Dr Haroon ur Rashid Assistant professor Radiotherapyoncology Hodgkin
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Dr Haroon ur Rashid Assistant professor Radiotherapy/oncology
� Hodgkin lymphoma (HL) is characterized by progressive enlargement of the lymph nodes. � It is considered unicentric in origin and has a predictable pattern of spread by extension to contiguous nodes.
Etiology is unknown. � worldwide incidence of HL is approximately 2 - 4 new cases/100, 000 population/yr � HL accounts for approximately 5% of cancers in persons 14 yr of age or younger; � it accounts for approximately 15% of cancers in adolescents (15 -19 yr of age)
� EBV (mixed cellularity subtype) � Family history of HL � Low socioeconomic status
� Reed-sternberg (RS) cell is the hallmark of Hodgkin lymphoma. � It is a large cell (15 -45 µm) with multiple or multilobulated nuclei. � It is neoplastic clone cell originating from B lymphocyte in lymphnode germinal centers. � It can’t synthesize immunoglobulin due to dysregulation of nuclear factor kappa B (NFĸB).
Lymphadenopathy ( 90% cases) ◦ Usually painless ◦ Cervical LN/ supraclavicular LN are involved in 6080% ◦ Discrete, elastic/rubbery, nontender ◦ Spreads mostly by contiguity from one chain to another
Mediastinal adenopathy (60%): ◦ 20% of patient have bulky mediastinal disease. ◦ Persistent nonproductive cough ◦ Superior vena caval symptoms �Enlargement of neck vessels �Hoarseness of voice �Dyspnoea �Dysphagia
Splenomegaly Systemic symptoms: ◦ Pel-Ebstein fever ◦ Weight loss >10% in 6 months ◦ Drenching night sweats Bsymptoms ◦ Mild itching may be present in 15 -25% of cases but it is not considered as B symptoms
Other less common manifestations are ◦ ◦ ◦ Pulmonary manifestation (17%) Neurological manifestation (late presentation) Bone disease(2%) Bone marrow infiltration(5%) Liver disease (2%) Renal manifestation
Haematological manifestation: ◦ Anemia ◦ Neutropenia(50%) ◦ Lymphocytopenia-Due to hypersplenism or BM infiltration ◦ Eosinophilia (50%) – due to IL-5 production ◦ In advance stage DAT test frequently positive with hemolysis ◦ Immune thrombocytopenia may be present in 1 -2% cases
Note: Can be further subclassified as A catagories- Asypmtomatic Bcatagories- presence of B symptoms
1) 2) 3) 4) CBC: Normocytic normochromic anemia Neutrophilia in 50% cases Eosinophilia in 50% cases Lymphocytopenia ESR: raiesd S. ferritin: raised CXR: both PA & Lateral view Mediastinal lymphadenopathy Lymphnode biopsy: Presence of RS cell with diffuse infiltration of lymphocyte, histiocyte and many eosinophil & plasma cell
CXR showing mediastinal mass
For staging: 1) CT scan of neck, chest, abdomen, pelvis 2) Positron emission tomography (PET) scan 3 ) Technitium-99 bone scintography For classification: 1) Immunohistochemistry
1) 2) 3) 4) 5) 6) 7) Liver function test Renal function test S. electrolyte S. uric acid S. inorganic PO 4 S. calcium DAT
In general ◦ Combined Chemotherapy ◦ Low dose involved field radiation � Intensity Considered Standard therapy of chemotherapy & volume of radiation depends on ◦ Presence of B symptoms ◦ Initial disease staging ◦ Presence of bulky disease
Chemotherapy regimen Corresponding agents ADVD Doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine ABVD-Rituxan Doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine, rituximab COPP Cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine OPPA ± COPP (females Vincristine (Oncovin), prednisone, procarbazine, doxorubicin (Adriamycin), OEPA ± COPP (males) Vincristine (Oncovin), etoposide, prednisone, doxorubicin (Adriamycin), BEACOPP (advanced stage) Bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine
� Most relapse occurs in 1 st 3 year after diagnosis, but relapse after 10 year have been reported. � Treatment of relapse Nature of relapse treatment Relapse with favorable at diagnosis Relapse with high risk disease Relapse with in 12 month of diagnosis Chemotherapy + LD-IFRT Chemotherapy + Autologous HSCT + radiotherapy
With the use of current therapeutic regimens, Disease stage event-free survival (EFS) Overall survival (OS) Early-stage disease + favorable prognostic factors Advanced-stage disease 85 -90% >95% 80 -85% 90% With dose intense chemotherapy OS has approached to 100%
Advanced stage of disease (Stage IIB, IIIB, or IV) The presence of B symptoms The presence of bulky disease Extranodal extension (liver) Male sex Elevated erythrocyte sedimentation rate White blood cell count 11, 500/mm 3 or higher Hemoglobin less than 11. 0 g / d l Histology : classical HL Initially not respond to chemotherapy
� Secondary malignancy � Cardiac toxicity � Pulmonary dysfunction � Thyroid dysfunction � Gonadal dysfunction & infertility � Growth retardation � Psychosocial problem
During therapy ◦ ◦ Physical exam (LN, Liver, spleen) Lab: CBC, ESR, LFT Imaging : CT scan, PET Organ toxicity monitoring: cardiac function test, Pulmonary function test � Disease monitoring after treatment: by CXR, CT scan � Long term sequelae monitoring: life long
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