Updated: 8/13/2017

Hodgkin Lymphoma

Topic
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Questions
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Evidence
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Snapshot
  • A 15-year-old boy presents with fatigue and masses around his neck. The masses are small, mobile, and do not hurt. A few months ago, he had had an episode of infectious mononucleosis. He is referred for a lymph node biopsy, which comes back with positive Reed-Sternberg cells.
Introduction
  • B-cell malignancy originating in lymphatic system
  • Pathogenesis 
    • 50% of cases associated with EBV infection
    • Reed-Sternberg cells 
      • CD15+ and CD30+
  • Epidemiology
    • bimodal distribution
      • young adulthood
      • > 55 years
    • male > female
  • Types of Hodgkin lymphoma
    • nodular sclerosing
      • most common
    • mixed cellularity
    • lymphocyte-rich & predominant
      • especially in < 35-year-olds but also in older adults
    • lymphocyte-depleted
      • especially in > 60-year-olds
      • other systemic diseases
  • Risk factors
    • infectious mononucleosis with EBV
Presentation
  • Symptoms 
    • constitutional ("B") symptoms
      • fever
      • night sweats
      • weight loss
      • all caused by cytokines released from Reed-Sternberg cells
    • persistent painless lymphadenopathy
  • Physical exam
    • nontender mass of localized, single group of nodes
      • rubbery
      • mobile
      • cervical
      • supraclavicular
      • axillary
Evaluation
  • Imaging for staging
  • Lymph node biopsy
    • Reed-Sternberg cells
      • binucleate or bilobed, “owl-eyed” nuclei
    • mixed cellularity type
      • large inflammatory infiltrate with many eosinophils
    • nodular sclerosing type
      • diffuse band-like fibrosis with lacunar spaces
Differential Diagnosis
  • Non-Hodgkin lymphoma
  • AIDS-related lymphadenopathy
  • Infection
  • Breast cancer
  • Cat-scratch fever
Treatment
  • Based on staging
  • Chemotherapy
  • Radiation
Prognosis, Prevention, and Complications
  • Prognosis
    • > 80% with treatment
      • better than non-Hodgkin lymphoma
      • lymphocyte-predominant = best prognosis
      • lymphocyte-deplete = worst prognosis
      • higher lymphocyte:RS cell ratio = better prognosis
  • Complications
    • SVC syndrome
    • paraneoplastic syndromes
      • calctriol secretion causes hypercalcemia
    • from treatment
      • risk of solid tumors (breast, thyroid, and lung)
      • risk of premature coronary artery disease
      • risk of infection
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.ON.4753) A 52-year-old female presents to her primary care physician complaining of fever, chills, and night sweats. She says that these symptoms have been present for several months but appear to be getting worse. Her past medical history is significant for mild hypertension and pre-diabetes. She has otherwise been healthy and does not currently take any medications. Physical examination reveals supraclavicular lymphadenopathy. A lymph node biopsy is performed and the result is shown in Figure A. Which of the following cell surface markers is most likely found on the prominent abnormal cell seen in the figure? Review Topic

QID: 108772
FIGURES:
1

CD3

8%

(8/106)

2

CD4

13%

(14/106)

3

CD8

17%

(18/106)

4

CD16

17%

(18/106)

5

CD30

43%

(46/106)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M1.ON.6) A 28-year-old male presents to his primary care physician complaining of fever, chills, night sweats, and a "lump" in the middle portion of his neck. A biopsy of the cervical protuberance is taken and shown in Figure A. The large cell shown in the center of Figure A is likely of which of the following origins? Review Topic

QID: 101316
FIGURES:
1

B-cell

69%

(50/72)

2

T-cell

8%

(6/72)

3

Basophil

3%

(2/72)

4

Metamyelocyte

4%

(3/72)

5

Monocyte

14%

(10/72)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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