single extralymphatic site (IE( • II: 2 or more nodal regions on the same side of diaphragm(II) or a single localized extralymphatic site and its regional nodes on the same side of diaphragm (IIE( • III: Nodal regions on both sides of the diaphragm

Designations applicable to any stage • A: No symptoms • B: Weight loss, unexplained fever, night sweats • E: Localized involvement of extralymphatic tissue • S: Spleen involvement

Treatment • Indolent Lymphoma – Stage I + II = RT – Stage III + IV = Chemotherapy + RT • Aggressive Lymphoma – Stage I + II = combined modality ( Chemotherapy + RT( – Stage III + IV = Chemotherapy (

Radiotherapy • Involve-field RT: –Involved region + first-echelon adjacent LN region • Extended field RT: –involve field + second-echelon adjacent LN region

Example

Radiation Dose: • Indolent: 2, 500 - 3, 500 c. Gy • Aggressive: 3, 500 4, 500 c. Gy

Late effects of treatment • Normal tissue toxicity • Secondary cancers