Hodgkin Lymphoma

• Hodgkin lymphoma is a haematological malignancy arising from lymphoid tissue

  Occurs when B lymphocytes derived from the germinal centres of the lymphoid tissues mutate
• Hodgkin lymphoma is characterised by the presence of Hodgkin and Reed-Sternberg cells

  • Reed-Sternberg cells are large, multinucleated malignant cells
  • Hodgkin cell = mononuclear variant of Reed-Sternberg cells
• HL can be subdivided into classical and nodular

  • Nodular sclerosis is the most common classical subtype - mediastinal mass is common
• Risk factors:

  ·       Epstein-Barr virus

  ·       HIV

  ·       Immunosuppression and autoimmune conditions

  ·       Previous history of non-hodgkin lymphoma

  ·       First degree relative family history of HL, NHL or CLL

  ·       Smoking
• Peak incidence is in young adults aged 20-34 and older adults aged over 70
• Most common symptom of HL:

  • Painless, rubbery, enlarged lymph node/nodes
  • Typically in the cervical or supraclavicular region
  • Tends to have a sequential spread
• Other typical symptoms of HL:

  • B symptoms - fever, drenching night sweats and unintentional weight loss
  • Chest discomfort +/- cough or dyspnoea - mediastinal mass is present in 80% of patients
  • Abdominal discomfort or pain - if abdominal lymphatic organs such as the liver or spleen have been effected
  • Alcohol induced pain at nodal sites
  • Pruritis
  • Malaise
  • Fatigue
• Clinical findings on exam:

  • Lymphadenopathy - typically in the cervical/supraclavicular region
  • hepatomegaly
  • Splenomegaly
  • SVC syndrome
  • Paraneoplastic syndromes - neuropathy or Guillain-Barre syndrome
• Consider a suspected cancer pathway referral (appointment within 2 weeks) for Hodgkin's lymphoma in adults presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss, or alcohol-induced lymph node pain
• Laboratory investigation:

  • FBC - to rule out leukaemia, infectious mononucleosis and other causes of lymphadenopathy
  • U&Es
  • LFTs - reduced albumin levels associated with a poorer prognosis
  • LDH - increased cell turn over
  • ESR
  • Rule out differentials - sputum for TB, HIV, hepatitis B and C
• Lymph node excision biopsy is required for diagnosis

  Light microscopy- hallmark cell is the Reed-Sternberg cell , surrounded by giant malignant mononucleated cells (Hodgkin cells)
• Imaging:

  • Chest x-ray: intrathoracic lymphadenopathy and mediastinal expansion
  • PET-CT: gold standard for staging
• If blood transfusion is required- must only receive irradiated blood products- life long requirement
• The 2 main types of Hodgkin lymphoma are classical (majority of cases) and nodular lymphocyte-predominant hodgkin lymphoma. Classical is further subclassified into four types:

  • Nodular sclerosis (most cases) - mediastinal mass is common
• Hodgkin lymphoma causes immunosuppression. The clonal expansion of B lymphocytes are abnormal and do not function properly. Patients are at a particularly higher risk of infection if there is bone marrow involvement.