Review Question - QID 109854

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Hodgkin Lymphoma Complications From treatment QID: 109854 (M2.ON.17.4871)

QID 109854 (Type "109854" in App Search)

A 48-year-old nurse presents with left-sided chest pain and a nonproductive cough. Both the chest pain and the cough began about 2 months ago. Deep breathing exercises exacerbate his chest pain. The patient denies headaches, fever, or chills. He reports a 3 pound weight loss over the last 2 weeks, which he attributes to a change in his diet that he and his wife recently started. The patient drinks a glass or 2 of whiskey on the weekends and is a non-smoker. The patient’s medical history is significant for type 2 diabetes and Hodgkin lymphoma. He was treated with chemotherapy and radiation 25 years ago without complications. His current medications include metformin and glyburide. His HbA1c is 7.5%. His temperature is 99°F (37.2°C), blood pressure is 121/82 mmHg, pulse is 86/min, respirations are 12/min, and oxygen saturation is 95% on room air. Physical exam is notable for coarse rhonchi in the left lung. There is no appreciable lymphadenopathy. A chest radiograph is performed, which is shown in Figure A. Which of the following is the most likely diagnosis for this patient?

Type & Select Correct Answer

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Aspergilloma

13%

7/52

Radiation-induced pulmonary fibrosis

10%

5/52

Recurrence of his Hodgkin lymphoma

12%

6/52

Secondary lung cancer

52%

27/52

Tuberculosis

10%

5/52

Select Answer to see Preferred Response

This patient is presenting with a history of Hodgkin lymphoma and a lung nodule, suggesting a diagnosis of a secondary malignancy.

Hodgkin lymphoma occurs in young patients and is treated with chemotherapy and radiation. These patients are at an increased risk for developing secondary cancers, including both solid tumors and secondary leukemias or lymphomas. The most common secondary solid tumor malignancies include the lung, breast, thyroid, bone, and gastrointestinal tract. Patients should undergo diagnostic work-up to identify the source of the malignancy and likely undergo surgical excision.

Görkem and O'Connell review the evidence regarding the diagnosis of malignancy after finding an abnormal lymph node. They discuss how lymphoma is a possibility in addition to breast cancer. They recommend carefully reviewing all possible diagnoses for these disorders.

Figure/Illustration A is a chest radiograph showing a left-sided upper lung nodule. This appearance is consistent with a secondary tumor or malignancy.

Incorrect Answers:
Answer 1: Aspergillomas present as intracavitary lesions that may have an air crescent on plain film. They are more common in patients that have existing cavitary lung diseases such as tuberculosis, sarcoidosis, and lung tumors. Neutropenia and glucocorticoid use can also predispose one to infection, especially invasive aspergillosis. Treatment is with antifungal medications and surgical excision.

Answer 2: Radiation can cause fibrosis, but a chest radiograph would show reticular or ground-glass patterns. In severe pulmonary fibrosis, cystic spaces can be seen, but they would appear in “honey-comb” patterns.

Answer 3: Hodgkin lymphoma has a cure rate of greater than 80% with treatment. While relapses occur, more prominent constitutional symptoms (fever, night sweats, and weight loss) would be expected as well as lymphadenopathy. Treatment is with systemic chemotherapy.

Answer 5: Tuberculosis can present with solitary cavitary lesions in the upper lobes on a chest radiograph. Although healthcare workers may have a higher exposure risk, patients will classically present with fever, night sweats, hemoptysis, and weight loss. Treatment is with a combination of agents such as rifampin and isoniazid.

Bullet Summary:
Secondary malignancy after chemotherapy and radiation treatment for Hodgkin lymphoma is common.