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Case Report
Classical Hodgkin’s lymphoma
(mixed cellular variant)
Sumith Gunawardane, Primali Jayasuriya1
Departments of Oral and Maxillofacial Surgery and 1Oral Pathology, Faculty of Dental Sciences, University of
Peradeniya, Peradeniya, Sri Lanka

ABSTRACT
Malignant lymphomas represent approximately 5% of all malignant neoplasms of the head and
neck. They are divided into two subgroups, Hodgkin’s lymphomas (HLs) and non‑HL. This is
a case report of a 23‑year‑old female, who presented with multiple nontender lumps on the
right posterior triangle of the neck of 4 months duration. She was diagnosed with, “Classical
Hodgkin’s lymphoma” (mixed cellularity type) of the head and neck region, which is poorly
reported and published in Sri Lankan literature. HL of head and neck region seems to involve
a broader histo‑morphologic spectrum than that generally recognized by the WHO and,
therefore, needs to be considered to improve the Sri Lankan figures in literature.

Key words: Head and neck, Hodgkin’s lymphoma, malignant lymphoma, Reed–Sternberg cells

Introduction into two distinct entities: Nodular

Address for correspondence:
Dr. Sumith Gunawardane,
Faculty of Dental Sciences, University
of Peradeniya, Peradeniya, Sri Lanka.
E‑mail: sumithgunawardane7
@gmail.com
Date of Submission: 07‑05‑2015
Date of Acceptance: 15-08-2015
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.176380
Quick Response Code:
Malignant lymphomas represent
approximately 5% of all malignant
neoplasms of the head and neck region.[1]
This heterogeneous group of tumors is
classically divided into two subgroups,
H o d g k i n’s l y m p h o m a s   ( H L s ) a n d
non‑HL (NHL), depending on the presence
or absence of Reed–Sternberg cells with
“spectacle” like arrangement of two
nuclei, found in HL.[2] This classification
is useful when determining the clinical
prognosis which is significantly poorer in
NHL (widely disseminated at the time of
diagnosis).[3]
HL was first described in 1938 by Thomas
Hodgkin with an incidence of about
24/100,000/year.[1] Prevalence in women
peaks in the third decade and then falls,
but in men it remains fairly constant after
this time.[2] As diagnostic tests have become
more sophisticated and understanding
regarding the biology of the lymphatic
system, several different classifications of
lymphoma have been described over the
last three to four decades.[3]
According to the WHO classification,
published in 2008 the disorder is classified
lymphocyte‑predominant  (LP) HL; and
classical HL (CHL).[4,5]
Ann arbor staging system with Cotswold
modifications for HL is commonly used
for the staging of the disease as:[5]
• Stage I: Involvement of one lymph node
region or lymphoid structure (e.g. spleen,
thymus, Waldeyer’s ring)
• Stage II: Two or more lymph node
regions on the same side of the
diaphragm
• Stage III: Lymph nodes on both sides
of the diaphragm
• Stage III (1): With splenic, hilar, coeliac,
or portal nodes
• Stage III (2): With para‑aortic, iliac, or
mesenteric nodes
• Stage IV: Involvement of extranodal
site (s).
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For reprints contact: reprints@medknow.com
How to cite this article: Gunawardane S,
Jayasuriya P. Classical Hodgkin's lymphoma (mixed
cellular variant). Indian J Oral Sci 2016;7:59-62.

© 2016 Indian Journal of Oral Sciences | Published by Wolters Kluwer ‑ Medknow 59

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Gunawardane and Jayasuriya: Classical hodgkin’s lymphoma: A case report

Radiation therapy, chemotherapy or combined therapies
are the treatment modalities used in managing HL.
To the best of knowledge, there aren’t any published cases
of CHL of the head and neck region reported in Sri Lanka.
A  retrospective, descriptive study of the Department
of Pathology, University of Peradeniya using biopsy
specimens of patients diagnosed or suspected to have
a lymphoma revealed that the most common sub types
of NHL are diffuse large B cell lymphoma and follicular
lymphoma. Of the HLs mixed cellular sub type was the
most common[6] [Table 1].
Case Report
A 23‑year‑old female with no significant medical history
was presented with multiple nontender lumps on right side
neck of about 4 months duration. Physical examination
demonstrated multiple oval shaped, firm lymph nodes
on the right posterior triangle of the neck. Laboratory
investigations yielded, a white blood cell count of
7.2  ×  103/µL, hemoglobin of 10  g/dL. An ultrasound
scan of the neck showed multiple enlarged lymph nodes at
Level 5, posterior to the right sternocleidomastoid muscle
and few nodes in the right side of the neck at Level 2. No
glands were detected on the left side of the neck clinically
or by ultrasound. The Intraoral examination was of no
significance, and all teeth were present in all four quadrants
with no caries or restorations. A  fine‑needle aspiration
cytology  (FNAC) report of the lesion showed a mixed
population of lymphoid cells admixed with singly scattered
large polymorphous cells with Reed–Sternberg like cells.
With a sputum test for screening of Mycobacterium tuberculosis
and sampling of a pleural effusion which were negative, a
provisional clinical diagnosis of either NHL or metastatic
carcinoma was made. An excisional biopsy of a lymph node
confirmed the definitive diagnosis of “Classical Hodgkin’s
lymphoma (mixed cellular variant).”
A computed tomography  (CT) scan was performed for
staging purpose prior to the initiation of therapy. It showed
bilaterally enlarged cervical lymph nodes and no mediastinal
or intrapulmonary nodules. A  bone marrow biopsy was
also performed before the initiation of therapy and the
condition was staged as “Hodgkin’s lymphoma Stage II,
bilateral Level 2 lymph node involvement.” The patient was
put on the follow‑up care at the oncology clinic, Teaching
Hospital, Jaffna.
Discussion
Although HL often involves the head and neck region, these
neoplasms usually arise in lymph nodes, most frequently in
the cervical region, and extranodal manifestation without
nodal involvement is rare. The frequency of HL involving
extranodal sites of the head and neck is approximately
4%.[7]
About 15–30% of all individuals suffering from HL in the
western world have mixed cellular type disease. In Asian
subcontinent including Sri Lanka, the incidence probably
is higher, but the exact figures are not available. It may
become the most common type in some populations. It
can occur at any age and is equally common in both sexes.[8]
On epidemiologic grounds, there appear to be three
different presentations: Childhood (0–14 years), young adult
(15–34 years), and older adult Hodgkin’s disease (55 + years).[8]
HL may present with asymptomatic lymphadenopathy
or with constitutional symptoms (e.g. unexplained weight
loss, fever, and night sweats) which are present in 40% of
patients.[9,10] These are known as “B” symptoms which are
positive in this case as well.
In clinical examination, it may be seen as palpable,
painless lymphadenopathy in the cervical area (neck,
60–80%), axilla (armpit, 6–20%), and less commonly in
the inguinal area (groin, 6–20%); it is described as rubbery
adenopathy.[11] Some studies have infrequently observed
the involvement of the Waldeyer’s ring (back of the throat,
including the tonsils) or occipital (lower rear of the head) or
epitrochlear (inside the upper arm near the elbow) areas.[11]
When a patient presents with neck lymphadenopathy and
risk factors for head and neck cancer, a FNAC is usually
advised as the initial diagnostic step, followed by excisional
biopsy if squamous cell histology is to be excluded.[11]

Table 1: Hodgkin lymphoma WHO subtypes of reported cases in Sri Lanka (Waravita et al. 2015)
Lymphoma sub type Frequency (%) Mean age in years (SD) Number of males (%) Nodal n (%) Extra nodal n (%)
Hodgkin lymphoma
Nodular lymphocyte predominant 0 0 0 0 0
Classic Hodgkin lymphoma
Mixed cellular 20 (57.1) 51.82 (20.9) 15 (75) 20 (100) 0 (0)
Nodular sclerosis 13 (37.1) 33.8 (19.4) 6 (46.1) 13 (100) 0 (0)
Lymphocyte rich 1 (2.9) 23 0 (0) 1 (100) 0 (0) 0 (0)
Lymphocyte depleted 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

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Gunawardane and Jayasuriya: Classical hodgkin’s lymphoma: A case report
Excisional node biopsy is better than fine‑needle or core
needle biopsy, as it allows the diagnosis of lymphomas
based on the morphology of the lymph node, which is not
offered by needle biopsy.[11]
Hence the diagnosis of lymphoma is based on the results
of pathological examination. In cases such as this, extra
nodal lesions should be looked for, and a deep biopsy
should be undertaken, similar to the procedure performed
in squamous cell carcinoma. This can usually be performed
under local anesthesia, except in some locations, such as the
paranasal sinuses, salivary glands, some laryngeal lesions,
and the thyroid gland which are not relevant to this case.
In cases in which the nodules are very deep, CT and
magnetic resonance imaging are useful in identifying the
nodule to be resected, which is then usually removed.
The foundation for determining the ideal HL treatment
is accurate staging, which requires a comprehensive
evaluation of possible sites of disease by imaging and
sampling (biopsy), as well as an assessment of prognostic
factors.[12]
The Ann arbor staging system is the main staging system
used and allows distinction between early‑stage and
advanced‑stage disease;[5] the International Prognostic
Score is the standard for risk stratification of patients
with advanced disease (0–7 scale), but is not applicable to
patients with early‑stage HL.[5] The presenting case was
staged as “Hodgkin’s lymphoma Stage II with bilateral
Level 2 lymph nodes involvement.”
The diagnosis of HL is primarily based on the
recognition of the typical tumor cells, either Hodgkin
and Reed–Sternberg  (HRS) cells or LP cells, in the
appropriate environment.[12] In addition, the character
of the inflammatory background and the surrounding
stroma as well as established immunophenotypic and
Figure 1: The large atypical lymphoid cells are morphologically
consistent with classical Reed–Sternberg cells/Hodgkin cells (H and E
original magnification, ×40)
Indian Journal of Oral Sciences  Vol. 7  Issue 1  Jan-Apr 2016
molecular markers help to classify the disease into
various tumor subtypes. A panel of markers is used for
immunophenotyping of HL including B‑cell surface
markers, transcription factors, and Epstein–Barr virus
associated proteins.[12]
Large atypical lymphoid cells, morphologically consistent
with classical Reed– Sternberg cells/Hodgkin cells were
present in the specimens of this case when viewed under
the microscope using hematoxylin and eosin stain under
magnification of  ×40. It also showed classic binucleated
RD cells and mononucleated Hodgkin cells which were
dispersed throughout the node in the background of mixed
cell population composed of lymphocytes, histiocytes and
plasma cells in the partially effaced nodal architecture.
Scattered multinucleated RD cells were also present with
increased mitosis [Figure 1].
In nearly all cases of mixed cellularity CHL, HRS cells
are positive for CD30, a glycoprotein belonging to the
tumor necrosis factor receptor super‑family. In addition,
the majority of HRS cells (85%) also express CD15, the
Lewis x carbohydrate adhesion molecule.[12]
The presenting case is in common agreement with the
immunohistochemical findings of HL  (mixed cellularity
type) with positive CD15, whereas negative CD20 around
malignant cells. CD68 showed positivity around histiocytic
cells [Figure 2].
Radiation therapy, chemotherapy, or combined therapies
are the treatment modalities used in managing HL. The
procedure can be helpful in rare cases in which radiation
therapy is under consideration as the sole treatment of
early‑stage HL.[13,14]
Unlike many other forms of cancer, it is often possible to
cure HL even if first‑line treatment fails. This fact creates
the dilemma of whether it is better to use more extensive
treatment initially, to cure as many individuals as possible,
Figure 2: CD20 positive around other lymph cells but negative
around malignant cells (immunohistochemistry, ×40)
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Gunawardane and Jayasuriya: Classical hodgkin’s lymphoma: A case report
or whether a less intensive treatment should be used first,
followed by aggressive salvage therapy in more patients.[13]
Conclusion
HL of the head and neck region seems to involve a broader
histo‑morphologic spectrum than that generally recognized
by the WHO and needs to be considered for improving
the Sri Lankan figures in literature.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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