Clinical features and diagnosis of Hodgkin's disease

A picture is worth a thousand words: a history of diagnostic imaging for lymphoma

The journey from early drawings of Thomas Hodgkin's patients to deep learning with radiomics in lymphoma has taken nearly 200 years, and in many ways, it parallels the journey of medicine. By tracing the history of imaging in clinical lymphoma practice, we can better understand the motivations for current imaging practices. The earliest imaging modalities of the 2D era each had varied, site-dependent sensitivity, and the improved accuracy of imaging studies allowed new diagnostic and therapeutic techniques. First, we review the initial imaging technologies that were applied to understand lymphoma spread and achieve practical guidance for the earliest lymphoma treatments. Next, in the 3D era, we describe how anatomical imaging advances replaced and complemented conventional modalities. Afterward, we discuss how the PET era scans were used to understand response of tumors to treatment and risk stratification. Finally, we discuss the emergence of radiomics as a promising area of research in personalized medicine. We are now able to identify involved lymph nodes and body sites both before and after treatment to offer patients improved treatment outcomes. As imaging methods continue to improve sensitivity, we will be able to use personalized medicine approaches to give targeted and highly focused therapies at even earlier time points, and ideally, we can obtain long-term disease control and cures for lymphomas.

Evolution of Hodgkin's disease

Hodgkin's disease is an oncogenic core disorder characterized by both mitotic and amitotic neoplastic multiplication, and is associated with collateral disorders such as lacunar formation and leukocytic infiltration. Research has demonstrated that Hodgkin's disease progresses stepwise, beginning with a reversible, biological stage during which Hodgkin and Reed-Sternberg cells are formed, followed by constitutive, but reversible Hodgkinogenic medical stage that leads to an irreversible, systemic and fatal proto-oncogenic stage. This disease results from collateral activation of cytokine and archaic oncogenes, suppression of DNA repair genes in multiple chromosomes. The variability of Hodgkin's disease manifestations has required antisynthetic (antimetabolites, radiotherapy), anti-viral (acyclovir) and anti-mitotic (vincristine, vinblastine) for different loci minores of treatment. Continued molecular biological research of the ancestral and prokaryotic oncogenes is recommended.

Spectrum and frequency of autoimmune derangements in lymphoproliferative disorders: analysis of 637 cases and comparison with myeloproliferative diseases

The records of 637 patients with lymphoproliferative disorders and 346 patients with myeloproliferative disorders were retrospectively analysed for the presence of additional autoimmune derangements. The frequency of autoimmune perturbations in lymphoproliferative diseases (51 cases; 8.0%) was significantly higher than in myeloproliferative diseases (six cases; 1.7%; P less than 0.0001). Rheumatic disorders, autoallergic haematological manifestations and other organ-specific autoimmune derangements were responsible for about one third each of the observed disturbances. Autoimmune diseases which preceded the onset of malignancy, occurred in lymphoproliferative and myeloproliferative disorders with a comparable frequency without significant differences between individual subgroups of lymphoproliferative diseases. In contrast, autoimmune complications developing in the course of the neoplastic disease were significantly more frequent in lymphoproliferative (4.9%) than in myeloproliferative disorders (0.3%; P less than 0.0005). Here marked differences were observed between individual lymphoma entities, the rate of concomitant autoimmune derangements ranging from zero to over 15%. With the exception of centroblastic-centrocytic lymphoma which in no case was associated with secondary autoimmune complications, the proportion of patients with autoimmune perturbations increased with improving prognosis of the lymphoproliferative diseases. Possible pathogenetic mechanisms involved in the manifestation of autoimmune complications in malignant lymphomas are discussed.

Hodgkin's disease of the nasopharynx

Malignant lymphoma of the Hodgkin's disease type involving the nasopharynx has been considered a rare entity. However, recent publications suggest that such involvement may not be uncommon. The authors describe their experience with two patients with histologically proven involvement of the nasopharynx by Hodgkin's disease. The diagnosis is difficult to establish. Histologic confirmation may require persistence and necessitates close cooperation with the pathologist. The prognostic significance of Hodgkin's disease involvement of the nasopharynx remains unknown. The otolaryngologist should be aware of these issues and be available to assist in the evaluation of the patient with lymphoma.

Endolymphatic radiotherapy in malignant lymphomas. A clinical evaluation of 285 patients

The authors report treatment of inguinal and retroperitoneal lymph nodes of 285 malignant lymphomas (143 Hodgkin's disease and 142 lymphoreticular sarcomas) with Lipiodol Fluide 131I (endolymphatic radiotherapy). From 1961 to 1966 the radioactive contrast material was injected in doses ranging from 0.2 to 2.5 mc/cc (10 cc each foot). Adequately opacified nodes responded promptly with marked and progressive reduction in size. When indicated, a second administration of Lipiodol 131I in a dose of 2.5 mc/cc was always feasible. Several factors prevented a homogeneous and satisfactory distribution of radioactive contrast material throughout the iliac and the para-aortic nodes in one third of the cases. Therefore, in many instances patients had to be treated with external radiation therapy. Histopathologic examination of lymph nodes removed at exploratory laparotomy (four cases) or at autopsy (ten cases) confirmed that Lipiodol 131I did not fill all the iliac and para-aortic nodes and that destruction of lymphomatous tissue was often incomplete. Recurrences were seen mostly in abnormal adequately filled nodes opacified with high doses of Lipiodol 131I. In Hodgkin's disease they occurred particularly in the para-aortic area and in lymphoreticular sarcomas in the inguinal and iliac chains. Side effects were minimal. They included amenorrhea, pulmonary insufficiency, hepatic failure and hemolytic anemia. Clinical and histologic signs of pulmonary and hepatic fibrosis were not seen. The authors conclude that endolymphatic radiotherapy should not be considered as a radical treatment for retroperitoneal adenopathies in malignant lymphomas and that its role as a prophylactic therapeutic tool deserves more extensive long-term studies.