Lymphoma
CASE PRESENTATION
Name: Haji Khan.
Age: 45 year. DOA: 21-02-24
Sex: Male.
Source of history: patient &his son
Religious: ISLAM. MR no: 52787
Marital status: Married
Occupation: Farmer
Adress: Khairpur mirs
CHIEF COMPLAINTS
Fever with cough for 10 months
• loss of weight, loss of appetite for 08 months
• Generalized lymphadenopathy starting in
cervical region then axillary then inguinal
region for 2 months.
HOPC
The patient states that he was alright 10 months back. Since
then, he has been suffering from occasional fever which is low
grade, continued, not associated with chill and rigor. There is
occasional evening rise of temperature and night sweating. He
also complains of cough which is dry, worse at night,
associated with difficulty in breathing and more marked on
moderate to severe exertion. There is no history of orthopnea
or paroxysmal nocturnal dyspnea. The patient also complains
of severe weakness, marked loss of weight and appetite for 08
months. For the last 02 months, he noticed painless lumps
initially starting in cervical glands then on the axilla and
groins. These lumps are painless, discrete, rubbery are
gradually increasing in size. The pattern of spread is
contiguous. There is no history of bleeding from any site,
polyarthritis, skin rash, contact with TB patients or history of
exposure. His bowel and bladder habits are normal.
PROVISIONAL
DIAGNOSIS HISTORY
With this history of fever, lymphadenopathy
and hepatosplenomegaly,
I have some differential diagnoses:
• Lymphoma
• Disseminated tuberculosis
• Sarcoidosis
• Chronic lymphatic leukemia
• SLE.
GENERAL EXAMINATION
• The patient is cachexic and moderately anemic
• No jaundice, clubbing, cyanosis, koilonychia,
leukonychia or edema
• Thyromegaly absent
• There is generalized lymphadenopathy involving
right cervical, both axillary and inguinal [Link]
lymph nodes are of variable size and shape, largest
one being 2 × 2 cm, nontender, firm in consistency,
discrete, not adherent to the underlying structure or
to the overlying skin. There is no discharging sinus
There is no sternal tenderness
• Pulse: 100/min• BP: 100/85 mm Hg.
SYSTEMIC EXAMINATION
Gastrointestinal System
• Lips, gums, teeth, oral cavity and tonsils normal
• Tongue pale and smooth.
• Abdomen Inspection:
• No abnormality detected.
Palpation:
• Liver palpable, 4 cm from the right costal margin in the midclavicular line,
margin is sharp, surface is smooth, nontender and firm in consistency, no
hepatic bruit or rub
.• Spleen--palpable, 10 cm, from the left costal margin in the anterior axillary
line towards the right iliac fossa.
Percussion:
• No evidence of ascites (no fluid thrill, no shifting dullness).
Auscultation:
No abnormality [Link] of other systems reveals no
abnormalities.
INVESTIGATIONS
TREATMENT
PLAN
- Bone Marrow Biopsy on followup
HODGKIN LYMPHOMA
General Considerations
Hodgkin lymphoma is characterized by lymph
node biopsy
showing Reed-Sternberg cells in an
appropriate reactive cellular background. The
malignant cell is derived from B lymphocytes
of germinal center origin.
Clinical findings
There is a bimodal age distribution, with one peak in the
20s and a second over age 50 years. Most patients seek
medical attention because of a painless mass, commonly
in
the neck. Others may seek medical attention because of
constitutional symptoms such as fever, weight loss, or
drenching night sweats, or because of generalized
pruritus.
An unusual symptom of Hodgkin lymphoma is pain in an
involved lymph node following alcohol ingestion.
An important feature of Hodgkin lymphoma is
its ten-
dency to arise within single lymph node areas
and spread
in an orderly fashion to contiguous areas of
lymph nodes.
Late in the course of the disease, vascular
invasion leads to
widespread hematogenous dissemination
Hodgkin lymphoma is divided into two subtypes: clas-
sic Hodgkin (nodular sclerosis, mixed cellularity, lympho-
cyte rich, and lymphocyte depleted) and non-classic
Hodgkin (nodular lymphocyte predominant). Hodgkin
lymphoma should be distinguished pathologically from
other malignant lymphomas and may occasionally be con-
fused with reactive lymph nodes seen in infectious mono-
nucleosis, cat-scratch disease, or drug reactions (eg,
phenytoin).
Patients undergo a staging evaluation to
determine the
extent of disease, including serum
chemistries, whole-body
PET/CT scan, and bone marrow biopsy.
TREATMENT
Chemotherapy is the mainstay of treatment
for Hodgkin lymphoma, and
ABVD (doxorubicin, bleomycin, vinblastine,
dacarbazine) remains the standard first-line
regimen due to its manageable toxicity.
The substitution of the antibody-drug
conjugate brentuximab vedotin for bleomycin
(AAVD) has demonstrated somewhat superior
progression-free survival and is frequently
used for patients with higher risk disease
The more intense regimen, escalated
BEACOPP (bleomycin, etoposide,
doxorubicin, cyclophosphamide, vincristine,
procarbazine, prednisone), is associated with
increased toxicity and is reserved for patients
with activity on an interim PET/CT scan after
starting ABVD.
Low-risk patients are those with stage I or II
disease without bulky lymphadenopathy or
evidence of systemic inflammation.
They traditionally receive a combination of
short-course chemotherapy with involved
nodal radiotherapy, but involved nodal
radiotherapy can be eliminated for those with
an early negative PET/CT scan without a
significant change in outcomes.
High-risk patients are those with stage III or
IV disease or with stage II disease and a large
mediastinal or other bulky mass or systemic
inflammation. These patients are treated with
a full course of chemotherapy for six cycles
Classic Hodgkin lymphoma relapsing after initial
treat-
ment is treatable with high-dose chemotherapy and
autologous hematopoietic stem cell transplantation.
This offers a 35–50% chance of cure when disease is
still chemotherapy responsive. Immune checkpoint
inhibition by PD1 blockade with nivolumab or
pembrolizumab has shown remarkable activity in
patients with relapsed or refractory disease (overall
response rate [ORR], 65%). These agents as well as
brentuximab vedotin are increasingly incorporated
in second-line regimens prior to or, for ineligible
patients, in lieu of stem cell transplantation.
