Hodgkin’s Lymphoma (HD)

Etiology, pathophysiology and prognostic factors of Hodgkin’s Lymphoma (HD)

  • Slightly more common in males than females (peaks around 15-30 & > 65)
  • Risk factors are largely unknown but HIV, EBV, chromosomal abnormalities & familial history may all lay a factor
  • Reed-Sternberg cells (multi-nucleated giant cell–malignant B cells) express CD30 & CD15
  • Prognostic factors:
    • Serum albumin < 4 g/dL
    • Hemoglobin < 10.5 g/dL
    • Male
    • Stage 4 disease
    • Age > 45
    • Leukopenia (WBC > 15000)
    • Lymphocytopenia < 600

Signs and symptoms on presentation for Hodgkin’s lymphoma

  • Painless adenopathy usually in the lymph nodes above the diaphragm
  • Spreads from one node to another
  • S & S (fever, night sweats, weight loss) wane over 5-6 months
  • Diagnosis: based on biobsy of node, CT scan & MRI-mediastinal involvement?, immunohistochemistry is recommended, a PET scan for staging

Principles behind various staging systems for Hodgkin’s lymphoma (HD) and its prognostic importance

  • Stage 1:  single node or site
  • Stage 2:  2(+) nodes or sites
  • Stage 3:  lymph node involvement on both sides of diaphragm
  • Stage 4:  diffuse/disseminated involved of organs/tissues
  • A:  No fever (asymptomatic)
  • B:  B-Symptoms
  • X:  Bulky disease (mass > 10 cm)
  • The goal of treatment in Hodgkin’s Lymphoma is to cure the patient while minimizing short & long-term complications

Commonly used drug regimens in Hodgkin’s Lymphoma.

  • Hodgkin’s Lymphoma
    • ABVD is most often used, less myelosuppressive
      • A:  doxorubicin (adriamycin)
      • B:  Bleomycin
      • V:  VinBlastine
      • D:  Dacarbazine

Chemotherapy regimen

Drugs

MOPP

Nitrogen mustardVincristine
Procarbazine
Prednisone

ABVD

Doxorubicin (Adriamycin)
Bleomycin
Vinblastine 
Dacarbazine (DTIC)

Stanford V

Nitrogen mustard
Doxorubicin (Adriamycin)
Vinblastine
Vincristine
Bleomycin
Etoposide (VP-16)
Prednisone

BEACOPP

BleomycinEtoposideDoxorubicin

Cyclophosphamide

Vincristine
Procarbazine
Prednisone

Expected outcomes (including overall and disease-free survival) based on stage, treatment and risk factors.

  • Patients in stage 1A or 2A (no fever, no B symptoms, no mediastinal mass) have a favorable prognosis
    • Use 4 cycles of ABVD (or 2 cycles of Stanford V regimen)
    • Disease free survival > 90%
  • Patients in stages 1 or 2 that do have a mediastinal mass, are symptomatic (B-symptoms), have numerous sites of disease, elevated ESR or have poor prognosis factors have an unfavorable prognosis
    • Use 6 cycles of ABVD (or 3 cycles of Stanford V regimen)
  • Patients in either stage 3 or 4 require combo chemo treatment (ABVD) & maybe radiation to minimize the spread of the disease
    • Overall survival = 60-70%
  • 5 year overall survival in stage 1:  90-95%
  • 5 year overall survival in stage 2:  90-95%
  • 5 year overall survival in stage 3:  80-85%
  • 5 year overall survival in stage 4:  60-70%
  • The goal of relapse treatment (failed radiation alone) is to cure the patient
    • Patients who fail chemo have worse prognosis & will require something like autologous stem cell treatment
      • These patients have a disease-free survival rate of 20-70% at 5 years
  • Long Term complications to monitor for:
    • Secondary malginancies:  annual chest X-ray (lung cancer) & mammograms (breast cancer)
    • Cardiac toxicities (both pericardial & ventricular complications):  ECHO & stress test 10 years after treatment
    • fertility issues:  provide patient counseling
    • Pneumonitis
    • hypothyroidism
    • growth abnormalities

Hyperuricemic agents

  • Allopurinol inhibits xanthine oxidase (only affects new uric acid production)
  • Rasburicase is a form of urate oxidase that decreases the concentration of uric acid

Things to monitor in chemo patients: LVEF (ejection fraction), renal function, liver function, neuropathies, blood sugar

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