Radiation Oncology/Hodgkin/Review

Review of Hodgkin's Lymphoma

Epidemiology

 * US incidence: ~8000
 * US deaths: ~1300
 * Age: bimodal, peak in 20's and 50's
 * Risk factors: likely genetic predisposition (increased incidence in Jews, siblings, HLA antigens)
 * Two separate entities
 * Classical Hodgkin's Lymphoma (CHL) - Reed-Sternberg cells
 * Lymphocyte-predominant Hodgkin's Lymphoma (LPHL) - "popcorn" lymphocyte cells

Clinical Presentation & Workup

 * Clinical presentation: lymph node mass(es)
 * Diagnosis
 * Excisional lymph node biopsy
 * Core needle biopsy may be adequate
 * FNA is insufficient
 * Pathology
 * CHL: Reed-Sternberg cells sufficient, CD15+ and CD30+
 * LPHL: CD20+ and CD45+, epithelial membrane antigen
 * Workup
 * Determination of B symptoms: fever >38C, drenching sweats, weight loss >10% weight
 * Exam: lymphoid regions, liver, spleen
 * Labs: CBC, differential, ESR, LDH, albumin, LFT, Bun/Cr
 * Bone marrow biopsy: Stage IB/IIB, III-IV
 * Imaging: CT neck/chest/abdomen/pelvis or PET/CT
 * PET: higher sensitivity for nodal regions (92% vs 83%) and organ involvement (86% vs 37%), though more false positives
 * Staging (Ann Arbor system; EORTC unfavorable criteria):
 * Early stage favorable (I-II, no unfavorable features)
 * Early stage unfavorable bulky (I-II, bulky mediastinum ratio >0.33 or size >= 10cm)
 * Early stage unfavorable non-bulky (I-II, B symptoms, or >3 sites of disease, or ESR >50)
 * Advanced (III-IV)
 * Advanced unfavorable (age >=45, male, stage IV, albumin <4, WBC >15k, WBC <600
 * Response criteria
 * Need for additional treatment based on response
 * 2007 IWG Guidelines using IHC, flow cytometry, PET: CR, PR, SD, relapsed, PD