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  • • A malignant neoplasm that originates in lymphoid tissue

    • Characterized histologically by the presence of Reed-Sternberg cells

    • Develops in lymph nodes and spreads in an orderly fashion to contiguous lymph node beds

    • Several histologic subtypes exist based on lymphocyte infiltration:

    • -Nodular sclerosis: 70%

      -Mixed cellularity: 20%

      -Lymphocyte predominance: 6%

      -Lymphocyte depletion: 2%

    • Most important prognostic factor is the disease stage

    • -Ann Arbor staging system most accepted classification

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Epidemiology

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  • • Bimodal age distribution with first peak occurring in the 20s and the second peak over age 50

    • Incidence appears to be higher among patients who meet the following criteria:

    • -Fewer siblings

      -Early birth order

      -Siblings with Hodgkin disease

      -Fewer playmates

      -Certain HLA antigens

      -Single-family dwellings

      -Post tonsillectomy

      -Immunodeficiency

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Symptoms and Signs

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  • • Nontender enlargement of lymph nodes

    • Constitutional symptoms that lead to a "B" designation include:

    • -Fever

      -Drenching night sweats

      -Weight loss

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Laboratory Findings

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  • • No distinctive basic laboratory findings present, although lymphomas tend to be associated with an elevated lactate dehydrogenase level

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Imaging Findings

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  • • Imaging findings are specific to the location and stage

    Chest film: May demonstrate mediastinal adenopathy

    • CT scan is the main staging tool used to demonstrate contiguous areas of adenopathy

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  • • Hodgkin lymphoma

    • Non-Hodgkin lymphoma

    • Reactive lymphadenopathy

    • -Infectious mononucleosis

      -Cat-scratch disease

      -HIV

      -Drug reactions (eg, phenytoin)

    • Tumor metastases

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Rule Out

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  • • Reactive lymphadenopathy

    • Metastatic disease to the lymph nodes

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  • • Detailed history; ask about risk factors and presence of constitutional B-symptoms

    • Thorough physical exam assessing all lymph node beds

    • Routine laboratory testing

    • Excisional biopsy of enlarged lymph node

    • Bone marrow biopsy

    • CT scans of the neck, chest, abdomen, and pelvis

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When to Admit

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  • • Most patients with lymphadenopathy suspicious for lymphoma are evaluated urgently as an outpatient or admitted to expedite the process

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When to Refer

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  • • Following histologic diagnosis, patients are referred to medical and radiation oncologists for definitive treatment

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  • • Treatment of Hodgkin disease involves radiation for localized disease and a combination of radiation and chemotherapy for more advanced disease

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Surgery

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  • • Excisional lymph node biopsy to establish diagnosis

    • Rarely, a staging laparotomy is necessary if the anatomic extent of disease in the abdomen is important in guiding therapy

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Medications

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  • • The 2 common chemotherapy regimens include:

    • -MOPP (mechlorethamine, oncovorin, procarbazine, and prednisone)

      -ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine)

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Treatment Monitoring

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  • • Physical exam to evaluate for lymphadenopathy

    • Radiographic evaluation as clinically indicated (eg, with the re-development of constitutional "B" symptoms)

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Complications

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  • • Localized radiation-induced complications

    • Chemotherapy-induced pancytopenia with ...

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