12-1: 1/12 - Hodgkin's Lymphoma

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Age-distribution of Hodgkin's Lymphoma.

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Bimodal distribution:
-Major peak 15-34
-Lesser peak after 55

Front 2

Hodgkin's Lymphoma:
Histologic Features
CD Markers
Cell Origin (location)

Back 2

-Multi-nucleate REed-Sternberg Cells (Owl's Eyes)
-Background of normal inflammatory cells (non-malignant)

Note: only 1-5% of total tumor mass are R-S cells

CD15+ and CD30+ = Hodgkin's

B-cells originate at germinal center or post-germinal center (even though fail to express Ig genes!)

Front 3

What is a crippling Ig gene rearrangement? When is it acquired?

Back 3

Acquired during somatic hypermutation and for some reason doesn't result in apoptosis.

Cells are allowed to escape cell death and acquire additional mutations-->malignant R-S cell

Front 4

What causes transformation of R-S cells?

Back 4

This is hypothetical:
EBV (EBV DNA localized in R-S cells)

There's more Hodkin's in HIV

Front 5

Hodgkin's Lymphoma:
Presentation

Back 5

Cervical LN enlargement
Mediastinal involvement by CT
Involvement of spleen

Front 6

Hodgkin's vs Non-Hodgkin's Lymphoma:
Spread

Back 6

HL: initially localized at single peripheral LN region; subsequent progression by contiguity within lymphatic system. Contiguous spread!

NHL: Diffuse spread initially

Front 7

Hodgkin's Lymphoma:
Ann Arbor Staging (I-IV)
Subscripts (E, S)

Back 7

I: Single LN group involved

II: Involvement of 2 or more LN groups on same side of diaphragm

III: involvement of LN regions on both sides of diaphragm

IV: Outside LN areas (BM, liver)

Subscripts:
S = splenic involement
E = extranodal extension

Front 8

What is bulky disease in HL?

Back 8

Widening of mediastinum by >1/3 of chest diameter

Front 9

A vs B Symptoms

Back 9

A: absence of constitutional symptoms
B: presence of constitutional symptoms (Fever >38 degrees C, Weight Loss >10% over last 6 mos, Night Sweats)

Constitutional syx present with widespread dz.

Front 10

What's the Pel-Epstein fever?

Back 10

Cyclical fever (on and off); pathognomonic of HL

Front 11

Patient presents with bilateral cervical and axillary LAD.

Complains of malaise, night sweats, loss of weight over last 3 months.

What's his Ann Arbor stage?

Back 11

Stage IIB (B bc has B syx)

Front 12

Classical HD vs Non-Classical HD: General

Back 12

Classical:
RS cells positive for CD15 and CD30

Non-classical:
RS cells ARE CD15-, CD30-, CD20+

Front 13

Lacunar cells are indicative of ________.

Back 13

Nodular Sclerosis subtype of Classical HD

Lacunar cells are RS cells (owl eyes) that undergo shrinkage when cells are fixed. All are CD15+, CD30+.

Front 14

What are popcorn cells?

Back 14

Popcorn cells are lymphocytic histiocyte cells (LH) present in non-classical HD.

Don't need to recognize for exam.

Front 15

What is the only subtype of non-classical HD?

Back 15

lymphocyte predominant

Front 16

What is the most common subtype of HD?
Age distribution?
Presentation?

Back 16

Nodular Sclerosis

Predominates in young adults

Presents with cervical and anterior mediastinal involvement in young adult FEMALES>

Front 17

Nodular Sclerosis:
Histologic Features

Back 17

Nodular (collagen bands)
Lacunar R-S cells

Front 18

The link with EBV is strongest in this subtype of HD.

Back 18

Mixed Cellularity HD

Front 19

Mixed Cellularity HD:
Histologic Features

Back 19

R-S Cells surrounded by a mix of cells (ephils, lymphocytes, histiocytes)

Front 20

Lymphocyte-Rich HD:
Histologic Features

Back 20

R-S cells surrounded by small lymphocytes

Front 21

Lymphocyte-Predominance HD:
Histologic Features

Back 21

NOT A CLASSICAL HD

Lymphocyte predominance with nodularity (subtle)

No R-S cells

Popcorn cells (L&H cells) with CD15-, CD30-, CD20+

Front 22

HD:
Treatment

Back 22

ABVD:
Adriamycin - cardiac tox
Bleomycin - pulm fibrosis
Vinblastine - MT agent
Dacarbazine - alkylating

Note:
Choice depends on stage of dz
XRT alone may be adequate for early stage favorable HD, but combined modality tx may be more effective

Also, higher doses of XRT are curative, but increase incidence of solid tumors in irradiation field (and inc CAD)

Front 23

What is the most important prognostic variable for HL?

Back 23

Staging!

Early stage cure rates of 90%

Front 24

HD:
Complications of treatment (early vs late mortality)
Non-malignant complications

Back 24

Early mortality due to HD recurrence

After 15 years, almost all deaths due to secondary malignancy, CV, pulm dz (related to radiation, alkylating agents)

Non-malig:
Sterility (MOPP)
Infectious complications
Cardiac/pulmonary complication of mediastinal XRT and chemotx

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