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hodgkin lymphoma

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by

Jenny Worth

on 29 January 2013

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Transcript of hodgkin lymphoma

Patient History Chemotherapy Case Review: Stage llX Hodgkin Lymphoma *Reed Sternberg cells*
Large
Multinucleated Histopathology Nodular Sclerosing Lymphocyte Predominant Lymphocyte Rich Mixed
Cellularity Lymphocyte Depleted young
females
B symptoms older
B symptoms young
males
good prognosis older
worst prognosis older
males What puts someone at risk? Age: 11-30, 70-80
High education, SES
Large family size
EBV
RS cells
Environmental carcinogens
Immunosuppression
HIV/AIDS
Siblings with HL (7x) Painless lymphadenopathy
B-symptoms


Pruritis (not common in children)
Pain
Alcohol-induced
Abdominal-splenomegaly
Bone-destruction/infiltration
Back-retroperitoneal node involvment
Neurogenic-spinal cord compression
Pressure Symptoms
Dysphagia
Dyspnea
Cough
SVCO syndrome How will it spread? 90% of patients have contiguous spread Meet "Jane"...
Jane is 12 years old and was diagnosed with nodular sclerosing Hodgkin Lymphoma, Stage llX. Let's find out more about Jane and what this means! How will it present? First...
Let's Review! Lymphoma is a cancer of the lymphocytes, WBCs that help us fight infection.
Hodgkin Lymphoma (HL) most often originates in the lymph nodes and spreads in a contiguous manner. Jennifer Worth & Alisha Jewell Supraclavicular Nodes
Mediastinal + Hilar Nodes Cervical Nodes Jane has lots of questions...
Let's take a look at her history and see if can answer them for her!
Lung Liver Spleen Or By Bloodstream To: Staging System Cotswold Modification to Ann Arbour Staging Stage Area of Involvment I II 5+7= (cc) image by anemoneprojectors on Flickr III IV Single lymph node group Multiple lymph node groups on same side of diaphragm Multiple lymph node groups on both sides of diaphragm Multiple extranodal sites or lymph nodes and extranodal disease X Bulk > 10 cm E Extranodal extension or single, isolated site of extranodal disease B B symptoms: weight loss > 10%, fever, drenching night sweats Younger age
Female
No B symtoms
Low ESR
Early stage
Lymphocyte predominant/Nodular Sclerorsing Histology
Localized nodal involvment
No bulky disease
Early response to chemotherapy Favorable Prognosis 2000 2010 2005 Jane is born
Second child of 4 2000 2009 Pedestrian MVA
Multiple skull fractures
ICU admission
Ventilation
Decompression craniotomy
Significant brain injury July Cranioplasty of rt cranium
Significant learning disabilities
Mood changes
Vision problems
Central diabetes insipidus April 2010 Lump noted in rt neck
Referred to family Dr.
No F/U until 2012 February 2011 Dr. discovers large mass in rt neck
largest = 4x3 cm
appears benign
attributed to cranioplasty January 2012 May FNA
insufficient sample
CXR
Possible mall pleural effusion June CT of chest-abdo-pelvis
Bulky disease in rt neck and supraclav
Small lesion in base of rt lung
Left sphenoid sinusitis
ECG
within normal limits
Lung Biopsy
Chronic inflammation
Reactive changes
Few cells +ve for EBV
Excisional biopsy
Hodgkin lymphoma
Nodular sclerosing
+ve for EBV
RT CW lesion-benign nevocellular nevus
Port-a-cath placement
Bilateral BMA, biopsy
-ve
Bone Scan
-ve
Gallium Scan
-ve June 22 Begins Tx
Based on Clinical Trial AHOD0031
Study closed August 13, 2012 http://upload.wikimedia.org/wikipedia/commons/thumb/c/cb/Lymph_node_regions.svg/220px-Lymph_node_regions.svg.png What testing is usually done? What is COG-AHOD0031? Before Jane consents to her treatment she wants to know the risks!
Let's take a closer look at Jane's treatment plan to determine what her short and long term risks will be... Radiation Therapy •M - Mechlorethamine (Nitrogen Mustard)
•O - Oncovin (Vincristine)
•P - Procarbazine
•P - Prednisone
Repeats every 21 days for 2 courses in the absence of progressive disease Initial chemotherapy (ABVE-PC) Studies have shown...
Alternating chemo regimens such as MOPP/ABVD, provides greater benefit and reduced toxities than if the drugs were used on their own
It is beneficial to start chemo immediately following diagnosis RER-Rapid Early Response In the past was common to treat large lymph node regions
Now, treat only involved sites at presentation or those that show uptake on PET post chemo
to decrease reoccurence where disease presents
Hemoglobin must be >10 gm/dL during RT SER-Slow Early Response 60% or more disease reduction less than 60% disease reduction 2 additional courses
ABVE-PC Randomized Complete Response (CR) Incomplete Response RT(T) Randomized Given 5 days a week RT(T)
No further tx Arm 1 Arm 2 Patients receive dexamethasone and additional chemo
Treatment repeats every 21 days for 2 courses in the absence of disease progression or unacceptable toxicity
After these 2 courses, patients then receive 2 additional courses of ABVE-PC chemotherapy.
Then undergo radiotherapy. Patients receive 2 additional courses of ABVE-PC chemotherapy.
Then undergo radiotherapy. Phase lll:
Chemotherapy With or Without Additional Chemotherapy and/or Radiation Therapy in Treating Children with Newly Diagnosed Hodgkin's Disease Patients are followed every 3 months for 2 years, every 6 months for 3 years, and then annually Follow-Up Why will Jane need to come back so often? Most relaspses occur within 2 to 5 years
Follow-up appts include:
Hx and Physical
CBC, ESR, CXR
CT scan every 3-6mos
TSH and thyroxine levels
Counseling and maintenance screening Her Dr predicts a 90% chance of cure! Jane has completed her chemo and has started RT... Thank you for listening, do you have any questions??? Hypothyroidism
Xerostomia
Dental caries
Secondary Cancers
AML
Epithelial
Sarcoma
Thyroid Early Effects of RT Skin Bone Marrow History & Physical
Lab Studies
CBC
Erythrocyte Sedimentation Rate
Elevated Serum Copper, Ferritin & Serum Lactate dehydrogenase
RFT
LFT
Serum alkaline phosphatase ( suggests bone/liver involvement)
Imaging
Chest X-ray
CT (chest, abdo, pelvis)
PET /PETCT
BMB (advanced cases, very rare)
MRI (rarely used)
Lymph Node Biopsy
Excisional lymph node biopsy (internal node structure)
CT guided needle biopsy Nausea & Vomiting
Fatigue
Erythema
Alopecia
Mild mucositis
Xerostomia
Dysgeusia
Thrombocytopenia
Leukopenia Early Stage Following Response to Chemotherapy


Advanced with Residual Disease Post Chemotherapy

Palliative Late Effects of RT Jane's Treatment Plan Effects of RT DOSE REGIMES Jane's complaints thus far... RER to chemo indicates possible benefit from aggressive adjuvant therapy
Still questionable to give 21Gy (to involved sites) to RERs who had CR (specifically if PET2-)
DECA (dexamethasone, etoposide, cytarabine) was successful in SERs and PET2+, however was unsuccessful with RERs
CT & PET each have advantages in demonstrating patient response to therapy
Further evaluation of AHOD0031 hopes to determine whether involved sites should be treated by RT or additional chemotherapy for RERs Study Conclusions thus far... Barrett, A., Dobbs, J., Morris, S., Roques, T. (2009). Chapter
23: Lymphomas: 4th edition. Hodder Arnold, London.

Casciato, D.A. and Territo, M.C. (2009). Manual of Clinical Oncology, (6th ed.). Lippincott Williams & Wilkins. Philadelphia, PA.3.CureSearch for Children’s Cancer.(2011).

CureSearch for Children’s Cancer. Retrieved from http://www.curesearch.org/

Friedman, D.I. et al., AHOD0031: A Phase III Study of Dose-Intensive Therapy for Intermediate Risk Hodgkin Lymphoma: A Report From the Children’s Oncology Group. Retrieved from https://ash.confex.com/ash/2010/webprogram/Paper33086.html

National Cancer Institute (2012). National Cancer Institute at the National Institutes of Health. Retrieved from http://cancer.gov/5.Goddard, K (Ed.). (2012).

Pediatric Oncology Education Materials. Retrieved from http://www.pedsoncologyeducation.com/index.asp Setup Prescription 2100cGy/14fx
AP/PA POP
10MV Skeletal system
Hypoplasia
Scoliosis
Atherosclerosis and fibrosis
Risk of stroke
CAD
Immunologic dysfunction
Herpes zoster
Sepsis Primarily older patients (median age: 65)
Risk factors: small dietary link
Not characterized by the RS cell
Random spread
Advanced presentation
Extranodal involvement
Histopathological subtypes: Follicular/DIffuse
RT Dose:3500-4000cGy
Gold Standard chemo: CHOP What are some differences between Hodgkin and Non-Hodgkin Lymphoma? MANTLE
Superior border: Tragus
Inferior border: T10 Jane's Chemotherapy 2 Cycles of MOPP/ABVD
Course 1:June 22
Course 2:July 14 Initial chemotherapy (ABVE-PC) RER-Rapid Early Response 88% disease reduction 2 additional courses RT(T) Given 5 days a week Course 3: Aug 3
Course 4: Sep 2
Delayed one week due to neutropenia Combo chemo & RT results in cure 80-90%
HL is very sensitive to chemotherapy •A- Adriamycin (Doxorubicin)
•B - Bleomycin
•V - Vincristine
•D -Dacarbazine Adriamycin -Cardiomyopathy
Bleomycin- Pulmonary fibrosis
Alkylating agent- Infertility, Secondary AML RISKS ABVD- 1970's Decreased risk secondary malignancy & infertility
Increased survival MOPP-1960's Doe, Jane 'A' Board SILVERMAN 'A' AT SIDES KB AP PA 96 91 INF STRAIGHTENING
10cm inf to iso MARKS ON CAST DO NOT AVERAGE DEPTHS
ISOMOVE DAY 1 Shielding
Mouth
Lung 20Gy/10fxns/2wks
21Gy/14Fxns/2.5wks 30Gy/15fxns/3wks + 6Gy/3fxns 8Gy/ 1 fxn
20Gy/5fxns/1wk30Gy/10fxns/2wk
30Gy/15fxns/3wks for extended fld INVERTED Y
Superior border: T10
Inferior border: L4 BORDERS TRADITIONAL RT Unexplained weight loss >10% over 6months
Unexplained fever >38C
Night Sweats OTHER CONSIDERATIONS Extensive team of doctors and support staff
Young age
Acquired brain injury
Emotional attachments
Requests female therapists
Religious beliefs Due to Jane's history and age there are a few more factors to consider... Xerostomia
Mild dyphagia
Fatigue References
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