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38 Cards in this Set

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Hodgkin's Disease

What increased risk do first-degree relatives of patients with HD have?
Hodgkin's Disease

What increased risk do first-degree relatives of patients with HD have?

Five-fold
Hodgkin's Disease

What is the hallmark pathologic finding in classic HD?
Hodgkin's Disease

What is the hallmark pathologic finding in classic HD?

Reed-Sternberg cell
- Binucleate CD15+/CD30+ cells
- Dervied from monoclonal B cells
Hodgkin's Disease

Among the 50% of patients who present with mediastinal disease, what is the most common histology?
Hodgkin's Disease

Among the 50% of patients who present with mediastinal disease, what is the most common histology?

Nodular sclerosis HL (NSHL)
Hodgkin's Disease

Among all patients with HD, what percentage experience B symptoms?
Hodgkin's Disease

Among all patients with HD, what percentage experience B symptoms?

33%
Hodgkin's Disease

What percentage of patients with early stage HD have B symptoms?
Hodgkin's Disease

What percentage of patients with early stage HD have B symptoms?

15-20%
Hodgkin's Disease

What are the two primary classes of HD and their IHC characteristics?
Hodgkin's Disease

What are the two primary classes of HD and their IHC characteristics?

Classic HL (CHL)
- CD15+, CD30+
- CD45-
Nodular lymphocyte predominant HL (NLPHL)
- CD15-, CD30-
- CD45+, CD20+
Hodgkin's Disease

What are the subtypes of classic HD?
Hodgkin's Disease

What are the subtypes of classic HD and their predominance?

Nodular sclerosis (HSHL) 70%
Mixed cellularity (MCHL) 20%
Lymphocyte rich (LRHL) 10%
Lymphocyte depleted (LDHL) <5%
Hodgkin's Disease

What primary class of HD has the best overall survival?
Hodgkin's Disease

What primary class of HD has the best overall survival?

NLPHL may have occasional late relapse but has best overall survival
Hodgkin's Disease

What is the most common presentation of HD?
Hodgkin's Disease

What is the most common presentation of HD?

80% present with cervical lymphadenopathy
Hodgkin's Disease

What are the unique characteristics of the subtypes of CHD?
Hodgkin's Disease

What are the unique characteristics of the subtypes of CHD?

NS - Med often involved; 1/3 have B sx
MC - More commonly presents as adv dz; often with subclinical subdiaphragmatic disease in pts clinically staged I-II above the diaphragm
LD - Rare but most adv with B sx in older patients
- Worst prognosis
- Associated with HIV
Hodgkin's Disease

What are the unique features of NLPHD?
Hodgkin's Disease

What are the unique features of NLPHD?

CD15-, CD30-, CD45+, CD20+
Often stage I-II
B symptoms < 10%
More common in patients > 40
Hodgkin's Disease

Workup
Hodgkin's Disease

Workup
- CBC with diff, LFTs, Chem10
- ESR, liver panel, preg test, HIV test
- MUGA & LVEF before ABVD
- Path: Excisional LN biopsy
- Bone marrow biopsy if
- B symptoms, bulky disease
- Stage III -IV, recurrent disease
- CXR; CT C/A/P, PET
- Dental consult if neck tx
Hodgkin's Disease

Ann Arbor staging
Hodgkin's Disease

Ann Arbor staging
I Single lymph node region or extralymphatic site
II Two or more lymph node regions on same side of diaphgragm or local extralymphatic extension plus one or more lymph node regions on same side of diaphragm
III Lymph node regions on both side of diaphragm +/- local extralymphatic involvement
IV Diffuse involvement of one or more extralymphatic organs or sites
Hodgkin's Disease

Ann Arbor staging suffixes
- B
- E
- X
Hodgkin's Disease

Ann Arbor staging suffixes
- B
- Unexplained wt loss (>10% in 6m prior a dx)
- Unexplained fever >38C
- Drenching night sweats
- E: Extranodal disease
- X: Bulky disease
- Greater than 10 cm
- > 1/3 intrathoracic diameter at T5/6
Hodgkin's Disease

Lymph node groups
Hodgkin's Disease

Lymph node groups
- Waldeyer's ring
- Occip/cerv/preauricular/supraclav
- Infraclavicular
- Axillary
- Epitrochlear
- Mediastinal
- R and L hilar (separate)
- Paraaortic
- Splenic
- Mesenteric
- Iliac
- Inguinal/femoral
- Popliteal
Hodgkin's Disease

Prognosis early stage disease
Hodgkin's Disease

Prognosis early stage disease

With chemoRT
- 5-year FFF 95%
- 5-year OS >95%
Hodgkin's Disease

In advanced disease, poor prognostic factors and ref
Hodgkin's Disease

Poor prognostic factors and ref (NEJM 1998)
- Male gender
- Age > 45 years
- Stage IV
- Hgb < 10.5
- WBC > 15K
- Lymphocytosis < 0.6 x 10EE9/L
- Albumin < 40 g/L
Hodgkin's Disease

Prognosis with <= 3 versus > 3 poor prognostic factors
Hodgkin's Disease

Prognosis with <= 3 versus > 3 poor prognostic factors

<=3: 5-yr FFP 70%
>3: 5-yr FFP 50%
Hodgkin's Disease

MOPP
Hodgkin's Disease

MOPP
- Mechlorethamine
- Oncovin (vincristine)
- Procarbazine
- Prednisone
Hodgkin's Disease

ABVD
Hodgkin's Disease

ABVD
- Adriamycin (doxorubicin)
- Bleomycin
- Vinblastine
- Dacarbazine

Decreased sterility and second malignancies vs MOPP
Hodgkin's Disease

Stanford V regimen
Hodgkin's Disease

Stanford V regimen
- Mechlorethamine
- Vincristine
- Prednisone
- Doxorubicin
- Bleomycin
- Vinblastine
- Etoposide

Decreased bleomycin and doxorubicin toxicity vs ABVD
Hodgkin's Disease

EORTC H6F
292 stage I-II favorable
1 No lapartotomy with STLI
2 Negative laparotomy
- NS/LP: mantle 40 Gy
- MC/LD: STLI alone
3 Positive laparotomy --> chemoRT
No diff in 6-yr DFS or OS with or without lap
Hodgkin's Disease

EORTC H7VF
Hodgkin's Disease

EORTC H7VF

Mantle alone is insufficient even for very favorable dz.

40 pts with very favorable NS or LP
- Women < 40 with IA nonbulky dz
- ESR < 50

OS 96% but RFS only 73%
Hodgkin's Disease

EORTC H7F
Hodgkin's Disease

EORTC H7F

ChemoRT improves RFS but not OS

EBVP x 6 with IFRT vs STNI + splenic RT

5 yr RFS 92 v 81% but no diff OS (98 v 96%)
Hodgkin's Disease

GHSG HD7
Hodgkin's Disease

GHSG HD7

622 pts with favorable I-II dz
- No bulky or extranodal disease
- No elevated ESR, <= 2 nodal regions

EFRT 30 GY + 10 Gy boost vs
ABVS x 2 and EFRT

ChemoRT improved 5yr DFS (90% v 75%) but no diff in OS (94%)
Hodgkin's Disease

SWOG 9133/CALGB 9391
Hodgkin's Disease

SWOG 9133/CALGB 9391

348 pts with favorable I-IIA

Doxorubicin and vinblastine x 3 with STLI (36-40 Gy)
vs
STLI alone (36-40 Gy)

ChemoRT improved overall response and 3yr FFS (04% vs 81%) but no OS
Hodgkin's Disease

Stanford G4
Hodgkin's Disease

Stanford G4

87 pts with nonbulky favorable I-IIA disease

Stanford V x 8 weeks then IFRT 30 Gy

8yr FFP 96% and OS 98%
Hodgkin's Disease

GHSG HD10
Hodgkin's Disease

GHSG HD10

1131 pts with favorable I-II disease with no risk factors
2 x 2 factorial design:
ABVD x 2 or 4 cycles
then IFRT 20 Gy or 30 Gy

Median follow-up 2 years
- No diff between any arms
- FFF 97%
- OS 98.5%
Hodgkin's Disease

EORTC H9F
Hodgkin's Disease

EORTC H9F

783 pts with favorable IA-IIB

All EBVP x 6 with CR (79% 783)

No IFRT or
IFRT 20 Gy or
IFRT 36 Gy

Median followup 33 months.

Improved 4yr EFS
- 70% with no IFRT
- 84% with 20 Gy IFRT
- 87% with 36 Gy EFRT

No diff in OS (98% all arms)
Hodgkin's Disease

Stanford G5
Hodgkin's Disease

Stanford G5

Currently accruing

Favorable I-IIA patients

Risk-adapted Stanford V-C and low-dose IFRT
HD: Unilateral cervical field
The unilateral cervical field includes the ipsilateral SCV. The top border begins at the mentum and extends to 1 cm superior to the lower tip of the mastoid process. Laterally the field includes the medial 2/3 of the clavicle then courses inferiorly along the clavicle with a 2-cm inferior margin. Medially it proceeds along the ipsilateral transverse processes unless medial nodes close to the vertebral bodies or the ipsilateral SCV nodes are involved. For involved nodes near the VB, the field includes the VB in their entirely. For the involved SCV, the field includes the contrlalateral transverse processes. Unless involved nodes are present at the larynx, I include a laryngeal block at 20 Gy. I also calculate the max cord dose and include a posterior cervical cord block if the dose exceeds 40 Gy.
Mediastinal Field
In HD the mediastinal field includes the medial SCL nodes even if they're not involved. If NHL the mediastinal field is limited to the mediastinum. With arms up if the axilla is involved or akimbo otherwise, the superior boder is at the C5-6 interspace or at the top of the larynx if the SCV is involved. It courses laterally to include the postop chemo volume with a 1.5-cm margin then inferiorly to 5 cm below the carina or 2 cm below the prechemo volume. The hila are included with a 1-cm margin unless initially involved; in that setting, it would have a 1.5-cm margin.
Axillary Field
The ipsilateral axillary, infraclavicular, and SCV regions are treated when the axilla is involved. With the arms up the upper border is at the C5-6 interspace. It extends laterally to include the proximal 2/3 of the clavicle then courses inferiorly, flashing the axilla, to the tip of the scapula or 2 cm below the lowest axillary node then medially to the medial margin of the chest wall and superiorly along the medial chest wall and the inferior aspect of the 4th rib. The field then runs superiorly along the ipsi transverse processes to the C5-6 interspace. If the SCV is involved, I include the vertebral bodies.
Speel Field
I treat the spleen only if abnormal imaging suggests involvement. In that case the postchemotherapy volume with a 1.5-cm margin is treated.
Abdomen (PA) Field
The para-aortic field extends from the top of T11 and at least 2 cm above the prechemo volume to the edge of the transverse processes and at least 2 cm from the postchemo volume down to the bottom of L4 and at least 2 cm below the prechemo volume.
Mantle field
The mantle field begins at the mentum and extends to 1 cm above the inferior tip of the mastoid process. It includes 2/3 of the proximal clavicle, flashes the axilla, and extends at to the tiip of the scapula and 2cm below the lowest axillary node. Moving medially to the medial aspect of the chest wall, the field continues superiorly along the chest wall then follows the inferior aspect of the 4th rib to the mediastinum with a 1.5-cm margin. Inferiorly it reaches the diaphragm.
Inverted Y Field
The inverted Y field begins at the level of the diaphragm at the right transverse process then extends left to include the spleen with a 1-5-cm margin. It proceeds to the left renal hilum then inferiorly along the left transverse processes with a 1-cm margin to the SI joint where it deviates laterally with 2 cm on the bony pelvis through the femoral head and along the medial aspect of the femur to about 3 cm below the ischial tuberosities. The field bisects the obturator foramen and reaches the left side of the coccyx sparing some bladder.
Inguinal Field
The inguinal field includes the femoral and externior iliac regions. It begins in the middle of the SI joint and extends laterally to the greater trochanter and 2 cm lateral to initially involved nodes. It courses inferiorly to 5 cm below the lesser trochanter then medially to the medial border of the obturator foramen with at least 2 cm margin medial to the involved nodes. If the common iliac nodes were involved, the field would begin at the L4-5 interspace and at least 2 cm above the superior most involved nodes.