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History
Thomas Hodgkin 1798-1866 Guys Hospital, London
Accomplishments: Clinicopathologic correlation (pre-microscope) Appendicitis c peritonitis
Local spread of cancer to nodes
Brought stethoscope to England (Laennac) Histology of RBCs, muscle (Lister)
Aortic insufficiency
Public health (cholera, lead pipes)
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History
Thomas Hodgkin 1798-1866 (cont)LAD: cancer, inflammation, TB, syphilis
1832 On Some Morbid Appearances of theAbsorbent Glands and Spleen
Six cases of LAD s pain, heat, or primary tumor
Billrothmalignant lymphomas
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Lymphoproliferative Disorders
Benign reactive lymphoproliferativedisorders
Histiocytosis X (Langerhans-cell) Plasma call neoplasms
Lymphomas
Non-Hodgkins lymphomas Hodgkins Disease
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Immunology Review
Blood WBCs
Lymphocytes
B-cells T-cells
NK-cells
Major histocompatibility complex (MHC)
I: all cellsII: immune cells
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Immunology Review
B-cellsBursa of Fabricius
Secrete immunoglobulin
Ig A, D, E, G, M
T-cellsThymus, thymic education
Tc, Th1, Th2, Ts
NK cellsNon-specific, no memory
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Lymphocyte Differentiation
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B-Cell Development
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Tumorigenesis
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Techniques for Investigation
Cytogenetics
Immunohistochemistry
FISH Flow Cytometry
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Cytogenetics
t(14,18) common (about 30%)Bcl-2
Follicular growth pattern
t(8,14)common in Burkittsc-myc
Multiple anomalies common
Correlation between cytogenetic change andoutcome is variable
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Cytogenetics
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Cytogenetics
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Immunohistochemistry
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Immunohistochemistry
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Immunohistochemistry
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Immunohistochemistry
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ClassificationHD
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Reed-Sternberg Cell
Described 1898 Sternberg, 1902 Reed
Popcorn cell variant
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Lymphocyte-PredominantMixed Cellularity
Lymphocyte-Depleted Nodular Sclerosis
Lacunar cell
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ClassificationNHLs
Rappaport1956Nodular vs. diffuse
Lymphocytes vs. histiocytes
Kiel, Lukes-Collins, BNLI, Dorfman, WHO
Working Formulation1982
Revised European-American LymphomaClassification (REAL)1994
From International Lymphoma Study Group
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Rappaport
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Kiel
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Kiel
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Working Formulation (1982)
Designed to be a translational schemebetween others, became free-standing
Essentially modified from RappaportHistiocyticLarge cell
Not based on cell of originBased on survival to 1970s chemo
H&E only, no special stains Test/Retest 0.53-0.93
Interobserver concordance 0.21-0.65
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Working Formulation
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Non-Hodgkins Lymphomas
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Small lymphocytic Small cleaved Mixed,
Small cleaved
and large cell
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Large cell,
Cleaved and
Non-cleaved
Mixed,
Non-cleaved
Large cell,
Non-cleaved
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REAL (1994)
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REAL
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Staging
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LN Zones
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Epidemiology
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Epidemiology
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Epidemiology
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Hodgkins Disease
Bimodal peak
Incidence decreasing
Geographic variation
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EpidemiologyHodgkins
Bimodal
Postulated tohave
infectious
association
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EpidemiologyHodgkins
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EpidemiologyHodgkins
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EpidemiologyHodgkins
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EpidemiologyNHLs
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EpidemiologyNHLs
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EpidemiologyNHLs
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Epidemiology
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EpidemiologyHIV
Anti-retroviral tx has decreased incidence
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Workup
H & P
Usually FNAr/o SCCaexcisional bxif lymphoma for architecture, flow cyt.
Chemistries, CBC c smear, LFTs c LDH,ESR, beta-2 microglobulin
CT chest, abdomen, pelvis
Bone marrow (MR directed?) Adjunct: Gallium, FDG-PET
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HD vs. NHLClinical Exam
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Gallium Scan
Gallium-67 isotope
Affinity for lymphomas
Good sensitivity/specificity If treatment makes Ga scan negative, good
chance at lasting remission
May find occult disease
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Gallium Scan
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FDG-PET
PETpositron emission tomography
FDG18-fluoro deoxy-glucose
Taken by actively metabolic cells Good sensitivity/specificity
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Staging Laparotomy
Looks for infradiaphragmatic disease Important if disease o/w would be Stage I/II
supradiaphragmatic
May change Tx Largely supplanted by non-invasive techniques
Not complication-free
Laparoscopy?
Controversial
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Burkitts Lymphoma
AfricanendemicUsually presents in
maxilla or mandible
EBV ++
SporadicSome EBV
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Lethal Midline Granuloma
Polymorphic reticulosis
Lymphomatoid granulomatosis
Idiopathic midline destructive disease Clinically similar to Wegeners
No granulomas or histiocytes
Poor survivial
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Treatment
ChemoHD: MOPP, ABVD
NHLs: CHOP
Radiation
Bone marrow transplant
ImmunotxRituxananti-CD20
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Case Report
34 yo WM c/o night sweats
Saw ID MD, told he had CMV
2 years later, still night sweats Trouble shaving due to fullness in neck
BiopsyNon-Hodgkins Lymphoma, low-
grade Bone marrow ++, both sides diaphragm
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Case Report
Rituxan, chemoDisease came back when off
Bone marrow transplant, allogeneic ++ Richters transformation
GVHD
Expired
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