INTRODUCTION

• Hodgkin Lymphoma (HL) first described by

Thomas Hodgkins in 1832 is defined as
monoclonal lymphoid neoplasm characterised
by the presence of multinucleated giant cells,
Reed-Sternberg and Hodgkin cells with
characteristic immunophenotype and
appropriate cellular background.

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Epidemiology;
• Worldwide ditribution.
• One of the common malignancies of young
adults.
• Constitutes about 1% of all malignancies and
about 18% of all lymphomas in the USA.
• Males affected more than females.
• Whites more than Africans.
• Has bimodal age distribution, 1st peak in the 3rd
decade and 2nd peak >60 years of life.
• Median age of occurence in Nigeria is 30 years.

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Etiology;
• The etiology of Hodgkin disease is unknown.
• Infectious agents, esp Epstein-Barr virus (EBV).
• About 50% of Hodgkin disease cases are EBV-
positive;
• Almost 100% of HIV-associated Hodgkin
disease cases are EBV-positive.
• The average incubation time to symptoms of
Hodgkin disease was 2.9 years.

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Etiology (contd);
• Genetic predisposition may play a role.
• ≈1% of pts have a family history.
• Siblings of an affected individual have a 3- to
7-fold increased risk.
• This risk is higher in monozygotic twins.

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PATHOGENESIS
• The exact origin of RS cell is not known.
• RS cells comprise only 1-2% of the total tumor
cell mass.
• Most of the cells are varieties of reactive,
mixed inflammatory cells consisting of
lymphocytes, plasma cells, neutrophils,
eosinophils, and histiocytes.

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CLASSIFICATION – WHO Histological
• Nodular Lymphocyte-Predominant HL (NLPHL)
• Classical HL – Nodular Sclerosis (NSHL)
- Mixed Cellularity (MCHL)
- Lymphocyte-rich (LRHL)
- lymphocyte-depleted (LDHL)

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CLASSIFICATION (contd);
NLPHL: 3–8%; contain large atypical B cells and
lymphocytic and histiocytic (L&H) ‘popcorn’
cells.
• These cells are CD30–, CD15–, CD20+, CD45+,
CD75+, CD79a+.

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CLASSIFICATION (contd);
‘Classical’ HL: large mononuclear (Hodgkin’s cells)
or binucleate/multinuclear cells
• RS cells make up only 1–2% of the cellularity of
the lymph node.
• These cells are CD30+ and typically CD15+,
CD20–, CD45–, CD75–, CD79a–.
• The predominant cells are an infiltrate of
lymphocytes, plasma cells, eosinophils and
histiocytes containing scattered neoplastic cells
and a variable degree of fibrosis.

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 A binucleate Reed-Sternberg cell with large,
inclusion-like nucleoli and abundant cytoplasm

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CLASSIFICATION (contd);
Nodular sclerosing HL (NSHL):
• ~80%;
• prominent bands of fibrosis and nodular
growth pattern;
• lacunar Hodgkin’s cells;
• variable numbers of RS cells.

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CLASSIFICATION (contd);
Mixed cellularity HL (MCHL):
• ~17%;
• mixed infiltrate of lymphocytes, eosinophils
and histiocytes with classical RS cells.

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Lymphocyte depleted HL (LDHL):
• rare
• diffuse hypocellular infiltrate with necrosis,
fibrosis and sheets of RS cells.
Lymphocyte rich classical HL (LRCHL):
• uncommon;
• diffuse predominantly lymphoid infiltrate with
scanty RS cells of ‘classical’ phenotype.
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CLINICAL FEATURES
• Usually present with enlarged, painless and rubbery
lymph node ≈ 80% cervical, and upto 50% have
mediastinal mass.
• Alcohol-induced nodal pain.
• Pattern of nodal spread is contiguous and usually axial.
• ≈ 25% have systemic symptoms
– unexplaned fever,
- drenching night sweats,
- unexplained weight loss > 10% of pre-
diagnosis weight,
- fatigue, weakness, anorexia.
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CLINICAL FEATURES
• Intensed pruritus.
• Hepatosplenomegaly.
• Infiltrative lung disease + pleural involvement.
• Skin infiltration – Leukemids.
• Bone marrow infiltration.

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CLINICAL FEATURES
• Because of defect in cellular immunity, they
are more susceptible to TB, fungal, protozoal
and viral infections including P carinii and HZV.
• Primary extranodal presentation (bone
marrow, CNS, skin) is rare.

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LABORATORY FEATURES
• Diagnosis is based on finding the RS/H cells in an
appropriate cellular background of reactive T cells,
histiocytes, & eosinophils with varrying degrees of fibrosis
from tissue biopsy.
Hematological;
• FBC – Eosinophilia, Lymphocytosis, Lymphopenia,
• Thrombocytopenia or Thrombocytosis,
• Anemia – chronic disease, immune-mediated hemolysis
• Raised ESR – index of disease progression and monitoring
response
• BMA/Biopsy – those with abnormal FBC or advanced-stage
disease

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LABORATORY FEATURES
• Biochemical;
• ↑ serum alkaline phosphatase – index of
disease activity
• ↑ serum lactate dehydrogenase – collerates
with tumour load.
• Hypercalcemia
• Hyperuricemia
• Impaired glucose
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LABORATORY FEATURES
• Radiological;
• CXR
• CT Scanning of chest, abdomen & pelvis
• Gallium or PET scans
• Bone scan
• Echocardiography

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DIFFERENTIAL DIAGNOSIS;
• NHL
• TB
• HIV
• Syphilis
• Infectious Mononucleosis

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TREATMENT
• The primary treatment is aimed at complete
response (CR), which is defined as the
"disappearance of all evidence of disease“
• Partial Response (PR) - Regression of
measurable disease and no new sites
• Stable Disease (SD) - Failure to attain CR/PR or
RD
• Relapsed disease - Any new lesion or
increase by 50% of Previously involved sites from
nadir

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TREATMENT
• Modalities includes;
• Radiotherapy
• Combination Chemotherapy
• Salvage therapy

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Pretreatment Evaluation
• Detailed history and complete physical examination
• FBC & ESR
• LFT, Test of renal function, and serum uric acid
• Lactate dehydrogenase
• CXR, CT, MRI & Bone scan
• ECG/Echocardiography
• Bone Marrow Biopsy
• Patient’s counselling
• Adequate hydration
• Prevention of hyperuricemia - TLS

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Unfavourable Factors:–
• Stage II with ≥ 4 nodes involvement/
stage III and IV
• Age > 50 years
• ESR > 50 mm/hr if asymptomatic or >
30mm/hr with B symptoms.
• Mediastinal/thoracic ratio > 0.35
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TREATMENT (contd);
• For early-stage disease (Ia & IIa)
combination chemotherapy (4-6 cycles) &
Involved Field Radiotherapy
• Advanced-stage disease –
Chemotherapy (6-8 cycles) with Radiotherapy
in the presence of bulky disease.

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TREATMENT (contd)
• Relapsed disease –
HSCT,
Extended-field RadioRx,
Combination ChemoRx,
Palliative Rx.

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Combination Chemotherapy
DRUG COMBINATION DOSAGE DAYS
ABVD – 28 Days
ADRIAMYCIN 25mg/m2 1 & 15
BLEOMYCIN 10mg/m2 1 & 15
VINBLASTINE 6mg/m2 1 & 15
DARCABAZINE (DTIC) 375mg/m2 1 & 15
COVP – 28 Days
CYCLOPHOSPHAMIDE 650mg/m2 1&8
ONCOVIN 1.4mg/m2 8
VINBLASTINE 6mg/m2 1
PREDNISOLONE 40mg/m2 Daily x 14

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Combination Chemotherapy
DRUG COMBINATION DOSAGE DAYS
COPP – 28 Days
CYCLOPHOSPHAMIDE 650mg/m2 1&8
ONCOVIN 1.4mg/m2 1&8
PROCARBAZINE 100mg/m2 PO x 14
PREDNISOLONE 40mg/m2 PO x 14
LOPP – 28 Days
LEUKERAN 6mg/m2 PO x 14
(CHLORAMBUCIL)
ONCOVIN 1.4mg/m2 1&8
PROCARBAZINE 100mg/m2 PO x 14
PREDNISOLONE 40mg/m2 PO x 14

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Combination Chemotherapy
• Other combinations includes:
• Alternating MOPP/ABVD

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COMPLICATIONS
Complications of Chemotherapy – Early and Late
• Early – Nausea & vomiting
Alopecia
Myelosuppression
Infection
• Late – Sterility – MOPP
Neuropathy – Vincristine
Cardiomyopathy – Doxorubicin
Pulmonary fibrosis – Bleomycin
Secondary leukemia – Alkylating agents
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COMPLICATIONS
Complications of RTH;
• Early - Anorexia & Nausea
Mouth dryness, pharyngitis, cough &
dermatitis
Myelosuppression – Neutropenia
Thrombocytopenia
• Late - Hypothyroidism
Pericarditis, Pneumonitis
Coronary artery disease
Secondary Neoplasms – lung, breast, stomach,
thyroid, skin, etc 30
 Differences Between NHL and HL
NHL HL
Unifocal origin Rare Common
Multi focal origin Common/ usual rare
Spread Centrifugal/non contiguous Centripetal/ contiguous
Haematogenous spread Common rare
Messenteric nodes Common rare
involvement
Hepatosplenomegaly at Common infrequent
diagnosis
Waldeyer’s ring and common rare
epitrochlear nodes
involvement
Generalized pruritus rare Common
Alcohol induced nodal pain rare Common
Systemic symptoms Common Rare 31