Historical review of Hodgkin's disease

Eponyms in Malignant Hematology

Eponyms have been traditionally used in the field of medicine to honor the contributions of an individual or group of individuals in understanding a disease. However, many eponyms have come under scrutiny given the personal backgrounds of individuals for whom they intend to honor. As we previously reviewed commonly used eponyms in medical oncology, we now aim to review commonly used eponyms in malignant hematology in order to highlight the individuals for whom they are named after. In this review, we discuss the pathophysiology of each disease, epidemiology, and the historical background for the individual or individuals for which the eponym honors.

Sudden death in an adolescent due to undiagnosed classic Hodgkin lymphoma

Few cases of natural sudden death presenting as an undiagnosed lymphoma have been reported in the literature, especially in adolescents. Herein we provide a report of sudden death caused by undiagnosed classic Hodgkin lymphoma (cHL). We describe an 18-year-old female who collapsed after several weeks of weight loss, decreased appetite, and dyspnea. At autopsy, a bulky mass arising in the mediastinum and neck compressed the esophagus and trachea, surrounded the great vessels, obliterated the pericardial sac, and infiltrated the myocardium. The lungs were collapsed and large pleural effusions were present. The tumor burden, which weighed at least 2710 g in aggregate, was entirely above the diaphragm. Microscopic examination of the masses showed features typical for nodular sclerosis cHL including large bands of sclerosis, numerous Hodgkin/Reed-Sternberg (HRS) cells, and an eosinophil-rich mixed inflammatory cell infiltrate. Immunohistochemical stains showed the HRS cells to be uniformly positive for CD30 and CD15 and negative for CD3, CD20, CD45, and PAX5. This case exemplifies a rare sudden natural death due to previously undiagnosed cHL in a young patient.

Molecular Pathogenesis of Hodgkin Lymphoma: Past, Present, Future

Our understanding of the tumorigenesis of classical Hodgkin lymphoma (cHL) and the formation of Reed–Sternberg cells (RS-cells) has evolved drastically in the last decades. More recently, a better characterization of the signaling pathways and the cellular interactions at play have paved the way for new targeted therapy in the hopes of improving outcomes. However, important gaps in knowledge remain that may hold the key for significant changes of paradigm in this lymphoma. Here, we discuss the past, present, and future of cHL, and review in detail the more recent discoveries pertaining to genetic instability, anti-apoptotic signaling pathways, the tumoral microenvironment, and host-immune system evasion in cHL.

Tuberculous Adenitis with Concurrent Hodgkin Lymphoma: A Case Report

The concomitant occurrence of tuberculous adenitis and Hodgkin lymphoma is rare, posing a diagnostic dilemma since both have similar symptoms, such as lymphadenopathy, weight loss, fever, and night sweats. We reported such a case in a 15-year-old girl who presented with fever and neck swelling and was found to have lymphadenopathy. A biopsy of the right supraclavicular lymph node showed Reed-Sternberg cells and stained positive for acid-fast bacilli and tuberculosis culture. The patient was diagnosed with tuberculous adenitis with concurrent Hodgkin lymphoma in the same lymph node. She was started on anti-tubercular medications and chemotherapy and showed clinical improvement. This case highlights the need for suspicion in order to identify these two disorders in the same patient, since missing one of them is possible and may lead to fatal complications.

Contemporary treatment options for a classical disease: Advanced Hodgkin lymphoma

Advanced classical Hodgkin lymphoma (cHL) is a rare lymphoid disease characterized by the presence of Hodgkin and Reed-Sternberg (HRS) cells. Each year, cHL accounts for 0.5% of all new cancer diagnoses and about 80% are diagnosed with advanced stage disease. Given the significant improvement in cure rates, the focus of treatment has shifted towards minimization of acute and long-term toxicities. PET-adapted strategies have largely been adopted as standard of care in the United States in an attempt to balance toxicities with adequate lymphoma control. However, the appropriate upfront chemotherapy regimen (ABVD versus eBEACOPP) remains controversial.

Response-Adapted Treatment Strategies in Hodgkin Lymphoma Using PET Imaging

Hodgkin lymphoma, a B-cell malignancy, is most common in patients younger than 55 years. Between 70% and 90% are cured with standard approaches. The high cure rate and long-term survival resulted in a need to minimize therapy toxicity. Response-adapted approaches have been developed to de-escalate therapy in those likely to be cured and intensifying therapy in those not responding to initial treatment. FDG-PET after chemotherapy is highly predictive of outcome. Thus, FDG-PET has been incorporated into response-adapted treatments. Use of FDG-PET to guide treatment in Hodgkin lymphoma has been recommended. We summarize literature and discuss challenges and future directions.

From bench to bedside: the past, present and future of therapy for systemic paediatric ALCL, ALK

Anaplastic large cell lymphoma (ALCL) is a T cell Non-Hodgkin Lymphoma that mainly presents in paediatric and young adult patients. The majority of cases express a chimeric fusion protein resulting in hyperactivation of anaplastic lymphoma kinase (ALK) as the consequence of a chromosomal translocation. Rarer cases lack expression of ALK fusion proteins and are categorised as ALCL, ALK-. An adapted regimen of an historic chemotherapy backbone is still used to this day, yielding overall survival (OS) of over 90% but with event-free survival (EFS) at an unacceptable 70%, improving little over the past 30 years. It is clear that continued adaption of current therapies will probably not improve these statistics and, for progress to be made, integration of biology with the design and implementation of future clinical trials is required. Indeed, advances in our understanding of the biology of ALCL are outstripping our ability to clinically translate them; laboratory-based research has highlighted a plethora of potential therapeutic targets but, with high survival rates combined with a scarcity of funding and patients to implement paediatric trials of novel agents, progress is slow. However, advances must be made to reduce the side-effects of intensive chemotherapy regimens whilst maintaining, if not improving, OS and EFS.

Thomas Hodgkin (1798-1866)

Thomas Hodgkin was a diligent, selfless and benevolent man whose name is instantly recognisable in the medical field due to his description of a type of the lymphoma that is named after him, 'Hodgkin's Lymphoma'. Based at Guy's Hospital, London, he created a vast catalogue of specimens in their Medical Museum and facilitated teaching at the establishment. He was dedicated to education, public health and social reform in the 19th century.

Primary Mediastinal Classical Hodgkin Lymphoma

Primary mediastinal Classical Hodgkin lymphoma (CHL) is rare. Nodular sclerosis CHL (NS-CHL) is the most common subtype involving the anterior mediastinum and/or mediastinal lymph nodes. Primary thymic CHL is exceedingly rare. The disease typically affects young women and is asymptomatic in 30% to 50% of patients. Common symptoms include fatigue, chest pain, dyspnea and cough, but vary depending on the location and size of the tumor. B-symptoms develop in 30% of cases. By imaging, primary mediastinal CHL presents as mediastinal widening/mediastinal mass that does not invade adjacent organs but may compress vital structures as bulky disease. Histopathology is the gold standard for diagnosis. Primary mediastinal NS-CHL consists of nodules of polymorphous inflammatory cells surrounded by broad fibrous bands extending from a thickened lymph node capsule. The cellular nodules contain variable numbers of large Hodgkin/Reed-Sternberg cells, required for diagnosis. Primary thymic CHL may exhibit prominent cystic changes. The histopathologic recognition of NS-CHL can be challenging in cases with prominent fibrosis, scant cellularity, artifactual cell distortion, or an exuberant granulomatous reaction. The differential diagnosis includes primary mediastinal non-HLs, mediastinal germ cell tumors, thymoma, and metastatic carcinoma or melanoma to the mediastinum. Distinction from primary mediastinal non-HLs is crucial for adequate therapeutic decisions. Approximately 95% of patients with primary mediastinal CHL will be alive and free of disease at 10 years after treatment with short courses of combined chemoradiotherapy. In this review, we discuss the history, classification, epidemiology, clinicoradiologic features, histopathology, immunohistochemistry, differential diagnosis, and treatment of primary mediastinal CHL.

Treatment of advanced-stage Hodgkin lymphoma

There is now good evidence that the escalated BEACOPP regimen (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procarbazine, prednisone) is more effective in controlling advanced-stage Hodgkin lymphoma (HL) than the widely used ABVD regimen (adriamycin, bleomycin, vinblastine, dacarbazine), but the extra efficacy comes at the expense of both short- and long-term toxicity, and there is debate as to whether overall survival is affected. Baseline prognostic factors have proven of limited utility for determining which patients require more intensive therapy and recent studies have sought to use interim fluoro-deoxyglucose positron emission tomography (FDG-PET) evaluation as a means to guide the modulation of treatment, both upwards and downwards in intensity. These suggest that if treatment starts with ABVD then patients remaining PET-positive after 2 months can be salvaged with escalated BEACOPP in around 65% of cases, but those becoming PET-negative may still experience recurrences in 15%-20%, an event that is more common in those with more advanced disease at presentation. There are early data to suggest that starting with escalated BEACOPP may reduce the rate of recurrence after a negative interim PET to less than 10%. This may be an attractive approach for those with very high-risk features at presentation, but risks overtreating many patients if applied nonselectively. New regimens incorporating antibody-drug conjugates may shift the balance of efficacy and toxicity once again, and further studies are underway to evaluate this.

Hodgkin's lymphoma--long-term outcome: an experience from a tertiary care cancer center in North India

Limited information is available from developing countries on long-term outcome of patients with Hodgkin's lymphoma (HL). Between January 1998 and December 2005, 262 patients (age ≥15 years) underwent treatment. Patients' median age was 30 years, ranging from 15 to 72 years. Male to female ratio was 2.8:1. B symptoms were present in 64% of patients. Seventy percent of patients had stage III and IV disease. Mixed cellularity (52.3%) was the most common histology followed by nodular sclerosis (38%). ABVD chemotherapy was used in 85% of the patients, and 50% received radiotherapy as consolidation. Following treatment 92% of patients achieved complete response. Five-year freedom from treatment failure (FFTF) and overall survival rate are 78.3% and 86.6% ± 0.02% (95% CI 80.0-93.2%), respectively. Stage at presentation, number of lymph node regions involved (≥3 vs ≤2), presence of B symptoms, and serum albumin (≥40 vs <40 g/L) were important determinants of FFTF. In a subset analysis of stage I and II HL patients, presence of bulky disease and pure infradiaphragmatic disease was associated with inferior outcome. On multivariate analysis involvement of three or more number of lymph node regions was a significant predictor of inferior freedom from treatment failure survival (hazard ratio 2.2, p < 0.01). Our analysis confirms excellent outcome for patients of Hodgkin's lymphoma with results comparable to developed countries.

Risk of radiation-related salivary gland carcinomas among survivors of Hodgkin lymphoma: a population-based analysis

BACKGROUND

Radiotherapy for Hodgkin lymphoma (HL) increases the risk of salivary gland carcinomas (SGC). To the authors' knowledge, however, the magnitude of the risk has not been assessed to date.

METHODS

The risks of SGC among 20,928 1-year survivors of HL who were diagnosed between 1973 and 2003 were evaluated in 11 population-based cancer registry areas of the Surveillance, Epidemiology, and End Results (SEER) program. Observed-to-expected ratios (O/E) were assessed by radiation treatment, sex, age at the time of HL diagnosis, calendar year of diagnosis, attained age, time since HL diagnosis, histologic type of SGC, and site of occurrence in the major salivary glands.

RESULTS

Among 11,047 HL patients who received radiotherapy as part of their initial treatment for HL, 21 developed subsequent invasive SGC (O/E = 16.9; 95% confidence interval [95% CI], 10.4-25.8). The risk of radiation-related SGC was highest for younger HL patients (age <20 years) (O/E = 45.5; 95% CI, 12.4-116.5) and among 10-year survivors (O/E = 23.9; 95% CI, 13.1-40.1), with risks remaining elevated for at least 2 decades after irradiation. Significant differences in risk by histologic type were observed, with a particularly high risk of developing mucoepidermoid carcinomas (O = 14; O/E = 44.2 [95% CI, 24.2-74.2]) and adenocarcinomas (O = 4; O/E = 30.6 [95% CI, 8.3-78.2]) noted.

CONCLUSIONS

HL patients treated with radiotherapy experienced a significantly increased risk of SGC, particularly when exposed at young ages or for at least 2 decades after exposure. Although the results of the current study reflect the late effects of former HL treatment approaches, they point to the importance of long-term follow-up and a heightened awareness of SGC risk in this population.

Clinical perspectives in lymphoma

The classification of both Hodgkin's and non-Hodgkin's lymphomas continues to evolve. The current World Health Organization classification incorporates data derived from advances in our understanding of the pathogenesis of these disorders together with their distinguishing immunophenotypic, genotypic, clinical and histopathological characteristics. As outcomes have improved, the main emphasis of treatment has been to incorporate a risk-adapted approach to reduce long-term toxicity without sacrificing efficacy through the use of varying combinations of chemotherapy, radiotherapy and immunotherapy.

Pathobiology of Classical Hodgkin Lymphoma

The World Health Organization has acknowledged the malignant nature of classical Hodgkin lymphoma (cHL), which encompasses four histological subtypes. The diagnosis of cHL is based on the detection of malignant Hodgkin and Reed-Sternberg cells (HRSC) confirmed by immunophenotyping and the detection of growth patterns specific to each histological subtype. The pathologic HRSC arise from germinal center or immediate postgerminal cells that lack detectable immunoglobulin/B-cell antigen receptor expression, with a consequent loss of B-cell identity; very few cHL cases are of T-cell origin. To escape apoptosis, which normally occurs in B cells with nonfunctioning antigen receptor machinery, HRSC develop concurrent antiapoptotic mechanisms by activation of nuclear factor-kappaB or are rescued by Epstein-Barr virus infection. HRSC are characterized by a variable and inconstant immunophenotype, with a remarkable loss of lineage-specific cell antigens and expression of antigens of other cell lineages. The master plan of B-cell identity in HRSC is disturbed not only at the immunoglobulin expression level, but also at the transcriptional factor level. HRSC are further characterized by profound cell cycle deregulation with futile replication, multinucleation and poly- and aneuploidy. Here, we review pathobiological aspects of cHL with respect to lymphomagenesis and routine diagnostics.

Contribution of PET imaging to the initial staging and prognosis of patients with Hodgkin's disease

BACKGROUND

Positron emission tomographic (PET) scanning utilizing [18F]fluorodeoxyglucose (FDG) is a new method of tumor imaging based on the increased glucose metabolic activity of malignant tumors. In Hodgkin's disease (HD), PET has proven value for the evaluation of residual masses following treatment and for the early diagnosis of relapse. In the initial staging of HD, PET frequently shows a higher stage than conventional methods (upstaging by PET). In the present study, we evaluated the frequency of stage changes by PET in a multicenter setting and determined its prognostic relevance.

PATIENTS AND METHODS

A total of 73 patients with newly diagnosed HD were staged with both conventional methods and whole-body PET scanning. All histological types and stages were represented. The median time of follow-up after the initial diagnosis was 25 months (range 1 month to 5 years). The response to treatment was determined by standard clinical and diagnostic criteria. For the purpose of this analysis, data from a PET center associated with a university medical center and a PET center associated with a group oncology practice were combined.

RESULTS

A total of 21 patients (28.8%) were upstaged by PET compared with conventional methods. In two cases (2.7%), a lower stage was suggested by PET scanning. With one possible exception, the upstaging had no obvious clinical or biological correlate. Among 12 patients in stage I (A + B) by conventional methods, seven were upstaged by PET (58.3%), four to stage II, one to stage III and two to stage IV. Among 42 patients in stage II, eight were upstaged by PET (19.0%), six to stage III and two to stage IV. Among 12 patients in stage III, six (50%) were upstaged to stage IV by PET. If only early-stage patients and major changes are considered (stages IA-IIB to III or IV), among 49, 10 were upstaged to III or IV, whereas in 39 staging was unchanged following PET. In the former group, three relapsed or were refractory compared with none in the latter group (P<0.006). In advanced stage patients (IIIA or IIIB) a trend toward treatment failure was apparent in patients who were upstaged by PET.

CONCLUSIONS

PET scanning is an interesting new modality for the accurate staging of patients with HD and frequently shows a higher stage than conventional methods. PET should be performed at initial diagnosis and should be included in prospective studies of patients with HD. Upstaging by PET may represent a risk factor for a more advanced stage or a biologically more aggressive tumor. Patients with early-stage disease as identified by conventional methods have a significant risk of treatment failure if a more advanced stage is indicated by PET. At present, major stage changes suggested by PET imaging should be confirmed by an independent diagnostic method.

Mechlorethamine, Vincristine, Procarbazine, and Prednisone (MOPP) Regimen for Advanced Hodgkin's Disease

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column reviews various issues related to the preparation, dispensing, and administration of cancer chemotherapy, both commercially available and investigational.