Updated: 11/24/2020

Hodgkin Lymphoma

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Snapshot
  • A 65-year-old man with mycosis fungoides presents with increased fatigue, low-grade fevers, and night sweats. Given his history, he is scared that "something is going on." His primary care physician does a thorough physical exam and finds several small, rubbery, mobile supraclavicular lymph nodes. They are nontender. A lymph node biopsy shows pathology of Reed-Sternberg cells.
Introduction
  • B-cell malignancy originating in lymphatic system
  • Pathogenesis
    • 50% of cases associated with EBV infection
    • Reed-Sternberg cells
      • CD15+
      • CD30+
  • Epidemiology
    • bimodal distribution
      • young adulthood
      • > 55 years
    • male > female except for nodular sclerosing type
    • more common in Caucasians
  • Commonly early stage when diagnosed
    • as opposed to non-Hodgkin lymphoma (NHL), where people are in later stage disease at diagnosis
  • Types of Hodgkin lymphoma
    • nodular sclerosing 
      • most common
      • female predominance
    • mixed cellularity
    • lymphocyte-rich/predominant
      • especially in < 35-year-olds
    • lymphocyte-depleted
      • especially in > 60-year-olds
      • other systemic diseases
  • Risk factors
    • infectious mononucleosis with EBV
    • immunosuppression
    • smoking
    • mycosis fungoides
Presentation
  • Symptoms
    • constitutional ("B") symptoms
      • fever
      • night sweats
      • weight loss
      • all caused by cytokines released from Reed-Sternberg cells
    • contiguous spread
    • persistent painless lymphadenopathy
  • Physical exam
    • nontender mass of localized, single group of nodes
      • rubbery
      • mobile
      • cervical
      • supraclavicular
      • axillary
    • potential SVC syndrome
    • potential erythema nodosum
Evaluation
  • Imaging for staging
  • Lymph node biopsy
    • Reed-Sternberg cells
      • binucleate or bilobed, “owl-eyed” nuclei
    • mixed cellularity type
      • large inflammatory infiltrate with many eosinophils
    • nodular sclerosing type
      • diffuse band-like fibrosis with lacunar spaces
Differential Diagnosis
  • Non-Hodgkin lymphoma
  • AIDS-related lymphadenopathy
  • Infection
  • Breast cancer
  • Cat-scratch fever
Treatment
  • Based on staging
  • Localized disease or early stage
    • excisional biopsy
    • chemotherapy
    • radiation
  • Late stage disease or anyone with B symptoms
    • ABVD
      • Adriamycin (doxorubicin)
      • Bleomycin
      • Vinblastine
      • Dacarbazine
Prognosis, Prevention, and Complications
  • Prognosis
    • > 80% with treatment
      • better than non-Hodgkin lymphoma
      • lymphocyte-predominant = best prognosis
      • lymphocyte-deplete = worst prognosis
      • higher lymphocyte:RS cell ratio = better prognosis
    • 5-30% chance of relapse
  • Complications
    • tumor lysis syndrome
      • hypocalcemia (most common) 
      • hyperkalemia
      • hyperphosphatemia
      • hyperuricemia
    • SVC syndrome
    • minimal change disease
    • paraneoplastic syndromes
      • calctriol secretion causes hypercalcemia
    • from treatment
      • risk of solid tumors (breast, thyroid, and lung) 
      • risk of premature coronary artery disease
      • risk of infection
      • doxorubicin – cardiomyopathy
      • vincristine – neuropathy
      • bleomycin – lung fibrosis

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(M2.ON.15.4622) A 31-year-old man presents to his primary care physician with fevers, chills, and night sweats. After a physical exam and a series of laboratory tests, the patient undergoes a lymph node biopsy (Image A). Three days later, while awaiting treatment, he presents to his physician complaining of generalized swelling and is found to have 4+ protein in his urine. Which of the following pathological findings is most likely to be found on renal biopsy in this patient?

QID: 107001
FIGURES:
1

Rapidly progresive glomerulonephritis

5%

(1/20)

2

Amyloidosis

5%

(1/20)

3

Membranoproliferative glomerulonephritis

10%

(2/20)

4

Focal segmental glomerulosclerosis

5%

(1/20)

5

Minimal change disease

70%

(14/20)

M 6 E

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