Dr. Ehsanur Reza SHOVANAssistant professor

D t t f Department of surgery

It is a malignant disorder of lymph node, It is a malignant disorder of lymph node, clinically characterized by progressive, painless enlargement of lymphoid tissue h h h b d Thi i h through out the body. This is the commonest

form of lymphoma.

wherever there is lymphoid tissue, it may occur. The following structures are commonly The following structures are commonly involved-Lymph nodes enlargement – a constant feature, starts more commonly either in the supraclavicular or jugulodigastric nodes. Localised initially become generalised at Localised initially, become generalised at variable interval.Spleen and liverSpleen and liverBones – mainly vertibral column and pelvis.Rarely single organ like stomach, lungs, y g g , g ,intestine or kidney is involved.

Macroscopic feature :Macroscopic feature :

Node – enlarged, g ,discrete, without periadenitis having firm, p g ,

elastic or rubbery consistency.

Cut section : Cut section : uniform pink-grey in color, moist and translucent like fish-flesh.Microscopic feature : normal architecture of LN is replaced by infiltration with lymphocytes, reticulum cells, eosinophils, plasma cells and the characteristic Reed-Sternberg (RS) cellscharacteristic Reed-Sternberg (RS) cells.

Lymphocytic predominant – abundance of Lymphocytic predominant abundance of mature lymphocytes and histiocytes but few RS cells. Uncommon (6% of Hodgkin’s l h ) E ll ilymphoma). Excellent prognosis.Nodular sclerosis – node divided into island of lymphoid tissue by dense fibrous bands with lymphoid tissue by dense fibrous bands with readily apparent RS cells. Common in young women. Most common form (70%). Excellent prognosis.

Mixed cellularity – increased number of small Mixed cellularity increased number of small lymphocytes, eosinophils, and plasma-cells and abundance of larger RS cells. Common (20 25%)(20-25%).Lymphocytic depletion - abundance of RS cells and few lymphocytes Occurs in older cells and few lymphocytes. Occurs in older males, aggressive clinically. Rare (2%).

Common subject – male (2 fold preponderance), j ( p p ),young adult (15-34 yr) but may occur at any age.Onset – insidious.Primary feature – painless progressive enlargement of LN, most commonly in the neck involving supraclavicular but sometimes in the involving supraclavicular but sometimes in the groin or axilla. First it is found on one side, subsequently appears on other side. Lymphadenopathy is generalised in nature nodes Lymphadenopathy is generalised in nature, nodes are discrete, non-tender elastic or rubbery in feel but later may become matted.

Splenomegally and hepatomegallySplenomegally and hepatomegallyPain in bones – due to osseous deposit.Pyrexia – Pal-Ebstain fever.yPruritis and pigmentation of skin

Dyspeptic symptoms, jaundice, pain in Dyspeptic symptoms, jaundice, pain in abdomen, sometimes bouts of diarrhoea may be present due to enlarged abdominal nodes

d i fil i f b l i h H d ki ’ and infiltration of bowel with Hodgkin’s tissue.Superior vena caval syndrome dyspnoea Superior vena caval syndrome – dyspnoea, cyanosis of face (mediastinal node involvement).Pallor (and pancytopenia) due to hypersplenism.Reduction of body weight.

[DROPS : D – diarrhoea, dyspnoea and dyspnoea and dyspeptic symptoms;

R reduction of body weight ;R – reduction of body weight ;O – osseous pain, onset ; P – painless palpable nodes P – painless, palpable nodes,

pyrexia, pigmented skin, pressure symptoms, pallor, pancytopenia, pathological freacture, paraplegia ;

S – splenomegally (and h t l ) ]hepatomegaly) ]

4 stage. 4 stage. Each again classified into ‘A’ and ‘B’ depending on the absence or presence of associated generalised symptoms – wt loss, fever, anaemia, pruritus and bone pain.

Stage 1 Single lymph node region or single extranodal site

Stage 2 Two or more nodal groups on same side of diaphragm

Stage 3 Two or more nodal groups on both sides of diaphragm, g g p p g ,may include spleen involvement

Stage 4 Disseminated involvement of one or more extra nodal Stage 4 Disseminated involvement of one or more extra nodal sites (eg. Liver, bone marrow, skin), with or without LN involvement.

Blood examination : anaemia, lymphopeniaBlood examination : anaemia, lymphopeniaand oesinophilia. ESR may be elevated.LN biopsy – diagnostic and histological grading. FNAC is not preffered. Chest x-ray – may show hilarl h d thlymphadenopathy.Skeletal servey.IVU to detect retropritoneal LN which may IVU – to detect retropritoneal LN, which may causes displacement and distortion of pelvis and ureter.

Lower limb lymphangiography – to detect Lower limb lymphangiography to detect pelvic LN involvement.USG and CT scan – to detect any mass.Staging laparotomy – for a) splenomegaly b) liver biopsy c) abdominal LN biopsyBone marrow biopsy

Two forms of treatments are available and they are stage and site dependent –they are stage and site dependent radiotherapy and combination chemotherapy.Radiotherapy is the treatment of choice in stage 1, 2, 3A diseases.Combination chemotherapy is used in stage 3B d 4 di3B and 4 disease.COPP – cyclophosphamide, oncovin, procarbazine and prednisoloneprocarbazine, and prednisolone.Surgery – 1) biopsy and staging laparotomy, 2) excision of localised LN lesion.)

In localised disease treated with irradiation there is a 5-year survival rate of at least 80% I di i d di d i h 80%.In disseminated disease treated with cytotoxic chemotherapy the 5-year survival falls to 50%.

Prognostic indicators include:age - better prognosis in younger patients g p g y g phistology - lymphocytic predominant >

nodular sclerosis > mixed cellularity > lymphocytic depletion lymphocytic depletion stage - lower has better prognosis symptoms - generalised symptomatic symptoms - generalised symptomatic

disease has worst prognosis

ThThanx