CASE 7

GROUP1
BAGWAN, LORENZE
BECYAGEN, MAY ANNE
JACOB, DOMINOS
ORATA, WEENA
PASTORES, NASUDI
PRUDENCIO, MARIA AUGUST
QUIRINO, MARA BELLE ESTHER
RITARITA, KRIZZA MAE
TABAGO, MARK ANTHONY
HISTORY
 DATA
NAME: J.J.
AGE: 10 years old
SEX: Male
BIRTHDAY: February 14, 2005
BIRTHPLACE: Novaliches, Quezon City
ADDRESS: San Bartolome, Novaliches, Quezon City
NATIONALITY: Filipino
RELIGION: Roman Catholic
NO. OF ADMISSIONS: 1
DATE & TIME OF ADMISSION: March 14, 2015, 8:00A.M.
RELIABILITY: History was obtained from the patient and his mother,
95% reliability
CHIEF COMPLAINT

"Nilalagnat po at may pasa-pasa sa

balat" as verbalized by the mother
HISTORY OF PRESENT ILLNESS
● This is the first hospital admission for this 10-year-old male. The patient is
apparently well until,
❏ 2 weeks PTA - bruises in lower extremities
❏ 1 week PTA - bruises, fever (38.2°C); (Patient was given Paracetamol
syrup, 7.5mL, every six hours by his mother but it was not relieved.)
❏ 4 days PTA - fatigue, bruises, fever (38.5°C), night sweats; (Patient was given
Paracetamol syrup, 7.5mL, every six hours by his mother but it was not relieved.)
❏ 2 days PTA - fatigue, bruises, fever (38.8°C), night sweats; (Patient was given
Paracetamol syrup, 7.5mL, every six hours by his mother but it was not relieved.)
❏ 12 hours PTA - fatigue, bruises, fever (38.5°C), night sweats; (Patient
was given Paracetamol syrup, 7.5mL, every six hours by his mother but it was
not relieved.)
PREGNANCY AND BIRTH HISTORY
A. Antenatal/ Prenatal
● The mother is 35 years old with an OB score of G1P1.
● Mother’s diet consists mostly of rice, fish and meat;
and drinks 12 glasses of water per day
● Mother does not smoke and does not drink alcohol.
● Took multivitamins, ferrous sulfate and folic acid
supplements during pregnancy
● Mother had no exposure to radiation during
pregnancy.
PREGNANCY AND BIRTH HISTORY
B. Natal
● Normal spontaneous delivery
● Cephalic presentation
● No complications during labor

C. Neonatal
● Birth weight = 3300g (3.3 kg)
● Full term at 38 weeks AOG
● BL: 49.5 cm
● NST: normal
● APGAR score: not recalled by the mother
● The baby looks healthy, no resuscitation was required.
● Baby went home with the mother at second day of life.
PAST MEDICAL HISTORY
• Childhood illnesses: None
• No infections, accidents, or injuries from birth was
reported by the mother.
• 3 years prior (exact date unrecalled), age 6, patient was
hospitalized at Novaliches District Hospital for 1 week
due to diarrhea and vomiting, diagnosed with
Amoebiasis.
• No history of surgery.
• No known allergies was also reported.
• No medication is currently being taken by patient.
GROWTH AND DEVELOPMENT
DEVELOPMENTAL MILESTONES
● Cognitive (learning, thinking, problem-solving)
■ Know the complete date (day of the week, day of the month,
month, and year).
■ Can name the months of the year in order
■ Can read and understand a paragraph of complex sentences
■ Can read books with chapters
■ Skilled in addition and subtraction and is building skills in
multiplication, division, and fractions.
■ Have learned to write in cursive
■ Can write simple stories
GROWTH AND DEVELOPMENT
DEVELOPMENTAL MILESTONES
● Language/Communication
■ Enjoys reading, seeks out books on subjects of
special interest
■ Can converse easily with people of all different ages
■ Have speech patterns that are nearly at an adult
level.
GROWTH AND DEVELOPMENT
DEVELOPMENTAL MILESTONES
● Movement/Physical Development
■ Have developed control of large and small muscles. He
enjoys activities that use these skills, such as basketball,
dancing, and soccer.
■ Have developed endurance. He can run, ride a bike, and
enjoy activities that require a degree of physical
conditioning.
■ Have clear handwriting and detailed artwork
GROWTH AND DEVELOPMENT
DEVELOPMENTAL MILESTONES
● Social, Emotional, and Behavioral
■ Enjoys being with his friends, and have a best friend of
the same gender.
■ Enjoys team and group activities
■ Like and listen to his parents, sometimes shows irritation
with or lack of respect for adults who are in charge.
GROWTH AND DEVELOPMENT
PHYSICAL GROWTH
Age Weight (kg) Height (cm) Head Circumference (cm)

At birth 3.3 49.5 37.0

6 months 7.0 59 45.0

12 months 9.6 66 47.1

3 years 14.0 95.0 51.0

6 years 20.0 115.0 -

8 years 25.5 128.0 -

9 years 30.0 133 -

10 years 26.5 138 -

IMMUNIZATIONS AND TESTS
● The patient received 1 dose of BCG and 1 dose of Hepatitis B
vaccine at birth in the RHU.
● Also received 3 doses of Pentavalent vaccine, Oral Polio vaccine, and
Pneumococcal Conjugate vaccine when he was 1.5 months old, 2.5
months old, and 3.5 months old, also 1 dose of IPV at 3.5 months in
the barangay health center.
● At 9 and 12 months, he received 1 dose of MMR each at the
barangay health center.
● No untoward reactions like difficulty of breathing or seizure noted after
immunization.
● Hearing test and newborn screening test were done at 2nd day of life.
IMMUNIZATION
FEEDING/NUTRITION HISTORY
The patient was exclusively breastfed from birth until 6 months of age. At 7
months of age, pureed carrots and banana as well as cerelac was
introduced until 9 months old. At 1 yr old breast milk was shifted to whole
milk able to feed in a cup, he was able to eat and chew fruits, soft
vegetables and proteins such as egg, meat and fish meat.

No allergies were noted upon food introduction. At present, patient has 3

meals a day with snacks in between. His diet consists mostly of rice, bread,
vegetables, meat and fish. Patient was reported to normally have good
appetite and not picky on foods but recently has loss of appetite.
FAMILY HISTORY
SOCIAL HISTORY
The patient’s parents are together and living in a
bungalow house together with their grandfather in paternal
side with 1 kasambahay. His father is a policeman in Quezon
city, a smoker and alcohol drinker while his mother is a
highschool teacher. They have a good family relationship,
they eat altogether, and go to mall and church every
weekend. He enjoys being with his best friend of the same
gender and often plays basketball and enjoys biking.
ENVIRONMENTAL HISTORY
The house is located in a subdivision in Novaliches,
Quezon City is well maintained, well ventilated with 3
bedrooms and 2 comfort rooms. Their drinking water is
from a refilling station and the water source is Maynilad.
Their garbages are collected during Tuesday and Friday.
They have 2 dogs and 1 cat.
REVIEW OF
SYSTEMS
GENERAL
(+) weight loss, (+) loss of appetite

SKIN (-) lumps, (-) mottling, (-) dryness, (+) itching

HEAD, EYES, EARS, Head: (-) head injury, (-) dizziness

NOSE, THROAT Eyes: (-) pain, (-) icteric, (-) excessive tearing, (-)
(HEENT) double or blurred vision
Ears: (-) tinnitus, (-) earaches, (-) discharge
Nose and Sinuses: (-) discharge, (-) itching
Throat: (-) bleeding, (-) dryness, (-) sore throat

CARDIOPULMONARY (-) murmur, (-) palpitations, (-) cyanosis, (+) chest pain,
(-) tachycardia, (+) cough
 (-) vomiting, (-) diarrhea, (-) nausea
GASTROINTESTINAL

URINARY (-) choluria, (-) polyuria, (-) pain during urination

(-) convulsion, (-) vertigo, (-) tremor, (-) loss of

NEUROLOGICAL
consciousness

HEMATOLOGIC
(-) edema, (-) stiffness
MUSCULOSKELETAL
 PHYSICAL
EXAMINATION
General Appears weak, alert, tired and slightly pale appearing, but in no apparent
distress

Vital Signs HR: 120 BPM Blood pressure: 110/56 mmHg

RR: 32 CPM Oxygen saturation: 100 %
Temperature: 38.5 °C

Skin (+) lesions, (+) bruises, Good turgor, No pallor, cyanosis, pale appearing.

HEENT Head: normocephalic without scalp lesions, symmetrical facial features, no palpable
mass, hair texture is normal,
Eyes:anicteric sclerae, pale conjunctiva, pupils equal, round and reactive to light, 20/20
vision in each eye, visual fields full by confrontation
Ears: no discharge, tympanic membrane intact and pearly gray bilaterally without
erythema or effusion
Nose: symmetrical nose, septum at midline, nares patent bilaterally without rhinorrhea
or redness, mucous membranes are dry and pale
Oral Cavity: posterior pharynx is erythematous without lesions and no tonsillar
enlargement, buccal mucosa moist, pink, without lesions, dentition and gums are
normal.
Neck: neck supple, trachea midline, bilateral cervical nodes, posterior cervical nodes,
axillary nodes,supraclavicular lymphadenopathy, mobile and nontender
Thorax and Lungs Thorax symmetric with good excursion, tachypneic, breath sounds clear to all
lung fields. Slightly tender, mobile, matted lymph node located inferior to the
sternocleidomastoid with several smaller cervical lymph nodes palpated
bilaterally

Cardiovascular Regular rate and rhythm. No thrills, splitting, murmurs, gallops or rubs noted.

Abdomen No surgical scars, normoactive bowel sounds. No distention, masses,

organomegaly or aortic pulsations. No dullness to percussion. Liver edge is
palpable at the costal margin. Spleen is palpable 4 cm below the left costal
margin

Genitourinary No acute abnormalities, normal external genitalia, no lesions

Rectum and Anus No irritation, fissures, prolapse, or imperforate anus, acolic or clay- colored stool

Extremities No gross deformity, no edema, no cyanosis, full and equal pulses, CRT= <2 sec,
moving all four extremities without difficulty or apparent pain, 2+ pulses in all 4
extremities.

Spine and Back No acute abnormalities

Neurological Exam Cranial Nerves:
CN I: Able to distinguish odor
CN II: Intact pupillary and consensual light reflexes
CN III, IV, VI: Full EOMs
CN V: Intact, no sensory deficits
CN VII: No facial asymmetry; able to perform different facial
expression
CN VIII: Intact gross hearing
CN IX, X: Intact gag reflex; uvula is midline
CN XI: Turns head from side to side
CN XII: Tongue midline
Neurological Exam Motor: 4/5 on both upper extremities, 4/5 on both lower
extremities; normal tone; no atrophy; symmetrical movements

Sensory: Responsive to light, touch, and pain

DTRs: ++ on biceps and knee

Meningeal Signs: No kernig’s and brudzinski’s sign, no nuchal

rigidity

Pathological Reflex: No babinski, no clonus

 • 10 years old
SALIENT • Male
FEATURES • Persistent fever and
night sweats
• Easy bruising
• Weight loss
• Loss of appetite
• Chest pain
 INITIAL
IMPRESSION
 HODGKIN LYMPHOMA
FEATURES RULE IN RULE OUT
● Painless, nontender, firm, rubbery, cervical
or supraclavicular lymphadenopathy and (+) cervical (bilateral),
usually some degree of mediastinal axillary, & supraclavicular
involvement (Chest pain, cough, shortness of lymphadenopathy
breath, or a combination) (+) bruises
● Night sweats, weight loss > 10% in the past 6
(+) fever
months, fever > 38°C (B Symptoms)
● Intermittent fever with periods of high (+) night sweats
temperature for 1–2 weeks, followed by (+) weight loss
afebrile periods for 1–2 weeks. Relatively rare (+) loss of appetite
but very specific for HL (Pel-Ebstein fever) (+) chest pain
● Severe or frequent infections (+) cough
● Easy bruising or bleeding; pruritus; fatigue (+) fatigue
● Bimodal (late adolescence and older (+) itching
adulthood) (+) age
LAB DIAGNOSIS TO RULE IN HL
● Chest radiography to identify the presence of a large
mediastinal mass before undergoing lymph node biopsy
● Complete blood cell (CBC) count studies
○ Anemia, leukopenia , neutrophilia, or eosinophilia
○ Serum chemistry → increased LDH and hypercalcemia
● Formal excisional biopsy both for light microscopy and for
appropriate immunohistochemical and molecular studies.
○ Reed-Sternberg cells, Hodgkin cells,
LAB DIAGNOSIS TO RULE IN HL
DIFFERENTIAL
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
01 HODGKIN LYMPHOMA

02 NON-HODGKIN LYMPHOMA

03 INFECTIOUS MONONUCLEOSIS

04 SARCOIDOSIS
 NON-HODGKIN LYMPHOMA
FEATURES RULE IN RULE OUT
● B-cell lymphomas (85%) and T-cell lymphomas
(15%)
(+) cervical (bilateral), (+) chest pain
● Nodal disease: typically painless axillary, & (+) itching
lymphadenopathy associated with fatigue and supraclavicular (-)hepatosplenomegaly
weakness (multiple noncontiguous lymph (-) GI bleeding
nodes may be involved) lymphadenopathy
(-) headache
● High grade: Constitutional symptoms (+) bruises (-) paraneoplastic
or B symptoms (+) fever syndromes
● Low grade: hepatosplenomegaly,
(+) night sweats (-) age
cytopenia
● Early satiety, GI bleeding; headache; skin rash,
(+) Reed-Sternberg
(+) weight loss Cells
plaques, tumors, or ulcers; thyroid nodules or
goiter
(+) loss of appetite (-) B-cell and T-cell
● Hypercalcemia, spinal cord compression, SVC (+) itching lymphoma
syndrome, cardiac tamponade, lymphomatous (+) fatigue
meningitis, and CNS mass
● Increases with age (peak> 50 years)
LAB DIAGNOSIS TO RULE IN NHL
● CBC may show anemia, thrombocytopenia, leukopenia or lymphocytosis
● Increased LDH; serum β2-microglobulin: may be elevated
● Nodal disease
○ Select the most appropriate node for biopsy (e.g., a node with
significant, progressive, and persistent enlargement).
○ Preferred: excisional lymph node biopsy or core needle biopsy
● Histopathology
● Immunophenotype (e.g., flow cytometry, immunohistochemistry)
○ Detects surface antigens, determines the specific cell type (B cell/T
cell), and identifies specific markers
○ Possible findings include:
■ B-cell lymphomas: CD20 positive
■ T-cell lymphomas: CD3 positive
LAB DIAGNOSIS TO RULE IN NHL
 INFECTIOUS MONONUCLEOSIS
FEATURES RULE IN RULE OUT
● Epstein-Barr virus (EBV)/ HHV-4 (+) chest pain
● Splenomegaly, fever, fatigue, malaise (+) bilateral posterior (-) abdominal pain
● Pharyngitis and/or tonsillitis, palatal cervical (-) hepato-
petechiae lymphadenopathy splenomegaly
● Bilateral cervical lymphadenopathy
(+) bruises (-) maculopapular
(especially posterior)
● May cause anemia and (+) fever rash
thrombocytopenia (+) chest pain (-) jaundice
● Abdominal pain (+) fatigue (+)
● Possibly hepatomegaly and jaundice (+) itching Reed-Sternberg
● Maculopapular rash (similar to Cells
measles) (-) age
● Peak incidence: 15–24 years of age
LAB DIAGNOSIS TO RULE IN IM
● Monospot test
○ Detects heterophile antibodies produced in response to EBV infection
using RBCs from sheep or horses
○ Specificity of ∼ 100%, sensitivity of 85%
● Laboratory analysis: elevated LDH and liver transaminases
● Peripheral smear: lymphocytosis with > 10% atypical lymphocytes (in
some cases, up to 90%)
● Serology: indicated if IM is suspected but monospot testing is negative
○ Anti-viral capsid antigen antibodies (anti-VCA)
■ Anti-VCA IgM: appears early and vanishes ∼ 3 months after
infection
■ Anti-VCA IgG: appears after 2–4 weeks and persists for life
○ Anti-EBV nuclear antigen-antibody (anti-EBNA-1) IgG
LAB DIAGNOSIS TO RULE IN IM
 SARCOIDOSIS
FEATURES RULE IN RULE OUT
● Acute Sarcoidosis (+) night sweats
● fever, malaise, lack of appetite, weight loss
(+) cervical (bilateral), (-) rales
● dyspnea, cough, chest pain
axillary, & supraclavicular (+) itching
● arthritis, anterior uveitis, erythema
nodosum lymphadenopathy (+) Reed-Sternberg
● Chronic Sarcoidosis (+) bruises Cells
● Interstitial fibrosis (+) fever (-) arthritis
● Peripheral lymph nodes involvement (+) chest pain (-) uveitis
● Ocular findings (∼ 25%) (+) weight loss (-) lupus pernio
○ Granulomatous uveitis (+) cough (-) maculopapular
○ Blurred vision (ocular (+) fatigue rash
sarcoidosis) (-) hepato-
● Skin findings (∼ 25%) [9] splenomegaly
○ Lupus pernio (-) age
○ Scar sarcoidosis (-) gender
SYMPTOMS TO RULE IN SARCOIDOSIS
LAB DIAGNOSIS TO RULE IN SARCOIDOSIS
● Chest x-ray
○ Best initial test
○ Findings: hilar lymphadenopathy with or without bilateral reticular
opacities
● HRCT: detect parenchymal and mediastinal abnormalities
● Acute Sarcoidosis: ↑ inflammatory markers; ↑ACE, ↑IgG, ↑calcium
● Chronic Sarcoidosis
○ ↑ inflammatory markers; ↑ACE, ↑IgG , ↑calcium
○ ↑ alkaline phosphatase; ↓ CD4+ T cells; hypercalciuria
● Bronchoscopy
○ Biopsy of lung tissue and lymph nodes
○ Non-caseating granulomas with giant cells, Asteroid bodies,
Schaumann bodies
LAB DIAGNOSIS TO RULE IN SARCOIDOSIS
FINAL DIAGNOSIS

HODGKIN'S
LYMPHOMA
ABOUT THE
DISEASE
HODGKIN'S LYMPHOMA

● It is a blood cancer that develops in lymphocytes, a

type of white blood cell. These blood cells are in the
lymphatic system, a network of vessels, nodes and
organs that filter wastes and toxins and help fight
infections.
HODGKIN'S LYMPHOMA
CLINICAL MANIFESTATIONS
● Patients commonly present with painless, nontender, firm, rubbery,
cervical or supraclavicular lymphadenopathy and usually some degree
of mediastinal involvement.
● Clinically detectable hepatosplenomegaly is rarely encountered.
● Depending on the extent and location of nodal and extranodal disease,
patients may present with symptoms and signs of:
➔ airway obstruction (dyspnea, hypoxia, cough)
➔ pleural or pericardial effusion
➔ hepatocellular dysfunction, or
➔ bone marrow infiltration (anemia, neutropenia, or
thrombocytopenia)
HODGKIN'S LYMPHOMA
CLINICAL MANIFESTATIONS
● Systemic symptoms, classified as B symptoms that are
considered important in staging, are
➔ unexplained fever >38°C (100.4°F)
➔ weight loss >10% total body weight over 6 months
➔ drenching night sweats.
● Less common and not considered of prognostic significance are
symptoms of pruritus, lethargy, anorexia, or pain that worsens
after ingestion of alcohol.
● Patients also exhibit immune system abnormalities that often persist
during and after therapy.
HODGKIN'S LYMPHOMA
EPIDEMIOLOGY
● The worldwide incidence of HL is approximately 2-4 new
cases/100,000 population/yr; there is a bimodal age distribution,
with peaks at 15-35 year of age and again after 50 year.
● It is the most common cancer seen in adolescents and young
adults, and the third most common in children younger than the
age of 15 year.
● A male : female predominance is found among young children,
but lessens with age.
HODGKIN'S LYMPHOMA
RISK FACTORS
● People between the ages of 15 and 40 and people older than 55

● In general, men are slightly more likely to develop Hodgkin

lymphoma than women, although the nodular sclerosis subtype is
more common in women
● Family History

● Virus exposure (e.g. Epstein-Barr virus, HIV)

HODGKIN'S LYMPHOMA
SUBGROUPS AND SUBTYPES
SUBGROUP: Classical Hodgkin Lymphoma
SUBTYPES:
❏ Nodular sclerosis Hodgkin lymphoma (NSCHL)
❏ Mixed cellularity Hodgkin lymphoma or (MCCHL)
❏ Lymphocyte-rich Hodgkin lymphoma
❏ Lymphocyte-depleted Hodgkin lymphoma

SUBGROUP: Nodular Lymphocyte-Predominant Hodgkin

Lymphoma
HODGKIN'S LYMPHOMA
SUBGROUPS AND SUBTYPES
HODGKIN'S LYMPHOMA
SUBGROUPS AND SUBTYPES
HODGKIN'S LYMPHOMA
SUBGROUPS AND SUBTYPES
HODGKIN'S LYMPHOMA
SUBGROUPS AND SUBTYPES
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
HODGKIN'S LYMPHOMA
COMPLICATIONS

❏ Weakened immune system

❏ Infertility
❏ Second cancers
❏ Other health problems (e.g. cardiovascular
disease and lung disease.
DIAGNOSTIC
EVALUATION
DIAGNOSIS
★ Laboratory studies
○ CBC
○ ESR
○ Serum ferritin
★ Imaging studies
○ CXR
○ CT scan
○ PET scan
★ Bone marrow aspiration and biopsy
Complete Blood Count (CBC)
● To identify abnormalities that might suggest marrow
involvement
● To rule out non-lymphoma conditions such as
leukemia
● CBC Findings: abnormal blood counts
○ Anemia
○ Thrombocytopenia
○ Leukopenia
Erythrocyte Sedimentation Rate (ESR)

● To measure how much inflammation is in the

body
● It is used to predict prognosis (based on
study of Shuang Wu, et. al)
○ Increased ESR= Poor prognosis
● ESR Finding: elevated
○ Normal value for children = 0-10 mm/hr
Serum Ferritin
● Serves as a baseline to evaluate the effects of
treatment
● It is an acute phase protein in the inflammatory
response
● Serum Ferritin Finding: elevated
○ Normal value for children= 7-140 ng/mL
Chest Radiography (CXR)
● To measure the size of the mediastinal mass in relation to the
maximal diameter of the thorax
● It determines bulk disease
Chest Computed Tomography (CT) Scan
● To clearly define the extent of a mediastinal mass if present
● To identify hilar nodes and pulmonary parenchymal
involvement, which may not be evident on chest radiographs
Chest Computed Tomography (CT) Scan
Chest Computed Tomography (CT) Scan
Positron Emission Tomography (PET) Scan
● Prognostic tool
○ Reduced therapy in those predicted to have a good outcome
● To identify those at risk of relapse
● To show the stage of lymphoma and how far it spread
Positron Emission Tomography (PET) Scan
Positron Emission Tomography (PET) Scan
Stages of Hodgkin Lymphoma
Bone Marrow Aspiration and Biopsy
● To rule out advanced disease
● Formal excisional biopsy is preferred over needle biopsy to ensure that
adequate tissue is obtained.
● Bone Marrow Biopsy Finding: presence of abnormal lymphocytes (Reed-
Sternberg Cell)
● Bone scans are performed in patients with bone pain and/or elevation of
alkaline phosphatase
 MANAGEMENT
AND TREATMENT
Treatment
Treatment
● Chemotherapy and Radiation therapy
➔ both effective in the treatment of HL

● Treatment of HL in pediatric patients

➔ risk adapted
➔ involves the use of combined chemotherapy with
or without low-dose involved-field radiation
therapy based on response.
Treatment
● Treatment is determined largely by:
➔ disease stage
➔ presence or absence of B symptoms
➔ presence of bulky nodal disease
Treatment
CHEMOTHERAPY
● Commonly used to treat children and adolescents
with HL
● Include cyclophosphamide, procarbazine, vincristine
or vinblastine, prednisone or dexamethasone,
doxorubicin, bleomycin, dacarbazine, etoposide,
methotrexate, and cytosine arabinoside
Treatment
CHEMOTHERAPY
● Rituximab - antiCD20 antibody, wherein ongoing clinical trials report
encouraging results particularly in nodular lymphocytepredominant Hodgkin
lymphoma where trials in relapsed disease have shown an overall response rate
of 94%

● Anti-CD30 agents are being used that are targeted to the RS cells themselves,
where CD30 is abundantly expressed

● Brentuximab vedotin - an antibody–drug conjugate that is now FDA approved

to treat Hodgkin lymphoma. It combines the chimeric anti-CD30 antibody
brentuximab linked to the antimitotic agent monomethyl auristatin E. This agent
shows impressive efficacy as single-agent therapy in refractory HL and is
currently being tested as part of upfront therapy combined with chemotherapy in
patients with newly diagnosed disease
Treatment
CHEMOTHERAPY
● Combination chemotherapy
❏“Risk-adapted” protocols are based on both staging
criteria and rapidity of response to initial chemotherapy.
❏Aim: to reduce total drug doses and treatment duration
and to eliminate radiation therapy if possible
Treatment
CHEMOTHERAPY
● Combination Chemotherapy
❏ regimens in current use are based on:
❖ COPP (cyclophosphamide, vincristine [Oncovin], procarbazine, and
prednisone)
❖ ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and
dacarbazine), with the addition of prednisone,
cyclophosphamide, and etoposide (ABVE-PC and BEACOPP)
❖ BAVD (brentuximab vedotin, doxorubicin [Adriamycin], vincristine,
dacarbazine) in various combinations for intermediate- and
high-risk groups
Treatment
CHEMOTHERAPY
Treatment
EBV-SPECIFIC CYTOTOXIC T LYMPHOCYTES (CTLs)
● Can also be generated from allogenic donors for patients
with advanced HL.
● In clinical trials, these show promising results, with
enhanced antiviral activity and stabilization of disease
even though all patients continue to have persistent
disease
Treatment
RADIOTHERAPY
● Radiation therapy alone, once given at higher doses, initially
resulted in prolonged remission and cure rates in patients with
low-stage HL.
● However, this treatment also caused significant long-term
morbidity in pediatric patients, including growth retardation,
thyroid dysfunction, and cardiac and pulmonary toxicity.
● Current radiation therapy utilizes lower amounts of overall
radiation in addition to narrowing the radiation treatment field to
either involved-field or even involved-node irradiation.
Treatment
RADIOTHERAPY
RELAPSE
Relapse

● Most relapse occur within the 1st 3 years after

diagnosis
● May occur as late as 10 years
● Cannot be predicted accurately
Relapse

● Poor prognostic feature in relapse

○ Tumor bulk
○ Stage at diagnosis
○ Extralymphatic disease
○ Presence of B symptoms (systemic symptoms)
Relapse
● Patients who achieve an initial chemosensitive
response but relapse or progress <12 months from
diagnosis = Candidates for myeloabaltice
chemotherapy/ autologous stem cell transplantation
w/ or w/out radiation therapy
○ Allogeneic transplant=18% decrease
○ Autologous transplant=41% decrease
● For more refractory cases= Zevalin or Bexxar are
trialed (radioisotope linked anti-CD20 mabs
○ Both shows to be more effective in NHL than
rituximab
PROGNOSIS
Prognosis

● Patients with favorable prognostic factors and

early-stage disease have
○ Event-free survival (EFS) = 85-90%
○ Overall 5-year survival (OS) = >95%
● Patients with advanced stage
○ EFS = 80-85%
○ OS = 90% (appriaches 100% with dose-intense
therapy)
Prognosis

● Prognosis after relapse depends on the ff:

○ Time from completion of treatment to recurrence
■ Relapse >12 mos after chemotherapy= best
prognosis
■ They usually respond to additional standard
therapy with long term survival of 60-70%
○ Site of relapse (nodal vs extranodal)
○ Presence of B symptoms
PREVENTION
Prevention
● Avoid known risk factors for HIV, such as intravenous (IV) drug
use or unprotected sex with many partners.

● There is no vaccine to protect against EBV infection. You can

help protect yourself by not kissing or sharing drinks, food, or
personal items, like toothbrushes, with people who have EBV
infection.

● You should make sure that all of your vaccinations are up-to-date.

● Have a healthy lifestyle to strengthen your immune system.

 REFERENCES
Dr. Felipe’s Lecture

American Society of Clinical Oncology. (). Lymphoma - Hodgkin Risk Factors. Access on October 28, 2021
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Center for Disease Control and Prevention (2021). About Epstein-Barr Virus. Access on October 28, 2021
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THANK
YOU