Hodgkin's Lymphoma

Bharat R Agarwal
Staging of Hodgkin's Disease
Hodgkin's disease is staged by the Ann Arbor staging system. It is divided into 4 stages and sub classified into A & B categories with a special subcategory E.

A: Patients are asymptomatic
B: Patients with following symptoms:
- Unexplained loss of weight > 10% in last 6 months
- Unexplained fever with temperature > 38 degree Celsius for more than 3 days
- Drenching night sweats
E: Minimal extralymphatic disease from direct extension. It denotes limited involvement of a single extranodal site

Stage I: Involvement of a single lymph node region (I) or single extralymphatic site (IE).
Stage II: Involvement of 2 or more lymph node regions on same side of diaphragm (II) or extension from these lymph nodes to extralymphatic adjacent organ (IIE).
Stage III: Involvement of lymph nodes on both sides of diaphragm (III); with extension to an adjacent extralymphatic organ (IIIE) or involvement of the spleen (IIIS+) or both (IIIE+S).
Stage IV: Disseminated disease with or without associated lymph node disease. (Occurs due to spread through the blood stream as opposed by lymphatics).

Hodgkin's disease is histologically classified as:
- Lymphocytic predominance
- Nodular sclerosis
- Mixed cellularity
- Lymphocyte depletion
- Unclassified
Patients with lymphocyte predominance, generally have localized disease, are usually asymptomatic and can be cured with less intensive therapy as compared with other subtypes. They are also at a higher risk of secondary malignancy.

However, determining the histologic subtype is not as important as in Non - Hodgkin's lymphoma, as with effective multiagent chemotherapy, histologic subtype does not influence the outcome.

More than 90% of all children with newly diagnosed Hodgkin's disease are curable with modern therapy. Multiagent chemotherapy alone or with relatively low dose field radiation is used to treat children in all stages. Historically, radiation alone was used to cure stage I, II, III disease. However, with the potential for secondary malignancies (solid tumors, breast cancer), irradiated field growth retardation and benign and malignant changes in the thyroid, radiation therapy alone has been discarded. However, patients with massive mediastinal disease (> than 1/3rd the maximal thoracic diameter, or tumor involving the pericardium or chest wall), should be treated with chemotherapy and radiotherapy, even if they have stage I or II disease.

Adolescent patients who have achieved maximum growth and have localized childhood Hodgkin's disease (pathologically staged I and II) may be treated as adults with standard dose radiation alone.

The various chemotherapy protocols used are :
MOPP - mechlorethamine, vincristine, Prednisolone and procarbazine.
ABVD - Doxorubicin, Bleomycin, Vinblastine and Dacarbazine.
VEEP - Vincristine, Etoposide, Epirubicin and Prednisolone.

Stage I and II a - Treatment includes combination chemotherapy with or without low dose radiation to involved fields.
Stage II B - Treatment is controversial. Combined modality therapy is preferred.
Stage III A - Combined modality therapy.
Stage III B & IV - Chemotherapy + full dose involved field radiotherapy.

Hodgkin's Lymphoma Hodgkin's Lymphoma 01/04/2001
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