Makindo Medical Notes

Related Subjects: |Hodgkin Lymphoma |Non Hodgkin Lymphoma |Diffuse large B-cell lymphoma |Intravascular large B-cell lymphoma |Mantle cell lymphoma |Marginal Zone Lymphoma |Gastric (MALT) Lymphoma |Primary CNS Lymphoma (PCNSL) |Burkitt's lymphoma |Follicular Lymphoma

🩸 Hodgkin Lymphoma (HL) is a highly curable disease, with a 5-year survival of ~90% under current treatments. Classical HL has a much better prognosis than most types of non-Hodgkin lymphoma (NHL).

📖 About

• ~2,000 cases per year in the UK.
• More common in men than women.
• Malignant disorder of lymphoid cells, primarily affecting lymph nodes.

📊 Incidence

• ~4 new cases per 100,000 per annum.
• HL represents ~10% of all lymphomas; the rest are NHL.
• Bimodal age distribution: peak in young adults (15–35) and another peak >50 years.

🧬 Aetiology

• More common in immunodeficiency & autoimmune disease.
• Epstein-Barr virus (EBV) often implicated, esp. in immunocompromised (HIV).
• B-lymphocyte predominates.
• Histological hallmark: Reed-Sternberg cells — giant B-cells with mirror-image “owl’s eye” nuclei.

⚠️ Risk Factors

• 👶 Age: Most common in 15–35 and >55.
• ♂️ Gender: Slightly more common in men.
• 👨‍👩‍👧 Family History: Lymphoma in relatives increases risk.
• 🦠 EBV infection: Linked to HL risk.
• 🛡️ Weakened immune system: HIV/AIDS, post-transplant immunosuppression.

🔬 Histological Subtypes

• Nodular Sclerosis: 🟢 Most common; young adults, esp. women; mediastinal nodes.
• Mixed Cellularity: Associated with HIV; commoner in older adults.
• Lymphocyte-Rich: Rarer; better prognosis; more in men.
• Lymphocyte-Depleted: Rare; aggressive; seen in older/HIV patients.

📍 Staging (Ann Arbor)

🔥 “B Symptoms”

• Low-grade fever 🌡️
• Drenching night sweats 😰
• Unexplained weight loss >10% ⚖️
• Reflect cytokine release → worse prognosis.

🧑‍⚕️ Clinical Features

• Fatigue, fevers, night sweats, weight loss.
• Pruritus (generalised itching).
• Breathlessness, bone pain, abdominal pain.
• Characteristic: Lymphadenopathy (firm, rubbery, non-tender, non-fixed).
• Common sites: Cervical, mediastinal, axillary nodes.
• Splenomegaly may be present.
• Unique: Lymph node pain after alcohol 🍷 (rare but exam favourite!).

🧪 Investigations

• Bloods: FBC, U&E, LFTs, ESR, Ca, Phosphate, ALP, LDH, urate.
• Definitive: Excisional biopsy of lymph node (>1 cm, persistent >4–6 weeks).
• Bone marrow aspirate & trephine biopsy (for staging).
• Imaging: CT/MRI neck, thorax, abdomen, pelvis; PET-CT gold standard for staging and response.
• Baseline echocardiogram if anthracyclines planned (cardiotoxic).

💊 Management

• 💡 HL is generally very curable, esp. when detected early. 5-year survival ~85–90%.
• Limited/intermediate disease (I–IIA): Short chemotherapy (e.g. 2–4 cycles ABVD) + involved-field radiotherapy.
• Advanced disease (III–IV): Chemotherapy systemic; RT only for bulky/residual disease.
• ⚠️ Always give irradiated blood products lifelong → prevent transfusion-associated GVHD.

💉 Chemotherapy Regimens

• ABVD (standard of care): Adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine. - Repeated q28 days = 1 cycle (usually 6 cycles). - Toxicities: 🚨 Adriamycin → cardiac, Bleomycin → lung.
• eBEACOPP (more intensive, younger patients): escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone.
• AVD + Brentuximab vedotin: Emerging option with intermediate toxicity profile. Requires G-CSF support.
• Older patients (>65–75): Limit bleomycin (max 2 cycles) due to pulmonary toxicity.
• Relapsed/Refractory HL: High-dose chemo + autologous stem cell transplant (ASCT). - Novel agents: Brentuximab vedotin, checkpoint inhibitors (nivolumab, pembrolizumab).

📚 References

• BNF Online
• NICE CKS
• Cancer Research UK

🧾 Clinical Case Examples – Hodgkin Lymphoma

Case 1 – Young Adult with Neck Lump 👩‍🎓 A 23-year-old woman presents with a painless swelling in her left neck for 3 months. She has drenching night sweats and 5 kg weight loss. On CXR, there is a widened mediastinum. 👉 Likely diagnosis: Classical Hodgkin lymphoma (nodular sclerosis subtype). 👉 Key points: Young adult, mediastinal mass, “B symptoms.”

Case 2 – Alcohol-Induced Node Pain 🍷 A 30-year-old man reports pain in a long-standing cervical lymph node after drinking alcohol. He also has pruritus but no fever or weight loss. 👉 Likely diagnosis: Hodgkin lymphoma. 👉 Key points: Alcohol-induced pain is rare but highly exam-specific for HL.

Case 3 – Older Adult with B Symptoms 👴 A 62-year-old man presents with fatigue, intermittent fevers, and weight loss. Exam reveals firm, rubbery, non-tender axillary and cervical lymphadenopathy. Biopsy shows Reed–Sternberg cells (CD15+, CD30+). 👉 Likely diagnosis: Classical Hodgkin lymphoma. 👉 Key points: HL has a bimodal age distribution (15–35, >55 years).

Case 4 – Generalised Itch & Chest Mass 🫁 A 28-year-old woman presents with persistent pruritus and cough. CXR shows a bulky mediastinal mass. 👉 Likely diagnosis: Hodgkin lymphoma, mediastinal disease. 👉 Key points: Pruritus can be a paraneoplastic symptom of HL; mediastinal involvement is common.

Case 5 – Relapsed Hodgkin Lymphoma 🔄 A 35-year-old man treated for Hodgkin lymphoma at age 20 re-presents with enlarging supraclavicular lymph nodes. PET-CT confirms stage II relapse. 👉 Likely diagnosis: Relapsed Hodgkin lymphoma. 👉 Key points: Relapse occurs in ~10–15% of patients; consider autologous stem cell transplant if fit.