Transcription
After talking about Hodgkin's disease in the previous video, I think it's time to talk about how to diagnose and treat Hodgkin's disease. So let's get started.
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Alrighty, so as you know, it's logical malignancies: leukemias, lymphomas, and myeloma. Lymphomas are either Hodgkin's or non-Hodgkin's. In the previous video, we have discussed Hodgkin's lymphoma. Again, male more than female, Caucasian, bimodal age distribution. Patients are usually younger than that of non-Hodgkin's lymphoma, etc. We classified Hodgkin's lymphoma in the previous video. So if you'd like to know more, please watch my previous video.
The clinical picture of Hodgkin's disease: lymphadenopathy, which is painless, splenomegaly, fever, and itching, nephrotic syndrome, obstructive jaundice, erythema nodosum, cerebellar degeneration, autoimmune hemolytic anemia, and pain in lymph nodes on alcohol consumption. By the way, this is a very specific sign. It's rare, it's not sensitive, but it's very specific. If you have it, it's a very specific thing and a very specific clue that you have Hodgkin's disease.
By the way, many people ask me, what books are you using? What's your reference? So here are my references. I use these books. I think they are amazing, and you will see links to them in the description.
Now, how to diagnose Hodgkin's disease? You need a complete blood count. It will show neutrophilia and eosinophilia, especially with mixed cellularity subtype of Hodgkin's disease. If you have anemia, it will be normocytic, normochromic, or lymphopenia. You'll have a poor prognosis if you have high LDH in the blood. Poor prognosis. On the chest x-ray, you can find a mediastinal mass, which is that lymphadenopathy. CT scan is used for staging. We do CT scan for the neck, chest, abdomen, and pelvis. Sometimes we see bulky parts of lymph nodes or bulky collections of lymph nodes, and this has poor prognosis.
When we take a biopsy, which is a fine needle aspiration, it's an excisional biopsy or an needle core biopsy, and put it under the microscope, we see the Reed-Sternberg cell in the lymph nodes. They are large malignant lymphoid cells of B-cell origin. The two nuclei containing a prominent, eosinophilic nucleolus has the characteristic owl eye appearance. I'll talk more about Reed-Sternberg cells in an upcoming video.
Staging of Hodgkin's: you did a physical exam and a CT scan. PET scan can help for initial staging and monitoring treatment. You give the treatment, you repeat the PET scan. Give treatment, repeat the PET scan. You should see the tumor shrinking by the signs of glucose consumption.
The Ann Arbor classification is famous in Hodgkin's lymphoma. So, stage one: single site, one lymph node, or one extra-lymphatic site, but has to be one. Stage two: two or more lymph nodes on the same side of the diaphragm. Stage three: lymph nodes on both sides of the diaphragm. Stage four: diffuse, one or more extra-lymphatic tissue. So, stage four has to have an extra-lymphatic involvement, such as liver involvement, bone marrow involvement, etc.
Then we have subtype A or subtype B. If you have no B symptoms, it's subtype A. If you have B symptoms, such as fever, drenching sweats, and weight loss, which has to be intentional and greater than 10% of the total body weight. So, for instance, if stage 3 has B-cell symptoms, we call it stage 3B.
I have good news for you. Patients with Hodgkin's are cured more than 90% of the time, which is great.
So, treatment of Hodgkin's involve radiation and chemo, depending on the stage. So, stage 1 or 2, which means localized disease, you can use radiation, but also you can use some chemo. The chemo we use is called the ABVD regimen: Adriamycin, Bleomycin, Vinblastine, Dacarbazine. Stage 3 or 4, which is advanced, more diffuse, less localized, you need six to eight cycles of ABVD plus radiation.
Relapsed or refractory cases: autologous hematopoietic stem cell transplant. Relapse disease after chemo or transplant, you can try Brentuximab vedotin, which is a monoclonal antibody against CD30. And as you know, the Reed-Sternberg cell can be CD15 positive and CD30 positive.
What are the unfavorable prognostic factors? If you see one of these, you have a worse prognosis. The more you have, the worse the prognosis. Age greater than 45, male gender, stage 4 disease, albumin less than 40, hemoglobin less than 10.5, white blood cells less than or more than 15,000, lymphocytes less than 600. Each item has one score. So you add them. Let's say you have a patient who is older than 45, he is a male, so this is two, and stage 4 disease. Now you have a score of three. The higher the score, the lower the chance of survival, i.e., the worse the prognosis. This is called the Hasenclever index.
You should absolutely check the renal function before giving chemo. Why? Because, as you know, chemo can destroy the kidney. Also, Hodgkin's disease can cause nephrotic syndrome. Radiation used to treat Hodgkin's unfortunately can lead to some complications, include non-Hodgkin's lymphoma, thyroid problems. This is very high yield, very crucial. Hypothyroidism. You should order thyroid panel if you suspect anything. Solid tumors in the chest, such as lung cancer, especially in smokers. Breast cancer. So you should start mammography 8 to 10 years after initiating treatment for Hodgkin's disease, or starting at the age of 40, whichever is earlier. Cardiovascular complications can occur, such as early coronary disease.
Side effects of chemo: we use Bleomycin can lead to pulmonary fibrosis, which will lead to cough and shortness of breath. Adriamycin will lead to cardiotoxicity, specifically cardiomyopathy. ABVD chemotherapy regimen is less likely to cause infertility. I'm not saying it's impossible, but it's less likely.
Again, imagine that the genie appeared to you and told you, you have been cursed with lymphoma. I'll give you the lymphoma and the appropriate treatment. Which one will you choose? Of course, you should choose the nodular sclerosing subtype of Hodgkin's. It has an excellent prognosis and a great response to treatment.
Alright, I'll leave you with that. I'm posting lots of stuff, lots of questions, almost daily on my Facebook page. Just go to facebook.com/medicosis. Thank you so much for watching. Until next time, be safe, stay happy, and study hard.