Clinical Significance
Ann Arbor’s classification indicates that Stage II disease denotes the involvement of at least two lymph nodes on one side of the diaphragm (Lash & Argiris, 2017). MP needs to undergo a PET-CT scan to help in her risk stratification. Stage II disease can either be early stage favorable or unfavorable. An echocardiogram is indicated to rule out the involvement of the heart while the pulmonary function tests rule out the involvement of the lungs. These two tests are essential in the management of elderly patients with Hodgkin lymphoma.
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Risk Factors
The risk factors for developing Hodgkin lymphoma include (American Cancer Society, 2017):
• HIV infection
• A higher socioeconomic status
• Positive family history of Hodgkin lymphoma
• Male sex
• Early adulthood (especially twenties) and late adulthood (after 55)
• Previous Epstein-Barr virus infection/ infectious mononucleosis
Pathophysiology
Hodgkin lymphoma affects germinal center B cells found in the lymphatic and reticuloendothelial systems. These affected B cells are referred to as Hodgkin Reed-Sternberg cells. The cells contain mutations in their genomic sequences and undergo clonal expansion. It is also during the expansion that the somatic mutations also occur. The cells are unresponsive to cell-cycle control molecules, and thus, their growth is unchecked.
The initial mutations may be random or caused by the Epstein-Barr virus infections (Alarcon, 2017). The mutations may also be idiopathic, and with the lack of inhibition of growth, the affected areas are characterized by the formation of masses. The tumor cells spread to other parts of the body via lymphatics and may also be disseminated by the direct spread or hematological spread. Due to the increased number of B-cells, higher amounts of inflammatory cytokines are produced and further leads to the constitutional signs and symptoms such as fever and night sweats. The immune system is highly organized, and any slight disruption of this integrity renders the patients susceptible to infections especially respiratory and gastrointestinal. The increased metabolism of the tumor cells leads to loss of weight.
Patient Considerations
The patient wishes to retain her fertility, and as such, preservation methods should be considered through adopting treatment regimens that are highly selective for the tumor. Procedures that are risky to the fertility of the patient, especially irradiation, should be avoided. In case radiation is used, it should be focused on the location of the lesion.
Management Strategy
In favorable disease, two to four cycles of combination/ ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) chemotherapy are recommended. This is followed by 20 Grays of involved-field radiation therapy (IFRT). In unfavorable disease, four cycles of ABVD are recommended followed by 30 Grays of IFRT (Ansell, 2016). The prognosis in both approaches is a survival rate that is approximately 90 percent (Ansell, 2016). Despite this being the standard methods of treatment, sole use of chemotherapy has been found to have similar survival rates. MP had indicated that she wishes to have children. Therefore, the irradiation step can be avoided especially if the pelvic nodes are affected. These two alternatives, with or without irradiation, should be provided to MP to aid her in making an informed decision. After recovery, she should be scheduled for follow up visits and advised on the tell-tale signs of relapse.
Social and Financial Considerations
Health transcends beyond physical wellbeing. It also includes the mental and social welfare of the patient. A significant cultural/ social consideration is her fertility after treatment. Management should be tailored to preserve this function. Failure to adhere to this wish may result in mental stress and anxiety. Her financial status should also be assessed to prevent the prescription of unaffordable drugs. The cost of treatment should not become a burden, if unavoidable. Patient management is a multi-faceted approach that goes beyond physical recovery. The patient should be able to retain previous functions and roles in society.
- Alarcon, P. (2017, March 20). Pediatric Hodgkin Lymphoma. Retrieved from Medscape: https://emedicine.medscape.com/article/987101-overview#a4
- American Cancer Society. (2017, March 28). Hodgkin Lymphoma Risk Factors. Retrieved from American Cancer Society: https://www.cancer.org/cancer/hodgkin-lymphoma/causes-risks-prevention/risk-factors.html
- Ansell, S. (2016). Hodgkin lymphoma: 2016 update on diagnosis, risk-stratification, and management. American Journal of Hematology, LXXXI(4), 434-442. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/ajh.24272/full
- Lash, B., & Argiris, A. (2017, July 6). Hodgkin Lymphoma. Retrieved from Medscape: https://emedicine.medscape.com/article/201886-overview
