1. Hodgkin’s
lymphoma
Dr.Prashant kumbhaj
SMS Medical College
Jaipur

2. Lymphoma
 Clonalmalignant disorders that are derived
from lymphoid cells: either precursor or
mature T-cell or B-cell
 Majority are of B- cell origin
 Dividedinto 2 main types :
1. Hodgkin’s lymphoma
2. Non - Hodgkin’s lymphoma

3. 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

4. Etiology
 Infection – EBV,HIV
 Higher social class,advanced education
 Environmental factors

5. WHO Classification
 Classic:(CD 15+,CD30+)
 Nodular Sclerosis-70%,Adolesent and young
adults,mediastinal mass
 Lymhocyte rich-10%
 Mixed Cellularity-20%,young children,
 Lymhocyte depleted-<5%,mostly in AIDS,B
symptoms ,worst prognosis
 Non-Classic
 NodularLymphocyte predominant
 Best OS,B Symptoms <10%

6. HISTOLOGY
 Diagnosis of HL depends on RS
cells(reedsternberg cells )
 Bulk of lymphatic tissue is not composed
of malignent cells but rather a vareity of
normal appearing lymphocytes ,plasma
cells ,eosinophils ,neutrophils,histiocytes.
 Importent varient of reedsternberg cells
includes L&H(lymphocyte and
histiocyte)cells,lacunar cells,RS like cells.

7.  Reed sternberg cells are giant cells with
binucleate and large cytoplasmic
eosinophilic inclusions
 CD 15+, CD30+

8. Clinical features
 Bimodal age distribution :
 young adults ( 20-30 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

9. MODE OF SPREAD
 HL always almost originate in a lymph
node
 It spreads in orderly fashion through
lymphatic system by contiguity
 Axial lymphatic system is always involved
whereas distal sites (epitrochiliar
,popliteal) rarely involved.
 Hematogenous involvement occurs late
and is common in LD type .

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

11. Sites of involvment
 Peripheral lymph node-Cervical or
Supraclavicular lymphadenopathy occurs
in >70% of cases .axillary and inguinal
lymph nodes are less frequently involved .
 Generalized lymphadenopathy is atypical
of HL
 Spleen ,splenic hilar nodes,and celiac
nodes are the earliest abdominal sites of
invovlement in infradiaphragmatic HL.
Mesentric lymph nodes are rarely involved

12. Thorax
 Ant mediastinum is primary location for NS
HL
 Lung involvement may occur by direct
contiguity with hilar involvement as well as
hematogenous invovlement .
 Plural effusion may occur by lymphatic
compression
 SVC is more common in NHL

13. Abdominal
 Spleen ,splenic hilar nodes ,celiac nodes
are the earliest sites of invovment in
abdomen
 Mesentric lymph nodes are rarely
involved.
 Liver involvement is uncommon at
diagnosis and is always almost associated
with infiltration of the spleen.

14.  Retero peritoneal lymph node involvement
occurs late in the course of
supradiagphramatic HL and after
spleen,splenic hilar nodes and celiac
nodal involvement .
 Bone marrow- rarely involved at the time
of diagnosis ,pt with advanced stage and
systemic symptoms ,LD,MC are common
types of bone marrow involvement .

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

16. Extranodal
 Liverand skin involvement is rare
 CNS involvement uncommon
 No involvement of meninges ,brain
,waldeyars ring.

17. Investigations
 CBC :
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

18.  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

19. REED-STERNBERG ( RS ) Cell

20. REED-STERNBERG ( RS) Cell

22. >10 cm
Bulky disease

23. An Arbor 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

25. Adverse prognostic factors
 Male sex
 Age >45yrs
 Stage IV
 Hemoglobin<10.5g/dl
 WBC count >15,000/ul
 Lymphocyte count <600/ul
 Serum albumin <4g/dl

26. Treatment
 RT
 Chemo
 BMT / SCT
 Supportive

27. Treatment - Guidelines
 Indicationsfor 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

28. Treatment
 Stage IA , Stage IIA with 3 or < 3 areas involved:
ABVD X 4 CYCLES WITH IFRT(CLASSICAL HL)
 NLPHL – IFRT ALONE ,OBSERVATION(IF PT
CANNOT TOLERATE RT)
 Stage IB, Stage II A with > 3 areas , Stage IIB:
ChemotherapyABVD every 3-4 weeks, 6
cycles; either alone, or in combination with
radiotherapy
 Stage
III & IV :
Chemotherapy + Radiotherapy ( for bulky

29. Irradiation fields used in Hodgkin’s Lymphoma

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

31. 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

32. Side effects of treatment
 HYPOTHYROIDISM
 STERLILITY
 LUNG DAMAGE
 BLEOMYCIN PULMONARY TOXICITY
 CARDIAC DAMAGE
 ASEPTIC NECROSISOF FEMORAL
HEADS
 DEPRESSED CELLULAR IMMUNITY

33.  SECONDARY NEOPLASM –
AML,NHL,EPITHELIAL TUMORS
,SARCOMAS ,
 NEUROLOGIC COMPLICATIONS
 RETROPERITONEAL FIBROSIS
 NEPHROTIC SYNDROME
 ICHTHYOSIS