LYMPHOMA : Any of various usually malignant tumors that arise in the lymph nodes or in other lymphoid tissue.

HODGKINS LYMPHOMA: is a separate category of lymphoma that exclusively is associated with the presence of the Reed-Strenberg cell in the lymph nodes

• Hodgkin's spreads in a predictable, systemic or contiguous pattern through the lymph system
• The Reed-Sternberg cells is a giant connective tissue cell containing one or two large nuclei
• The presence of the Reed-Sternberg cell determines of it is Hodgkin's or Non-Hodgkin's lymphoma
• Usually occurs in young people (10 – 45 years of age / peaks at age 26)
• Also can occur in older people 75 – 80 (older patients have a poorer prognosis

Presentation:

Young people : disease usually occurs above the diaphragm

Old People : disease usually occurs below the diaphragm

(rarely presents in the middle para-aortic area)

Etiology:

• Mononucleosis (Epstein-Barr Virus)
• T-Cell dysfunction

Appears as a painless mass (neck is the most common site of presentation)

• 80% of patients present with a swollen lymph node in the neck (males)
• mediastinal lump can be found by accident on chest xray or scan / also by pressure in the chest or cough
• most patients have disease above the diaphragm

Symptoms :

A : no symptoms (malaise, pruritus, alcohol induced muscle pain would all be considered group A with NO symptoms)

B : symptoms are present, these are :

• unexplained fevers above 100.4
• night sweats
• weight loss of 10% in 6 months

(symptoms are related to staging groups A or B)

Types of Hodgkins:

Classical Hodgkins (all associated with presentation of Reed-Sternberg Cell)

Subtypes of Classical Hodgkins:

• NSHL (Nodule Sclerosis Hodgkins Lymphoma) : is the most common type and usually found in young people
• Mixed Cellularity : second most common
• Predominant (Lymphocyte Rich)
• Lymphocyte Depleting : worst prognosis of them all and usually occur in old people and occurs below the diaphragm

Diagnostic Tests for Hodgkins:

• Chest xray
• CT
• MRI
• PET scan
• Gallium
• Lymphangiogram

Biopsies:

• Bone marrow biopsy
• Laparectomy
• STAGING IS THE MOST IMPORTANT FACTOR DETERMINING TREATMENT TYPE

Hodgkins does not skip spread ( this is why survival is good because we know which station it will spread to next and can treat than along with the primary area)

Ann-Arbor Staging:

Stage I : 1 lymph node area or 1 lymphatic organ

Stage II : 2 or more lymph nodes on the same side of the diaphragm / nearby tissue involvement

Stage III : nodes on both sides of diaphragm / spread to spleen

Stage IV : more than 1 spot on an organ or 2 or more organs outside of the lymph system (may or may not be in the nodes)

Staging is Clinical and Pathological

Staging Subdivisions:

A: No symptoms

B: Symptoms

E: extranodal

S: spleen

N: Nodes

H: liver

P: pleura

L: lung

O: Bone

M: Bone Marrow

D: skin

In General for All Stages Prognosis is Good 

Unfavorable outcomes:

• Can occur if there is a large mass in chest (SVC can also occur)
• Patient is over 50 years old
• More than 2 or 3 regions of lymph nodes

WBC : 5000 – 10000 normal range (below 2000 stop treatments)

Platelets : 250000 – 500000 normal range (below 100000 stop treatments)

Hemoglobin : 12 – 16 normal range (below 7 or 6 stop treatments)

RBC's : live for 120 days

Treatment Options:

Stage IA / IIA

• Old school : total nodal irradiation (mantle + inverted Y which is the para aortics and pelvic nodes)
• Next they went to : mantle + para aortics or pelvic field + para aortic
• Present Treatment :   Chemo alone (usually young patients) or Chemo and Radiation

Chemotherapy Protocols for Hodgkin's:

MOPP :

• Nitrogen Mustard
• Oncavin (vinacristin)
• Prednison
• Procarbozin

ABVD: (less toxic)

• Adriomyacin
• Bleomyacin
• Vincristin
• Diacarbazine

2 Types of Radiation Fields:

Full Mantle Field:

Mini Mantle Field:

What is Blocked in Fields:

• Humerus : AP/PA
• Lung : AP/PA
• Larynx : AP
• Occipital : PA

Doses:

• Involved area : 3600 – 4400 cGy
• Uninvolved area : 3000 – 3600 cGy
• dose when treated with chemo will be lower