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A 40-year-old male presented with cervical lymphadenopathy

Presented by

DR. Sharmin Easmin

Phase- B Resident

Green Unit

Department of Haematology

BSMMU

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Particulars of the patient�

Name: Mr. Jewel
Age: 40 years
Gender: Male
Occupation: Imam of mosque
Religion: Muslim
Address: Noakhali
Haematology - OPD

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Presenting complaints

Nodular swelling over the right side of the neck for one and half month.

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History of present illness

Patient was reasonably well one and half month back.
Then he noticed a swelling over the right side of the neck-

Insidious
Painless
Progressive

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Cont….

No history of fever, night sweat, weight loss,
No H/O cough, SOB, haemoptysis,H/O bleeding, contact with TB patient.
No swelling other side of the body.

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Cont…..

History of Past illness: No significant past history.
Drug History: Nothing
Immunization history: Not knowen
Family History: No significant Family history
Socioeconomic History: Lower middle class
Educational History : Madrasa, Class eight equivalent
Personal History: Nothing
Allergic History: Nothing

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General Examination

Appearance: Normal
Body build : Average
Decubitus: On choice
No Anaemia, jaundice, clubbing, cyanosis, koilonychia, leukonychia or oedema
Pulse: 88 beat/min
BP: 120/80 mm of Hg
Temperature: 98 ⁰F
Respiratory: 22/ min

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Cont…..

Lymphadenopathy involving on the right anterior and posterior cervical chain of the neck

Variable size and shape, largest one 2x2 cm in diameter,
Non tender,
Firm in consistency,
Discrete,
not adherent to the underlying structure or overlying skin
no discharging sinus.

No bony tenderness
No thyromegaly

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Systemic Examination

Examination of all systems including Gastrointestinal & respiratory system reveals no abnormality

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Salient feature:

Mr.Jewel,40years,old,Imam, normotensive, nondiabetic, nonsmoker, hailing from Noakhali presented with nodular swelling over the right side of the neck for one and half month. These swelling are insidious on onset, painless and gradually increasing in size. There is no history of fever, night sweat, weight loss, cough, SOB, haemoptysis, H/O bleeding, skin rash, arthritis contact with TB patient or history of exposure. No swelling other side of the body. His bowel and bladder habits are normal. There is no family history of such illness. He has no drug or treatment history.

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On examination-

General examination:

Appearance: Normal, Body build : Average, Decubitus: On choice, No Anaemia, jaundice, clubbing, cyanosis, koilonychia, leukonychia or oedema. Pulse: 88 beat/min, BP: 120/80 mm of Hg, Temperature: 98^oF,Respiratory: 22/min.

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Lymphadenopathy involving on the right anterior and posterior cervical chain of the neck which are variable in size and shape, largest one 2x2 cm in diameter,non tender,firm in consistency,discrete,not adherent to the underlying structure or overlying skin,no discharging sinus.No bony tenderness,no thyromegaly. Examination of all systems including Gastrointestinal & respiratory system reveals no abnormality.

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CBC


Hb	12.1 gm/dl
Total WBC count	3.6 x 10 u/L
Platelet count	110 x 10 u/L
ESR	03 mm Hg/1^st hour

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Other parameter:


LDH	190 mg/dl
Creatinine	1.2 mg/dl
Electrolytes	Na 136 mmol/L, K 3.9 mmol/L
SGPT	45 IU/ml
Bilirubin	0.9 mg/dl
Albumin	38 mg/dl
Mantoux test	Negative

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Chest X-Ray- normal
ECG- normal
Echocardiogram- pending
HIV- pending
HCV and HBV- pending

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Lymph node histopathology

Microscopic examination:

Section show lymph node, nodal architecture is lost and replaced by lymphocytes, plasma cells, histocytes and eosinophils.

Few Reed-Sternberg like cells is also seen.

Diagnosis:

Lymphoproliferative disorder, features are highly suggestive of Hodgkin lymphoma

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Immunohistochemistry:

CD20: positive
CD30: positive
CD15: positive
CD3: positive
LCA/CD45: negative

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Confirm Diagnosis:

Hodgkin Lymphoma

(mixed cellularity)

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FDG PET Scan shows

Bilateral centrimetric sized multiple non-avid cervical lymph node including one rt. cervical level II hypermetabolic LN suggest malignancy.
Bilateral low avid to avid axillary lymphnodes suggest malignancy.
No avid reactive lymph node.

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Diagnosis:

Hodgkin Lymphoma (mixed cellularity) stage II A

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Prognostic factors for early stage HL

Age ≥ 50 years
Elevated ESR
Involvement of multiple nodal sites
Extra nodal involvement
Large mediastinal mass
Massive splenic disease

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* Rajkumar et el 2022, Hoffbrand 8^th edition

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NCCN guideline version 2.2020

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What will be our chemotherapeutic option for this patient?

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Advanced stage (IIB-IV)

ABVD vs. BEACOPP + local RT

Standard & escalated BEACOPP vs. COPP alter with ABVD

MOPP, ABVD & MOPP alternating with ABVD

The Stanford V vs. ABVD

6 cycle ABVD vs. 4 cycle esc BEACOPP + 2 cycle std BEACOPP

6 cycle BEACOPP + RT to PET positive site

6 x esc BEACOPP + RT to PET positive site

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2 cycle ABVD>> PET scan

Patients with negative scan>

4 cycle ABVD/ AVD

Pt with positive scan>

4 x BEACOPP-14/ 3 x escalated BEACOPP>

PET>

Negative> 2 x BEACOPP

Positive> switch off

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early HDCT+ASCT as early intensification

Brentuximab + AVD

Brentuximab + ABVD

Brentuximab + BrECAPP

Brentuximab + BrECADD

PD- 1 Ab +AVD

PD- 1 Ab + Brentuximab

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Ann Arbor Staging

Stage I	Involvement of a single LN region or lymphoid structure
Stage II	Involvement of two or more LN regions or LN structures on the same side of the diaphragm
Stage III	Involvement of LN regions or lymphoid structures on both sides of the diaphragm
Stage IV	Diffuse or disseminated involvement of one or more extralymphatic organs or tissues with or without associated LN enlargement Involvement of liver and bone marrow always considered stage IV