Angeles University Foundation

College of Allied Medical Professions

HEMATOLOGY 2
CASE ANALYSIS

GROUP 6

CUDIA JAZER

DANAN, MARK LENNON

DE LEON, MARIA ROCHER

DE LUNA, JOSHUA

LUMANLAN, JOSHU

MARCH 2018
CASE

A 24 year-old American was brought to the hospital for experiencing

extreme fatigue, weight loss, loss of appetite, fever and night sweats. The patient
was also swelling from the lymph nodes of the upper parts of the body which seems
to be painless. A tissue biopsy was requested and showed large bilobed or two
nuclei with prominent eosinophilic nucleoli and abundant cytoplasm B cells, and
mononuclear lymphoid cells with an oval nucleus, thick nuclear membrane and
distinct eosinophilic nucleolus.

Guide Questions
1. What is the most probable diagnosis of the patient?
-HODGKIN’S LYMPHOMA
Hodgkin's lymphoma — formerly known as Hodgkin's disease — is a cancer of the lymphatic system,
which is part of the immune system. It may affect people of any age, but is most common in people
between 20 and 40 years old and those over 55. It may affect people of any age, but is most common in
people between 20 and 40 years old and those over 55.

Signs and symptoms of Hodgkin's lymphoma may include: Painless swelling of lymph nodes in
your neck, armpits or groin, persistent fatigue, fever, night sweats, unexplained weight loss,
severe itching, increased sensitivity to the effects of alcohol or pain in your lymph nodes after
drinking alcohol

2. Give 5 subtypes of this disease and briefly discuss each.

Types of Hodgkin lymphoma

The World Health Organization (WHO) classifies HL into 5 subtypes – 4 are referred to as classic
HL and 1 is classified separately as nodular lymphocyte-predominant HL. These classifications
are based on what the lymphoma cells look like under a microscope. This includes the type of
lymphoma cells, how they are organized and other characteristics that are seen in the sample
from the lymph node.
The different types of HL can start in lymph nodes in different parts of the body and can affect
people at different ages. Some types are more likely to cause B symptoms, which are
unexplained fever of 38°C or higher, drenching night sweats and unexplained weight loss of
more than 10% of body weight over the last 6 months.

Classic Hodgkin lymphoma

About 95% of all HLs are classic HL. The 4 subtypes all have Hodgkin and Reed-Sternberg (HRS)
cells.

Nodular sclerosis HL

Nodular sclerosis HL (NSHL) is the most common type of HL. It accounts for 60%–80% of all
cases of HL. NSHL occurs equally in men and women. It usually develops in teens and young
adults 15–35 years of age

NSHL usually starts in lymph nodes in the neck or chest and is most often diagnosed at stage 2.
It causes B symptoms in 30%–40% of people.

Mixed cellularity HL

Mixed cellularity HL (MCHL) is the second most common type of HL. It accounts for 15%–30% of
all cases of HL. It is most often seen in older adults and is the type of HL that most often
develops in people with HIV infection.

MCHL can start in any lymph node. It usually develops in the upper half of the body and
generally affects lymph nodes in the abdomen and the spleen. It is often advanced when it is
diagnosed and usually causes B symptoms.

Lymphocyte-rich classic HL

Lymphocyte-rich classic HL (LRHL) accounts for about 5% of all cases of HL. It is more common
in older people and develops more often in men.

LRHL usually develops in lymph nodes in the neck, in the armpits and above the collarbone. It is
most often diagnosed at an early stage (stage 1 or 2) and it rarely affects more than a few
lymph nodes. It doesn’t usually cause B symptoms.

Lymphocyte-depleted HL

Lymphocyte-depleted HL (LDHL) is the least common type of HL. It accounts for only about 1%
of all cases of HL. It is more common in older people and develops more often in men. It may be
seen in people with HIV infection. LDHL usually affects lymph nodes in the abdomen and the
spleen, liver and bone marrow. It is often advanced when it is first found and most people have
B symptoms.

Nodular lymphocyte-predominant Hodgkin lymphoma

Nodular lymphocyte-predominant HL (NLPHL) accounts for about 5% of all HL cases. This type
of HL has abnormal cells called LP cells, which may also be called popcorn cells because of how
they look when viewed under a microscope. (These cells used to be called lymphocytic and
histiocytic, or L&H, cells.) There may be very few or no HRS cells in the sample from the lymph
node.

NLPHL can occur at any age, but it is most common in young men. It usually starts in lymph
nodes in the neck and armpit. It is usually slow growing, or indolent, and diagnosed at an early
stage. Most people don’t have symptoms other than enlarged lymph nodes in the neck, armpits
or groin. B symptoms are rare.

3. What differentiates this disease from other “lymph swelling” diseases?

Both Hodgkin's lymphoma and non-Hodgkin's lymphoma are lymphomas — a type of cancer
that begins in a subset of white blood cells called lymphocytes. Lymphocytes are an integral
part of your immune system, which protects you from germs.
The main difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is in the
specific lymphocyte each involves. A doctor can tell the difference between Hodgkin's
lymphoma and non-Hodgkin's lymphoma by examining the cancer cells under a microscope. If
in examining the cells, the doctor detects the presence of a specific type of abnormal cell called
a Reed-Sternberg cell, the lymphoma is classified as Hodgkin's. If the Reed-Sternberg cell is not
present, the lymphoma is classified as non-Hodgkin's.
The two forms of lymphoma are marked by a painless swelling of the lymph nodes. Hodgkin
lymphomas are more likely to arise in the upper portion of the body (the neck, underarms, or
chest). Non-Hodgkin lymphoma can arise in lymph nodes throughout the body, but can also
arise in normal organs. Patients with either type can have symptoms such as weight loss, fevers,
and night sweats. The diseases often follow different courses of progression. Hodgkin
lymphoma tends to progress in an orderly fashion, moving from one group of lymph nodes to
the next, and is often diagnosed before it reaches an advanced stage. Most patients with non-
Hodgkin lymphoma are diagnosed at a more advanced stage.

4. What hematological tests can be helpful in diagnosing this disease?

Blood tests aren’t used to diagnose Hodgkin lymphoma, but they can help your doctor get a
sense of how advanced it is and how well you might tolerate certain treatments.

Typical laboratory findings in HL include anaemia, elevated ESR, leucocytosis and/or

eosinophilia; however, blood tests may not differentiate HL from other causes of systemic
illness. A patient with HL may have entirely normal laboratory parameters. In those patients
with clearly pathological nodes, referral for lymph node biopsy under the two week rule is
appropriate.

The complete blood count (CBC) is a test that measures the levels of different cells in the
blood. People with Hodgkin lymphoma can sometimes have abnormal blood counts. For
example, if the lymphoma invades the bone marrow (where new blood cells are made) a
person might have anemia (not enough red blood cells). A high white blood cell count is
another possible sign of Hodgkin lymphoma, although it can also be caused by infection.

A test called an erythrocyte sedimentation rate (ESR) can help measure how much
inflammation is in the body. It can be elevated in some people with Hodgkin lymphoma.

5. Give ways to treat this disease.

Hodgkin lymphoma consultation

Your doctor will review your scans and discuss treatment options with you. Which
Hodgkin's lymphoma treatments are right for you depends on the type and stage of your
disease, your overall health, and your preferences. The goal of treatment is to destroy
as many cancer cells as possible and bring the disease into remission.

Chemotherapy

Chemotherapy is a drug treatment that uses chemicals to kill lymphoma cells.

Chemotherapy drugs travel through your bloodstream and can reach nearly all areas of
your body. Chemotherapy is often combined with radiation therapy in people with early-
stage classical type Hodgkin's lymphoma. Radiation therapy is typically done after
chemotherapy. In advanced Hodgkin's lymphoma, chemotherapy may be used alone or
combined with radiation therapy. Chemotherapy drugs can be taken in pill form or
through a vein in your arm, or sometimes both methods of administration are used.
Several combinations of chemotherapy drugs are used to treat Hodgkin's lymphoma.
MOPP

 The original treatment for Hodgkin's was MOPP. The abbreviation stands for the four
drugs Mustargen (also known as chlormethine), Oncovin (also known as vincristine),
Prednisone and Procarbazine (also known as Matulane). The treatment is usually
administered in four week cycles, often for six cycles. MSD and VCR are administered
intravenously, while procarbazine and prednisone are pills taken orally. MOPP was the
first combination chemotherapy brought in that achieved a high success rate
 Although no longer the most effective combination, MOPP is still used after relapse or
where the patient has certain allergies or lung or heart problems which prevents the use
of another regimen.
6. Chlormethine
7. Oncovin
8. Prednisone
9. Procarbazine

ABVD:

 Currently, the ABVD chemotherapy regimen is the standard treatment of

Hodgkin's disease in the US. The abbreviation stands for the four drugs
Adriamycin, bleomycin, vinblastine, and dacarbazine. Developed in Italy in the
1970s, the ABVD treatment typically takes between six and eight months,
although longer treatments may be required.

1. Doxorubicin (adriamycin),
2. Bleomycin
3. Vinblastine
4. Dacarbazine

Stanford V:

The newer Stanford V regimen is typically only half as long as the ABVD but
involves a more intensive chemotherapy schedule and incorporates radiation
therapy

1. Mechlorethamine,
2. Doxorubicin
3. Vinblastine, vincristine,
4. Bleomycin
5. Etoposide,
 6. Prednisone

BEACOPP

 BEACOPP is a form of treatment for stages > II mainly used in Europe. The cure
rate with the BEACOPP esc. regimen is approximately 10–15% higher than with
standard ABVD in advanced stages. This was shown in a paper in The New
England Journal of Medicine (Diehl et al.), but US physicians still favor ABVD,
maybe because some physicians think that BEACOPP induces more secondary
leukemia. However, this seems negligible compared to the higher cure rates.
1. Bleomycin
2. Vincristine
3. Cyclophosphamide, Procarbazine
4. Etoposide
5. Prednisone

Depending on the regimen, Hodgkin lymphoma chemotherapy treatments may be

administered in pill form, as an injection or intravenously. You may receive chemo
alone, or in combination with radiation therapy and/or stem cell transplantation.

Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays and protons, to kill
cancer cells. For classical Hodgkin's lymphoma, radiation therapy is often used after
chemotherapy. People with early-stage nodular lymphocyte-predominant Hodgkin's
lymphoma may undergo radiation therapy alone.

During radiation therapy, you lie on a table and a large machine moves around you,
directing the energy beams to specific points on your body. Radiation can be aimed at
affected lymph nodes and the nearby area of nodes where the disease might progress.
The length of radiation treatment varies, depending on the stage of the disease. A
typical treatment plan might have you going to the hospital or clinic five days a week for
several weeks. At each visit, you undergo a 30-minute radiation treatment.

Radiation therapy can cause skin redness and hair loss at the site where the radiation is
aimed. Many people experience fatigue during radiation therapy. More-serious risks
include heart disease, stroke, thyroid problems, infertility and other cancers, such as
breast or lung cancer.

Bone marrow transplant

 Bone marrow transplant, also known as stem cell transplant, is a treatment to
replace your diseased bone marrow with healthy stem cells that help you grow new
bone marrow. A bone marrow transplant may be an option if Hodgkin's lymphoma
returns despite treatment. During a bone marrow transplant, your own blood stem cells
are removed, frozen and stored for later use. Next you receive high-dose chemotherapy
and radiation therapy to destroy cancerous cells in your body. Finally your stem cells
are thawed and injected into your body through your veins. The stem cells help build
healthy bone marrow. People who undergo bone marrow transplant may be at
increased risk of infection.

Other drug therapy

Other drugs used to treat Hodgkin's lymphoma include targeted drugs that focus
on specific vulnerabilities in your cancer cells and immunotherapy that works to activate
your own immune system to kill the lymphoma cells. If other treatments haven't helped
or if your Hodgkin's lymphoma returns, your lymphoma cells may be analyzed in a
laboratory to look for genetic mutations. Your doctor may recommend treatment with a
drug that targets the particular mutations present in your lymphoma cells.

Targeted therapy is an active area of cancer research. New targeted therapy drugs are
being studied in clinical trials.

Steroid medication

Steroid medication is sometimes used in combination with chemotherapy as a more intensive

treatment for advanced cases of Hodgkin lymphoma, or if initial treatment hasn't worked. The
steroid medication is given intravenously, usually at the same time as your chemotherapy.

Common side effects of steroid medication include: increased appetite, which can lead to
weight gain, indigestion ,problems sleeping and feeling agitated

Rituximab

If you're diagnosed with a rare type of Hodgkin lymphoma called lymphocyte-predominant

Hodgkin lymphoma, you may have chemotherapy in combination with a medication called
rituximab. Rituximab is a type of biological therapy called a monoclonal antibody. It attaches
itself to the surface of cancerous cells and stimulates the immune system to attack and kill the
cell. It's given through a drip directly into a vein over the course of a few hours.
Side effects of the drug can include: flu-like symptoms, such as headaches, fever and muscle
pain ,tiredness, nausea and diarrhea

References: http://www.cancer.ca/en/cancer-information/cancer-type/hodgkin-
lymphoma/hodgkin-lymphoma/types-of-hodgkin-lymphoma/?region=on#ixzz59hOvT24R

https://medlineplus.gov/bloodcounttests.html

https://www.nhs.uk/conditions/hodgkin-lymphoma/treatment/