Section 1-1

sizes of lymph nodes

• vary in size from 2-30mm in length

• size of a small kidney bean

spleen

• largest mass of lymphatic tissue

• manufactures B-lymphocytes for immunity

• has no afferent lymphatic vessels and does not filter lymph

• bone marrow and liver assume the spleen’s functions if removed

thymus

• located along the trachea superior to he heart and posterior to he sternum in the upper thorax

• site where T-lymphocytes mature

tonsils

• protect against foreign body infiltration by producing lymphocytes

• pharyngeal tonsils (adenoids) are located in the nasopharynx

• palatine tonsils are in the posterior lateral wall of the oropharynx

• lingual tonsils are at the base of the tongue in the oropharynx

lymphatic ducts

• thoracic duct

  • approximately 35 to 45 cm in length

  • begins at about L2 at the cisterna chyli

  • drains all but the upper right quadrant of the body

• right lymphatic duct

  • drains the upper right quadrant of the body

palpable lymph nodes

• axillary

• inguinal

• cervical

• popliteal or brachial (occasionally)

described seven cases in literature and distinguished these cases from leukemias and other lymphomas (person and year)

Thomas Hodgkin 1832

first controlled clinical trials radiation therapy for Hodgkin’s (person and year and location)

Henry Kaplan 1962 Stanford

symposium on staging Hodgkin’s (location and year)

Ann Arbor, Michigan 1971

epidemiology of Hodgkin’s (cases/deaths per year, incidence rate, peak incidence, median age, males vs females, countries)

• 8200 cases per year resulting in 1350 deaths

• incidence is slowly increasing but unknown why

• peak incidence: 11-30 years old

• second peak in 70’s and 80’s

• median age: 26

• males have slight predominance and poorer prognosis

• more common in developed countries

etiology of Hodgkin’s

• infection

• environmental

• immunodeficiency - defective T-cell functioning is a risk factor

• heredity - increased incidence in siblings of patients with Hodgkin’s

• virus - Epstein-Barr Virus (EBV)

presentation and symptoms of Hodgkin’s

• large painless mass in neck or supraclavicular region

• enlarged lymph node supradiaphragmatic 90% of the time and civical region 60-80% of the time

• adenopathy may produce local pain, lymphatic or venous obstruction, or airway narrowing

• typically several weeks or months elapse between onset of signs/symptoms and diagnostic biopsy

detection/diagnosis for Hodgkin’s

• patient history for B symptoms

• physical exam

• chest x-ray

• lymph node biopsy

• CT or MRI

• bipedal lymphangiogram (LAG)

• PET scan for imaging thoracic and abdominal nodes

• bone marrow biopsy for higher risk patients with > stage II

staging laparotomy (exploratory abdominal surgery) was standard practice before advent of the CT scans

differences in pathology between lymphoma and Hodgkin’s

• Reed-Sternberg cell - giant connective tissue cell containing one or two large nuclei

• contiguous spread - “predictable” spread from one lymph node group to another

types of Hodgkin’s disease

• lymphocyte predominant AKA lymphocyte rich HD

• nodular sclerosing (NSHL)

• lymphocyte depleted

• mixed

lymphocyte predominant Hodgkin’s (AKA, origin, stages, prognosis)

• AKA lymphocyte rich HD

• B-cell origin

• usually clinically localized disease - stage 1 or 2 and asymptomatic

• excellent prognosis

nodular sclerosing Hodgkin’s (NSHL) (stages, appearance, epidemiology, prognosis)

• most common - 60 to 80%

• generally localized - stage 1 or 2

• usually first appears in the lower cervical or supraclavicular region

• typically occurs in the teenage years

• good prognosis with high survival rate

lymphocyte depleted Hodgkin’s (epidemiology, prognosis)

• tends to occur in patients who are older or have immune disorders (ex. HIV)

• least common

• worst prognosis

mixed cellularity Hodgkin’s (description, epidemiology)

• mix of other cell types

• 2nd most common cell type

major lymph group pathways of Hodgkin’s

• Waldeyer’s ring and cervical, preauricular, and occipital nodes

• supraclavicular and infraclavicular

• axillary

• thorax (including hilar and mediastinal nodes)

• abdominal cavity (including paraaortic nodes

• pelvic cavity (including iliac nodes)

• inguinal and femoral nodes

Waldeyer’s ring

tonsilar lymphatic tissue surrounding the nasopharynx and oropharynx

Ann Arbor staging for Hodgkin’s

• stage I - involvement of a single node or site

• stage II - involvement of 2 or more lymph nodes on same side of diaphragm

• stage III - involvement of lymph nodes on both sides of the diaphragm

• stage IV - diffuse involvement of one or more organs

• H+ = liver (hepato)

• L+ = lung

• M+ = bone marrow

• P+ = pleura

• O+ = bone (osseous)

• D+ = skin (dermis)

A vs B symptoms

• A = asymptomatic

• B = unfavorable prognosis

  • unexplained weight loss of more than 10% of body weight in last 6 months

  • unexplained fever w/ temps above 38C (100.5F) for 3 or more consecutive days

  • night sweats (sometimes w/ pruritus)

metastases tendency of Hodgkins

lungs and bones

treatment principles for Hodgkin’s

• surgery only used for biopsy to grade and stage disease or debulk large tumors

• stage I and II: definitive RTT with chemo

• stage III and IV: definitive chemo with RTT

radiation technique for Hodgkin’s (types, position)

• APPA mantle field

• Akimbo position

• Waldeyer’s ring if involved

• subdiaphragmatic fields: para-aortic and inguinal nodes (inverted Y)

• total nodal irradiation (TNI): mantle + inverted Y

• mini-mantle: limited to cervical, supraclav, and/or axillary regions

• subtotal lymphoid irradiation: mantle + para-aortics

lymph regions treated with mantle field

• all major regions above the diaphragm

  • submandibular

  • occipital

  • cervical

  • supraclavicular

  • infraclavicular

  • axxillary

  • hilar

  • mediastinal

borders, field size, blocking, and dose for mantle field

• superior border: line from mental point to mastoid tip

• inferior border: xiphoid tip/diaphragm (T10)

• lateral borders: include axilla

• may require extended SSD for field sizes larger than 40×40

• blocking

  • throat

  • humeral heads

  • lungs

  • spine (safety block)

  • sometimes, heart

• dose: 35-44 Gy, 150-200 cGy/day

Waldeyer’s ring technique (border, fields, energy, dose)

• abutts with superior border or mantle field

• parallel-opposed portals (POP) or single lateral field

• 6-9 MeV electrons

• dose: 36 Gy

subdiaphragmatic fields for Hodgkin’s (stages, fields, border)

• used for late stages 3 or 4 or early stages w/ B symptoms

• most commonly involve para-aortic and inguinal nodes via inverted Y field

• field includes the spleen if intact or splenic pedicle if splenectomy

• single or two fields

• superior border of inverted Y abuts to the inferior border of mantle field

name of method used for irregular field calculations

Clarkson’s method

acute vs late symptoms of Hodgkin’s radiation treatment

• acute

  • fatigue

  • occipital hair loss

  • skin erythema

  • sore throat/esophagitis

  • altered taste

  • transient dysphagia from esophagitis

  • dry cough

  • nausea

  • occasional vomiting

• late

  • mild radiation pneumonitis

  • hypothyroidism (1/3 of patients)

  • herpes zoster

  • transient xerostomia

  • increased dental caries

  • radiation arteritis (fewer than 5%)

  • Lhermitt’es syndrome (numbness, tingling, electric shock like sensations)

• patients are also at higher risk for lung, breast, and GI cancers after mantle

  treatment

• patients with secondary breast cancer tend to develop more aggressive breast cancers

• treatment related malignancies and cardiac complications are the main causes of death in long-term survivors

chemotherapy for Hodgkin’s (types, children)

• MOPP (less commonly used now)

  • Nitrogen Mustard

  • Oncovin (Vincristine)

  • Prednisone

  • Procarbazine

• ABVD - new standard treatment with less complications and side effects such as secondary malignancies like leukemia and sterility

  • Adriamycin

  • Bleomycin

  • Vincristine (Oncovin)

  • Dacarbazine

• treatment of choice for children to spare bone growth

prognosis for Hodgkin’s

• 80% overall 5 year survival

• 40-50% cure rate for widespread metastatic disease

• stage and age of patient are biggest factors

  • older patients have poorer prognosis than younger patients

  • presence of B symptoms = worse prognosis