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

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Presentation on theme: "Hodgkin’s Disease (HD) A disease of lymph nodes with a predictable pattern of spread."— Presentation transcript:

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

2 Epidemiology Age: bimodal peak age –Third decade –After 50 Gender: male to female = 1.3 to 1.0

3 Etiology and Risk Factors Unknown Possible etiologic factor –1) Familial factor –2) Viruses - EBV

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

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

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

7 Extranodal Involvement “E” lesion by direct invasion Hematogenous metastasis (Stage IV): spleen, lungs, liver, bone marrow

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

9 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 prognosis

10 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 –2: with involvement of paraaortic, iliac, or mesenteric nodes IV: Extranodal site(s) beyond that designated E ( a single extranodal site, contiguous or proximal to a known nodal site)

11 Designations applicable to any disease stage A: No symptoms B: Fever, drenching sweats, weight loss X: Bulky disease –> 1/3 the width of the mediastinum –> 10 cm maximal dimension of nodal mass E: Involvement of a single extranodal site, contiguous or proximal to a know nodal site

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

13 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 –open iliac crest Bone Marrow Biopsy –Oophoropexy

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

15 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 Dose = 3,600 cGy

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

17 Non-Hodgkin’s Lymphoma Heterogeneous group of lymphoproliferative malignancies

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

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

20 NHL Usually originates in lymphoid tissues Can spread to other organs Prognosis depends on the histologic type, stage and extent of disease, age, and treatment

21 Clinical Manifestations Asymptomatic LN enlargement (most 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 –depend on the site of origin

22 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

23 Histology: 2 prognostic groups Indolent lymphoma Aggressive lymphoma

24 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 IV: Diffuse or disseminated involvement of 1 or more extralymphatic organs with/without associated nodal involvement

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

26 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 ( Doxorubicin based)

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

28 Example

29 Radiation Dose: Indolent: 2,500 - 3,500 cGy Aggressive: 3,500 - 4,500 cGy

30 Late effects of treatment Normal tissue toxicity Secondary cancers

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