1. Hodgkin’s Disease (HD)
A disease of lymph nodes with a predictable pattern of spread

2. Epidemiology Age: bimodal peak age Gender: male to female = 1.3 to 1.0
Third decade
After 50
Gender: male to female = 1.3 to 1.0

3. Etiology and Risk Factors
Unknown
Possible etiologic factor
1) Familial factor
2) Viruses - EBV

4. Signs and Symptoms HD is a lymph node-based malignancy
Common = asymptomatic lymphadenopathy
Systemic symptoms
Extranodal involvement

5. Location of Lymphadenopathy
80% LN above the diaphragm
Anterior mediastinum
Cervical, supraclavicular, axillary

6. Systemic Symptoms 40% of patients -> systemic symptoms
B-symptom => Fever, Night sweat, Weight loss
Chronic pruritus

7. Extranodal Involvement
“E” lesion by direct invasion
Hematogenous metastasis (Stage IV): spleen, lungs, liver, bone marrow

8. Diagnosis Biopsy Pathology : “Reed - Sternberg Cell”
Diagnostic tumor cell
Must be identified
Large size, binucleated, large eosinophilic nucleoli

9. Histology
1. Lymphocyte predominant (LP) = few RS cells, good prognosis
2. Nodular sclerosis (NS) = the most common, young adult, female
3. Mixed cellularity (MC) = generalized lymphadenopathy
4. Lymphocyte depletion (LD) = numerous RS cells, poor prognosis

10. Staging : The Coltswolds Classification for HD
I: A single LN region or a lymphoid structure (eg., spleen, thymus, Waldeyer’s ring)
II: Two or more LN regions on the same side of the diaphragm
III: LN regions or structures on both sides of the diaphragm
1: with/without involement of splenic, hilar, celiac, or portal nodes
2: with involvement of paraaortic, iliac, or mesenteric nodes
IV: Extranodal site(s) beyond that designated E ( a single extranodal site, contiguous or proximal to a known nodal site)

11. Designations applicable to any disease stage
A: No symptoms
B: Fever, drenching sweats, weight loss
X: Bulky disease
> 1/3 the width of the mediastinum
> 10 cm maximal dimension of nodal mass
E: Involvement of a single extranodal site, contiguous or proximal to a know nodal site

12. Prognostic Factors
Stage of disease: the most important prognostic factor
Number of sites of involvement
Bulky disease ( particularly in the mediastinum)
B symptoms
Age

13. Investigations 1. Imaging : CT scan of the chest/ abdomen
2. Lab tests: CBC, ESR, LDH
3. Bone marrow biopsy: B-symptoms
4. Staging laparotomy : consist of
Splenectomy
LN sampling: celiac/splenic/hilar/paraaortic/paracaval/iliac nodes
Wedge/needle biopsy of the liver
open iliac crest Bone Marrow Biopsy
Oophoropexy

14. Treatment
Stage I-II = Radiotherapy
Stage III-IV = Chemotherapy

15. Radiotherapy Subtotal lymphoid irradiation = Mantle + Paraaortic field
Mantle field = base of mandible to diaphragm
Cover LN above diaphragm -> submandibular, cervical, supraclavicular, infraclavicular, axillary, mediastinum, hilar
Dose = 3,600 cGy

16. Side Effects of Radiotherapy
Acute
N/V, Dermatitis, Fatigue
Delay
Pneumonitis
Herpes zoster infection
Subclinical hypothyroidism
Infertility
Secondary malignancies
secondary solid tumors ( lung, breast)
chemotherapy -> most common = leukemia

17. Non-Hodgkin’s Lymphoma
Heterogeneous group of lymphoproliferative malignancies

18. Epidemiology The incidence has been increasing worldwide.
This increase is more marked for older persons.

19. Etiology and Causative Factors
The origin is UNCERTAIN.
Causative factors with a predisposition
Immunosuppression
Infectious agents (EBV, HTLV-1, Herpes type 8, H.pylori)

20. NHL Usually originates in lymphoid tissues Can spread to other organs
Prognosis depends on the histologic type, stage and extent of disease, age, and treatment

21. Clinical Manifestations
Asymptomatic LN enlargement (most common presentation)
1) Location of lymphadenopathy
most common = neck, inguinal, and abdominal LNs
2) Systemic symptoms
fever, weight loss, night sweats ( usually heralding more advanced disease)
3) Primary extranodal lymphoma
depend on the site of origin

22. Staging Evaluation
Pathologic diagnosed by an experienced hematopathologist.
Staging Evaluation includes:
History + Physical Exam
Lab : CBC, LDH
Bone marrow biopsy
Chest X-Ray
CT abdomen and pelvis/chest
Gallium scan

23. Histology: 2 prognostic groups
Indolent lymphoma
Aggressive lymphoma

24. Staging: Ann Arbor System (commonly used)
I: A single nodal region (I) or single extralymphatic site (IE)
II: 2 or more nodal regions on the same side of diaphragm(II) or a single localized extralymphatic site and its regional nodes on the same side of diaphragm (IIE)
III: Nodal regions on both sides of the diaphragm
IV: Diffuse or disseminated involvement of 1 or more extralymphatic organs with/without associated nodal involvement

25. Designations applicable to any stage
A: No symptoms
B: Weight loss, unexplained fever, night sweats
E: Localized involvement of extralymphatic tissue
S: Spleen involvement

26. Treatment Indolent Lymphoma Aggressive Lymphoma Stage I + II = RT
Stage III + IV = Chemotherapy + RT
Aggressive Lymphoma
Stage I + II = combined modality ( Chemotherapy + RT)
Stage III + IV = Chemotherapy ( Doxorubicin based)

27. Radiotherapy Involve-field RT: Extended field RT:
Involved region + first-echelon adjacent LN region
Extended field RT:
involve field + second-echelon adjacent LN region

28. Example

29. Radiation Dose: Indolent: 2,500 - 3,500 cGy
Aggressive: 3, ,500 cGy

30. Late effects of treatment
Normal tissue toxicity
Secondary cancers