Download Hodgkin`s diseas

Hodgkin’s disease
นพ.เอกสิ ทธิ ธราวิจิตรกุล
• จาก Chiang Mai Cancer Registry ปี 1999 พบอุบตั ิการณ์ของ Hodgkin’s disease 0.6%
(12ใน 2023) ของผูป้ ่ วยใหม่ที่ได้รับการวินิจฉัยว่าเป็ นโรคมะเร็งทั้งหมด•Sex male:
female = 2:1•Two peak of incidence of age: 20-30 years and 60-70 years
ชนิดของ cell type ตาม pathological classification
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Nodular lymphocyte-predominant HL
Classical HL
Nodular sclerosis HL
Lymphocyte-rich classical HL
Mixed cellularity HL
Lymphocyte depletion HL: poor prognosis
อาการของโรค
• Painless enlarged node in the neck
• B symptoms are character of lymphomas and are Fever greater than 38 degrees
Weight loss of more than 10% body weight in 6 mos Drenching night sweat
Investigation
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CBC, BUN/Cr, LFT
Bone marrow examination:
–Unusual in HD, no longer routine for those patients presenting with stage
I-III without B symptoms
• CXR: widening mediastinum (³10 cm or > 1/3 internal transverse chest diameter@
T5-6 on PA chest x-ray) or lung parenchyma infiltration, pleural effusion
• CT or MRI : CTchest+abdomen+pelvis:
– Most accurate assessment of LN
– Now superseded the use of bipedal lymphangiography (imaging of choice in staging
in lymphoma)
• Biopsy : Reed-Sternberg cell
• Splenectomy:
• Previously standard , nowadays rarely because :
– Current indications for systemic treatment mean that information about
splenic status will rarely influence management and imaging with US
– CT and MRI will give an accurate picture of sub-diaphragmatic disease
disease for which laparotomy was once required.
The Cotswald’s staging classification for Hodgkin’s disease
I:Involvement of a single lymph node region or lymphoid structure (eg, spleen,
thymus, Waldeyer’s ring)
II:Involvement of two or more lymph node regions on the same side of the diaphragm
(ie, the mediastinum is a single site, hilar lymph nodes are lateralized). The number of
anatomic sites should be indicated by a subscript (eg, II2).
III:Involvement of lymph node regions or structures on both sides of the diaphragm:
III1: With or without involvement of splenic, hilar, celiac, or portal nodes
III2: With involvement of para-aortic, iliac, or mesenteric nodes
IV:Involvement of extranodal site(s) beyond that designated E
General management
•Hodgkin’s Lymphoma
Early stageTreatment options
• IA
• IIA
• STNI (standard)
• ABVD*3-4 + IFRT
Advanced stage
• III
• IV
• Bulky disease
( > 1/3 of mediastinum)
• B symptom
• Chemotherapy (eg. ABVD *6)
+ RT to:
– sites of initial bulk (IFRT 35-40 Gy)
– sites of residual disease (IFRT 40-50 Gy)
** role of RT to sites of initial bulk is uncertain if CR. it seems reasonable because
of the risk of recurrence at sites of initial bulk.
Acute
• Skin erythema
• Local alopecia
• Xerostomia
• Dysphagia (esophagitis)
• Fatigue
• Decrease WBC, platelets
• Para-aortic RT: nausea, vomiting, diarrhea
• Subacute
– Fatigue
– Xerostomia
– Pneumonitis
– Herpes zoster
– Lhermitte’s syndrome•Late
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Hypothyroidism
Cardiac
CAD, vascular disease, pericarditis
5% risk cardiac death in 20 years
Second malignancy (solid tumor, lung, GI, breast )
Major breast cancer risk in young women
Lung cancer risk in smoker
Over 20% of patients will develop second malignancy by 25 years
Non Hodgkin’s Lymphoma•จาก Chiang Mai Cancer Registry ปี 1999 พบอุบตั ิการณ์ของNHL 3.5% (71 ใน
2023) ของผูป้ ่ วยใหม่ที่ได้รับการวินิจฉัยว่าเป็ นโรคมะเร็ งทั้งหมด โดยเป็ นผูป้ ่ วยชาย 41 ราย และ ผูป้ ่ วยหญิง
30ราย•Infective agents:Epstein-Barr virus
• Altered immune status: HIV
• Irradiation:exposure in Hiroshima and Nagasaki
• Low-grade–Small lymphocyte
– lymphoplasmacytic
– Follicular lymphoma grade 1,2**
• Intermediate-grade–Follicular, large cell
– Diffuse, small cleaved cell
– Diffuse, mixed small and large cell
– Diffuse, large cell***
– Peripheral T cell lymphoma
• High-grade–Immunoblastic
– Lymphoblastic
– Diffuse, small noncleaved cell•Painless lump: most commonly the neck,
B symptoms are also an important feature
• Other symptoms: Primary Extranodal Lymphoma (E-lesion) Gastrointestinal
- Waldeyer’s ring
- Paranasal sinuses
- Salivary gland
- Thyroid
- Orbital
- Lung
- Breast
- Bone, extradural
- Genitourinary
- Central nervous system
- Skin
Treatment
• Low-grade NHL:
– Common types are follicular and diffuse small cell lymphoma in WHO-REAL
classification
– Localized low-grade NHL (stage IA) is treated using IFRT, low doses of 20-30 Gy
in 2-3 weeks
– Alternate : combined modality–Other stages: chemotherapy
– Monoclonal antibody: B-cell surface marker CD20 for low grade follicular
lymphoma (Rituximab)
High-grade lymphoma
– Common types is diffuse large cell lymphoma
• Localized high grade lymphoma {Ia and IIa}: short course chemotherapy ( 3-4
courses of CHOP) followed by IFRT, delivering a dose 30-40 Gy in 3-4 weeks
– Advanced disease (1B, 2, 3 or 4) is treated with chemotherapy + IFRT 35-45 Gy at
initial bulk or residual disease
Note
– Sperm banking for young males
– Well-hydration
– Starting allopurinol to prevent Tumor Lysis Syndrome
Breast cancer
• 30% of all female cancers
• Treatments
– Multidisciplinary approach
• Diagnostic radiology
• Pathology
• Surgery
• Reconstructive surgery
• Medical oncology
• Radiation oncology
Treatment
Premalignant lesion
DCIS
• Total mastectomy is curative treatment ~98-99% but radical
• Breast conserving therapy: NEJM 1993 : BCT with radiation show recurrence rates
of 10-15% at 10 years
• Axillary LN dissection: not recommended : axillary nodal metastasis 3.6%( JAMA
1978)
Early stage breast cancer
• Stage I, II and IIIA
• Multi-modality treatment :
– Surgery
– Adjuvant hormonal or chemotherapy
– Radiation therapy
• Surgical management
– Primary surgical approach
• Breast conserving therapy: lumpectomy followed by radiation therapy
• Mastectomy with breast reconstruction
• MRM alone
• Contraindication of BCT
– Absolute
• Multi-centric disease
• Extensive malignant appearing micro-calcifications,
• Pregnancies
• Previous breast or mantle irradiation
– Relative
• Collagen vascular disease
• Large pendulous breasts
The current standard: BCT followed by radiation therapy
Sentinel LN biopsy
– ALND cause arm discomfort and swelling
– SLN developed by Morten et al. in melanoma in 1990s
– Use in T1-2 without axillary LN metas (clinical) and no multiple lesion(NEJM
1998)
– Sentinel LN is first node in the lymphatic chain that receives primary lymphatic
flow, being at the highest risk for harboring occult metastatic disease in breast cancer
with axillary node negative
• Indication of postoperative RT
– Positive surgical margins
– Primary tumors more than 5 cm in size
– Involve of four or more LN
Hormonal therapy in ER or PgR positive
Adjuvant chemotherapy is routinely offered to women with a primary tumor of 1 cm
or larger, however, within the subset of node-negative disease
Locally advanced cancer
• T3, T4 or N2 or N3 (older stages): multimodality treatment
• NAC is indicated in this patient population and may cause tumor shrinkage to
allow surgical resection with clear margin
• Poor prognosis and high rate of local and distant recurrence
• NAC– Surgery– RT or systemic from I/C
Metastatic breast cancer•Low risk
– Long disease-free interval
– hormone +ve
– Bone, soft tissue or limited visceral organ involvement
High risk
– Rapidly progressive disease or extensive visceral involvement
– Hormone refractory breast cancer
• Low risk patients
– Hormone is mainstay of treatment:
• ER/PR+ response 60-70%
• ER/PR – response5-10%
– Present data show AI produce higher response rates and longer remissions than
TAM(JCO 2000)
• High risk of patients
– Chemotherapy is first choices
• Anthracycline-based : FAC
• Taxanes
• Capcitabine
• HER-2 antagonist
• Combinations
Complication
• Arm edema
• Pneumonitis
• Rib fracture
• Heart disease
• Brachial plexopathy
• Fibrosis or soft tissue necrosis