1. Hodgkin’s lymphoma Rakesh Biswas
MD, Professor, Department of Medicine, People's College of Medical Sciences, Bhanpur, Bhopal, India

2. A 25 year old lady 1 month of evening rise of temperature, night sweats and noticed a lump in her neck On examination pallor, generalized lymphadenopathy, hepatosplenomegaly
Case history
Possibilities, approach to management

3. I wasn't feeling well, still couldn't shake the cold that had been plaguing me for what seemed like months. But all in all, not feeling too bad, either.
Case history

4. It is required that anybody teaching in the schools have a clear tuberculosis record. After waiting several minutes, the nurse read my test site. She said it seemed to her there was a little swelling that shouldn't be there, and she asked me to wait and see the doctor.
Case history

5. I started to get a little bit nervous, I mean, Tuberculosis
I started to get a little bit nervous, I mean, Tuberculosis? Was that possible? The doctor brought me into her room and she examined me, and she said she could feel tumors in my neck. Had I noticed them?
Case history

6. Lymphoma
Clonal malignant disorders that are derived from lymphoid cells: either precursor or mature T-cell or B-cell
Majority are of B- cell origin
Divided into 2 main types :
1. Hodgkin’s lymphoma
2. Non - Hodgkin’s lymphoma

7. Hodgkin’s Disease
Histologically & clinically a distinct malignant disease
Predominantly, B-cell disease
Course of the disease is variable, but the prognosis has improved with modern treatment

8. Etiology
? Infection – EBV
? Environmental factors

9. REAL* Classification Classic: Non-Classic Nodular Sclerosis
Lymhocyte rich
Mixed Cellularity
Lymhocyte depleted
Non-Classic
Nodular Lymphocyte predominant
*REAL – Revised European,American,lymphoma

10. Clinical features Bimodal age distribution : M > F Lymphadenopathy:
young adults ( yrs) & elderly (> 50yrs) May occur at any age
M > F
Lymphadenopathy:
most often cervical region
asymmetrical, discrete
painless, non-tender
elastic character on palpation ( rubbery)
not adherent to skin
fluctuate in size

11. Contiguous spread via the lymphatic chain eg
Contiguous spread via the lymphatic chain eg.involvement of abdominal & thoracic LNs
Extra nodal disease - rare
Hepatospleenomegaly

13. Constitutional symptoms ( B symptoms )
Night sweats,
sustained fever > 38 degree celsius,
loss of weight >10% of body weight in 6 mo
Fever sometimes cyclical (‘Pel-Ebstein fever’)
Pain at the site of disease after drinking alcohol
Pallor
Pruritis
Symptoms of Bulky (>10 cm) disease

14. A zillion tests were done, blood drawn a zillion times, a zillion questions by a million doctors. Finally it was decided they would have to perform a biopsy on one of the tumors to get a diagnosis.
Case history

15. Investigations
CBP : Anemia ( normochromic / normocytic), eosinophilia, neutrophilia, lymphopenia
ESR -raised
LFT- (liver infil / obs at porta hepatis)
RFT- prior to treatment
Urate , Ca,
LDH - adverse prognosis
CXR- mediastinal mass
CT thorax / abdomen / pelvis-for staging
Other: Gallium scan, PET, Lymphangiography , Laporotomy

16. LN FNAC / biopsy :
Malignant REED-STERNBERG ( RS) Cell: Bi-nucleate cell with a prominent nucleolus. Derived from B cell, at an early stage of differentiation
Reactive background of eosinophils, lymphocytes, plasma cells
Fibrous tissue

17. The operation was done on February third, my boyfriend's birthday
The operation was done on February third, my boyfriend's birthday. I made him a card out of paper I had… Hard to celebrate your boyfriend's birthday while getting ready to get operated on.
Case history

20. REED-STERNBERG ( RS ) Cell

21. REED-STERNBERG ( RS) Cell

23. The X-ray technician came out again, looking for me
The X-ray technician came out again, looking for me. "We're not ready for you yet, the Doctors are still reading your chart, but we wanted to make sure you didn't leave. Just wait a few minutes and the doctor will be out to talk to you."
Case history

24. I've read in novels the expression "my heart sank" but I'm not sure I ever really felt that sort of thing until just about then. I'd been telling myself there was nothing to worry about, all was ok, but this was a clear cut sign that something was very. very wrong
Case history

25. >10 cm
Bulky disease

28. Lymphangiography

29. Staging
Stage I : Involvement of single LN region (I) or extra lymphatic site (IAE )
Stage II : Two or more LN regions involved (II) or an extra lymphatic site and lymph node regions on the same side of diaphragm
Stage III : Involvement of lymph node regions on both sides of diaphragm, with (IIIE) or without (III) localized extra lymphatic involvement or involvement of the spleen (IIS) or both (IISE)
Stage IV : Involvement outside LN areas (Liver, bone marrow)
A : Absence of ‘B’ symptoms
B : B symptoms present

31. I had Stage IVb Hodgkin's Disease, a form of cancer of the lymph nodes
I had Stage IVb Hodgkin's Disease, a form of cancer of the lymph nodes. Well, it's sort of hard to describe what hearing something like that does.
Case history
It seemed impossible that the nodes in my neck, and the masses that were supposedly on my lungs were cancer. How could that be? I just was amazed. I said "this is unbelievable." and felt more or less detached, numb.

32. Treatment RT Chemo BMT / SCT
Antibody treatment: Rituximab target CD-20
Supportive

33. Treatment - Guidelines
Indications for RT:
Stage I disease
Stage II disease with 3 or lesser areas involved
For Bulky disease
For pressure problems
Indications for CT
All with B symptoms
Stage II disease with >3 areas involved
Stage III and IV disease

34. Treatment
Stage IA , Stage IIA with 3 or < 3 areas involved: Radiotherapy
Stage IB, Stage II A with > 3 areas , Stage IIB: Chemotherapy every 3-4 weeks, 6-8 cycles; either alone, or in combination with radiotherapy
Stage III & IV : Chemotherapy + Radiotherapy ( for bulky disease or palliation of symptoms)

35. Irradiation fields used in Hodgkin’s Lymphoma

36. Chemotherapy
MOPP : Nitrogen Mustard, Vincristine (Oncovin), Procarbazine, Prednisolone
ABVD: Adriamycin, Bleomycin, Vinblastine, Dacarbazine
Higher dose for relapse or younger pts with poor prognostic features

37. After six cycles of chemotherapy, my CT scans still show masses on my chest and in my neck. On July 7, I had a meeting with my doctors, and was told that if I continued with standard chemotherapy, my chances of being cured stand at less than ten per cent.
Case history

38. Prognosis Overall 10 yr survival – 80%
In long term survivors there is a risk of
secondary malignancy: (leukemia , NHL), Solid tumors- Lung, breast
Infections
Cardiac, pulmonary, endocrinal abnormalities

39. International Prognostic Index (IPI)
Age
Advanced stage disease
Performance status
Elevated LDH
Presence of Extra nodal disease

40. Non Hodgkin’s lymphoma
Incidence is increasing
NHL>HD
Median age of presentation is yrs
M>F
More often clinically disseminated at diagnosis
B-cell-70% ; T-cell-30%

42. ‘1990…Although I had been feeling fine, no different from normal, I was worried about this lump in my neck that I had for several months. I first thought it was just because I had some sort of infection, but it didn't go away.
Case history

43. Clinical features Widely disseminated at presentation
Nodal involvement: Painless lymphadenopathy, often cervical region is the most common presentation
Hepatospleenomegaly
Extranodal : Intestinal lymphoma ( abdominal pain, anemia, dysphagia); CNS ( headache, cranial nerve palsies, spinal cord compression) ;
Skin, Testis; Thyroid; Lung Bone marrow (low grade): Pancytopenia

44. Compression syndrome:
Systemic symptoms
Sweating, weight loss, itching
Metabolic complications: hyperuricemia, hypercalcemia, renal failure
Compression syndrome:
Gut obstruction
Ascites
SVC obstruction
S/C Compression

46. 'The surgeon took a biopsy of the lump, taking a few cells out with a needle to be looked at under the microscope. When the results came back a few weeks later, he told me that they showed I had non-Hodgkin's lymphoma
Case history

48. Diagnosis and staging Similar to HD plus,
Bone marrow aspirate & trephine
Immunophenotyping : Monoclonal antibodies directed against specific lymphocyte associated antigens B cell antigens ( CD 19, 20, 22); T cell antigens ( CD 2, 3, 5 & 7)
Immunoglobulin determination: Ig G / IgM praprotein marker
HIV
CT / MRI

49. Classification REAL Clinical / Working Formulation Low grade
Inermediate grade
High grade

50. Classification Staging Low grade Proliferation: Low Course: Indolent
Symptoms: ve
Treatment: Not curable
High grade
High
Rapid, fatal(un-Rx)
+ve
Potentially Curable
Staging
Similar to HD

51. Etiology Cannot be attributed a single cause
Chromosomal translocations: t (14, 18)
Infection:
Virus:EBV, HTLV,HHV-8, HIV
Bacteria: H.Pylori - Gastric lymphoma
Immunology:
Congenital immunodeficiency,
Immunocompromised patients - HIV, organ transplantation

52. 'When I went back a couple of weeks later, he said that the results showed I had stage I indolent follicular non-Hodgkin's lymphoma, which is a slow-growing form of the disease. He said that the good news was that only one lymph node was affected and that I had no B symptoms.
Case history

53. So, he suggested that I have radiotherapy on the swollen lymph node in my neck to make it go away. Because I had heard so many stories about how radiotherapy can make you sick and your hair fall out, I was quite worried
Case history

54. 'In the end, I didn't have any real side effects, apart from feeling a bit tired, and the lump in my neck went away completely. After a check-up a couple of weeks later, the haematologist told me that I should come back every 6 months for another CT scan to make sure that the non-Hodgkin's lymphoma hadn't come back.
Case history

55. Management Low grade: Asymptomatic : No treatment ;
Radiotherapy for localised disease (Stage 1);
Chemotheraphy: mainstay is Chlorambucil; Initial response good , but repeated relapses, median survival 6-10 yrs;
Newer: Fludarabine, 2-CdA (Chlorodeoxyadenosine)
Monoclonal antibody: Rituximab
SCT/BMT
All cells have protein markers on their surface, known as antigens. Monoclonal antibodies are designed in the laboratory to specifically recognise particular protein markers on the surface of some cancer cells. The monoclonal antibody then 'locks' onto this protein. This either triggers the cell to destroy itself or signals to the body's immune system to attack and kill the cancer cell.
For example, rituximab, the monoclonal antibody that is used in the treatment of non-Hodgkin's lymphoma, recognises a protein marker known as CD20. CD20 is found on the surface of the abnormal B cells that are found in some of the most common types of non-Hodgkin's lymphoma.
When rituximab locks onto CD20 on the surface of a B cell, the cell may be destroyed directly, but also the body's natural defences are alerted. Rituximab effectively targets the lymphoma cells for destruction by the body's immune system, which can now kill the cancer cells.
CD20 is also found on the surface of normal B cells, one of the types of white blood cells that circulate in the body. This means that these normal B cells, too, may be destroyed when rituximab is used. However, the stem cells in the bone marrow that develop into B cells do not have CD20 on their surface.
Stem cells are therefore not destroyed by rituximab and can go on to replenish the body with healthy B cells. Although the number of mature, normal B cells is temporarily reduced by the treatment, they return to previous levels after the treatment.

56. In 1994, when I was between my CT appointments, I found another lump in my neck, so I called up the specialist hospital and they told me to come back early for my next scan. At the same time, they did the bone marrow test and the LDH blood test again.
Case history

57. When I went back to see the haematologist, he told me that they had found… …swollen lymph nodes in my chest and my armpit, as well as my neck, …which really worried me, although he said the disease had not spread to my bone marrow.
Case history

58. Aggressive ( high / intermediate grade):
Chemotherapy: mainstay CHOP every 3 weeks, at least 6 cycles Cyclophosphamide, Doxorubicin Hydrochloride, Vincristine, Prednisolonone

59. 'We talked about what treatment I should have, and the doctor said that, as I had radiotherapy on my neck before, and now other lymph nodes were involved, I couldn't have the same treatment again. However, he offered me chemotherapy instead, and I was given the treatment over the next six months.
Case history

60. High risk cases with poor prognostic factors or relapse : High dose chemotherapy combined with autologous BMT / SCT
Monoclonal antibody
With CNS involvement / leukemic relapse : Similar to ALL

61. Prognosis Low grade : Median survival –10 yrs High Grade:
Increasing age, advanced stage, concomitant disease, raised LDH,T- cell phenotype : Poor prognosis
Please supply the written feedback…