3. EPIDEMIOLOGY H L IS common lymphoid malignancy of young Hodgkin l ymphoma r epresent about 11% of all lymphoma Incidence of HL is 3.2 per 100.000 :1
4. Sex;- HL affects males slightly more than female 1.3 ; 1 Age group;- bimodal peak 25—30 & over 55 Associated with EBV & HIV 1st degree relatives of PTS have 5 fold increase in risk
5. HISTOLOGY Hall mark is Reed Sternberg cell [binucleate CD 15 – CD30 Derived from monoclonal population of B CELL HL is classified in to two main categories and sub types
10. clinical presenton Cervical lymphadenopathy;- more common presention about 80% of the Cases [pain less palpable cervical masses ] Although any group of lymph nodes can be affected Mediastinal disease ;- about 50% of the cases, appears as opecity in cxray Or as symptoms of compression [repiratory difficulty ] B symptoms ;- fever temp of 38 c or higher for multiple reading Un explainded weight loss more than 10% over 6 months .drenching
11. night sweats Usally patients with B symptoms have worse prognosis other commonly observed symptoms;-pel-Ebstein fever -- alcohol induced Pain --- bone pain ----abd pain --- neuro pain Signs ;-hepatosplenomagaly --- present of effusions --- evidence of neuotherapys Signs of obs- [extremity edema ----superior vena cava syndrome ---spinal Cord compression lymph nodes examination ;- sub mental – supraclavicular --infrsclavicular - Epitrochlear --iliac --- femoral ---&politeal Tonsil &oropharynx ;- waldeyer ring involvement mandate comp lety evaluation Of NPH …OPH &hypopharynx by endoscopy
12. work up After take we complete H& P Lab-tests;-CBC with differential --- LFTS ----BUN --Cr --ESR Chemistries;- alkaline phosphatase-- LDH ---Alumen --pregnance Test ---HIV [ risk ] Pathologyp- excisional LN s biopsy ;- mandatry to diagnosis & to start of treatment Bone marrow biopsy ;-inducated in Bsymptoms --- bulky disease –stage 3-4 & Recurrent disease
13. Imaging studies ;- chest xray PA & LAT CT scan ;-thorax --- abd ---& plevis for staging & evauation of the bulk Of the disease and determining the extent of the radiation treatment CT scan in the neck area in the cervical & mediastinal disease ==M M W Divided by M TD = or greater than 1|3 on BA cxray. [GHSG] . M M greater Than 1o cm in standford . Bone scan ;- for patients of high alkaline phosphatase or c bone Pain PET scan ;- is used to evaluate equivocal disease seen in CT , to differentiating Active versus uninvolved nodes [ accuracy 95% ] Oophoropexy;- for women to preserve ovarian function Dental evaluation if go to treat the neck Pretreatment dental for neck treatment . Staging laprotomyno longer being do
14. staging Involvement of single lymphatic site;-nodal region, waldeyer ring Thymus --spleen or single extralymphatic organ Involvement of 2 or more lymph node region on the same side of the Diaphragm or extralymphatic organ or site in association with regional LNs on the same side of the diaphragm Involvement of LNs regions of both side of the diaphragm which also Associated with extralymphatic extension in aassociation with adjacent Lymph nodes or spleen
15. Diffuse involvement of one or more extralymphatic organs with or with out Assciated LNs involvement or isolated rxtralymphatic organ involvement In the absence of LNs involvement but in conjection with disease in distant Sites [any involvement of the liver –bone marrow -lunge -cerebrospinal Bsymptoms ;-fever ---- wt loss ---night sweat x= Bulky disease
16. prognosis Staging;- the most important prognosis factors . H L divided in to two ; - 1] early stage;- treated with chemo-RT , 5yrs f ff 95 % & O S more Than 95 % [inculed stage 1 &2 ] adverse factors inculed ESR more Than 50 - more nodal sites -- bulky mediastinal mass more than 33 % of thoracic diameter or more than 10 cms --extranodalsites 2]Advanced stage ;- poor prognostic factors inculed male gender --age More than 45 yrs ---stage 4 --HGB more than 10,5 -- WBC more Than 15 ---lymphocyte less than 0,6 x 10 -- albumin less than 40 g -- * Less than 3 factors 5 yrs f fp 70 % . More than 3 factors is 50 %
17. B symptoms in all stage present of B symptoms is poorer Prognosis Histopathology ;- is independent prognosic variable [ apart From stage ] is less clearly defined than past Independent adverse prognostic factor for NSHL Include eosinophilia -- lymphocyte depletion -- RS cell
19. Treatment recommendation Stage 1A & 2 A [ favorable no bulky disease - -less than 3 sites ESR less than 50 ];- ABVD X 4 --IFRT [30 GY [subclinical ] 36 clinical Alternative chemo = 8 week standford v &IFRT [30 GY ] for lp 1 A may give IFRT 30 GY or regional RT alone 30 – 36 gy . stage 1 &2 A IFRT 30 then boost to 36 for residual disease Then PET T if CR chemo –[ ABVD R , CHOP R ] Preliminary stage 2 data support Rituximab . 10 yrs EFS S 85-90 % Unfavorable ;- ABVD x 4—6 then [30—36 ]GY subclinical 36 GY CLINICAL [ bulky disease – more than 3sites or ESR more than 50 ] Alternative -12 week standford v IFRT 36 to any node more than 5 cm If refuse chemo STNI [mantle –PA –splenic ] or mantle alone . 36- 44 gy 10 Yrs FFP 82 % OS 90 %
20. Stage 3 &4 ;- 4- ABVD then restage with PET T if CR . ABVD X2 & IFRT 20-30 GY to bulky sites optional . If PR ABVD X 2—4C ,-6 Then IFRT 30-36 GY to bulky sites ptional br />Alternative ; 12 weeks stanford v & IFTR 36 GY [to any nodes more than 5 cms and residual PET & sites . Or , dose escalated BEACOPP with IFRT 30 GY to initial sites more than 5 cm . 40 GY to residual PET & areas Yrs ffp stage 3 75% stage 4 65 % os stage 3 80 % stage 4 75 % 10 Yrs ffp 85 % os 90 %
