Hodgkin Presentation

HODGKIN
LYMPHOMA
Oleh:
Kevin Raymond T 110100304
Supervisor:
dr. Johannes H. Saing, Sp.A(K)
1
LITERATURE REVIEW
2
BACKGROUND
Hodgkin
Malignant Intoleransi
Rare cases in the
lymphoma world, 5th in Indonesia
aktivitas
Non Hodgkin
If left
untreated  Bad progressivity, harder to cure
3
DEFINITION
 Malignancy of lymphoreticular system

and its supporting tissue that often attacks
the lymph nodes and marked by a typical
histopatologic findings
4
Classification
I Lymphocyte predominant
II Mixed cellularity
III Lymphocyte depletion
N= 25
IV Nodular sclerosis
5
Staging
I 1 lymph region
II 2 or more lymph region in one side of diaphragm
III 2 or more lymph region above and below diaphragm
IV Extra nodular involvement
A no systemic symptoms
B 1 or more systemic symptoms
X bulky mass
S Spleen involvement
6
Epidemiology
Incidence and prevalence of HL in pediatric

population are still not well known
HL In Indonesia, NHL>HL, and male>female
In USA, male>female, with peak incidence

occurred in 15-35 yrs old and 50 years old
7
Genetic
change
Etiology
Virus and Growth factor

immunologic disregulation
effect
8
Clinical Manifestation
Swelling
Night sweating Fever

Clinical
Manifestation
Weight loss Specific organ

involvement
9
Diagnosis
History taking
Physical examination
Biopsy aspiration
Radiology
Laparotomy
Laboratory tests
Complete blood count (CBC)
Prothrombin time (PT)
Activated partial thromboplastin time (aptt)
Erythrocyte sedimentation rate (ESR)
Liver function test
Differential Diagnosis
Non Hodgkin lymphoma
Nasopharing cancer
Thyroid cancer
Bacterial/viral pharyngitis
Treatment (new case)
Only radiotherapy
Only chemotherapy
Radiotherapy+chemotherapy
Treatment (relaps case)
A = Adrianmisin 40 mg/sqm i.v. every 3 weeks
B = Bleomisin 15 U 1-v- every week
C = Lomustin (CCNU) 80 mg/sqm p.o. every 6 weeks
D = Dakarbasin 800 mg/sqm i-v- every 3 weeks
C = Lomustin (CCNU) 80 mg/sqm p.o. day 1
E = Etoposid 100 mg/sqm p.o. day 1
P = Prednimustin 60 mg/sqm i.v.day 1, every 3-6 weeks

E = Etoposid 200 mg/sqm p.o. day1-5
V = Vinkristin 2 mg/sqm i.v. day1
A = Adriamisin 20 mg/sqm i.v. day1, every 3 weeks
M = Metil-GAG 500 mg/sqm i.v. day 1-14
I = Ifosfamid 1 gram/sqm i.v. day1-5
M = Metotreksat 30 mg/sqm i.v. day3
E = Etoposid 100 mg/sqm i.v. day 1-4, every 3 weeks

C = Lomustin 100 mg/sqm p.o. day1
E = Etoposid 100 mg/sqm day1-3 and 21-23
M = Metotreksat 30 mg/sqm p.o. day1,8,21,28, every 6

weeks
M = Metotreksat 30 mg/sqm i.v. every 6 h for 4 days from day 1

and 8
C = Siklofosfamid 750 mg/sqm i.v. day15
H = Doksorubisin 50 mg/sqm i.v. day15
O = Vinkristin 1 mg/sqm i.v. day15 and 22
P = Prednison 100 mg/sqm p.o. day 22-26, every 4 weeks

Prognosis
•Depends on the classification, mostly good with
no remission
•Late complication may occur, including:
1. Emergence of a second malignancy or secondary
2.Endocrine dysfunctio: thyroid and gonad
3. CVS disease, especially those who received a combination of
radiation and administration of the high anthracycline dose
4.Lung disease in those who received radiation and bleomycin
5.In children can occur growth disorders
17
Case Report
18
History taking
R, male, 6 years and 3 months old
Chief complaint :
Swelling on the right neck, 2 years before admission
and worsen until admission. No pain was experienced
on the swelling. Swelling on another body parts was not
found.
Cough , found a month ago. The cough was non-
productive
Weight loss, since 6 months ago, losing ±5kg of body
weight
History taking
Nausea and vomiting was not found.
History of urination and defecation is normal.
Previously, the patient has been diagnosed with Hodgkin
lymphoma in Haji Adam Malik General Hospital a
month ago.
General Status:
Body weight: 16 kg,
Body length: 116 cm,
BW/age: 72,7%
BL/age: 98,1%
BW/BL: 78,1%
Present status
Consciousness : GCS 15 (E4 V5 M6)
Blood Pressure : 110/70 mmHg
Heart Rate : 88 x/i
Respiratory Rate : 24 x/i
Body Temperature : 37,0 oC.
Anemic (-). Icteric (-). Cyanosis (-). Edema (-).
Dyspnea (-).
Local Status
Head:
Eyes : Isochoric pupil . Inferior palpebral
conjunctiva pale (-/-). Icteric sclera (-/-). Light
reflex (+/+). Face edema (-). Inferior and
superior palpebral edema (-/-). Bleeding (-/-).
Ears/ nose/ mouth: Within normal range/
nasal flaring (-)
Neck:
Swelling on the right neck, single nodule, size 20x10
cm, well demarcated, pain (-), Jugular venous pressure:
R+2 cmH2O.
Thorax:
Symmetrical fusiform (+). Venectasia (-). Retraction (-
). S1 and S2 normal, HR: 88x/i, regular, murmur (-).
RR: 24x/i, regular, breath sound: vesicular, ronchi (-/-
).
Abdomen :
Soepel, peristaltic (+), non-palpable liver
and spleen, Skin pinch returns quickly
Extremities :
Pulse 88x/i, regular, adequate pressure and
volume, warm, CRT < 3”. Pitting oedema(-
)
WORKING DIAGNOSIS
Hodgkin lymphoma
MANAGEMENT
IVFD D5% NaCl 0,45% (minimal)
Inj. Ceftriaxone 500 mg/ 12 hrs/ IV
Inj. Ranitidine 20 mg/ 12 hrs/ IV
Paracetamol drips 200 mg/ 6 hrs/ IV
LABORATORY STUDIES
Haematology Result Reference
Haemoglobin g/dL 9.70 11.3 – 14.1
Erythrocyte 4.32 4.40 - 4.48
Leukocyte 7.3 4.5 - 13.5
Hematocrit % 29.9 37 – 41
Thrombocyte 347 150 – 450
MCV fL 69.20 81 – 95
MCH pg 22.50 25 - 29
MCHC g% 32.40 29 - 31
RDW % 16.60 11.6 - 14.8
Neutrophil % 47.70 37 – 80
Lymphocyte % 33.00 20 - 40
Monocyte % 14.40 2–8
Eosinophil % 4.20 1–6
LABORATORY STUDIES
Arterial Blood Gas Analysis
pH 7.369 7.35 – 7.45

pCO2 mmHg 39.3 38-42
pO2 mmHg 124 85-100
Bicarbonate mmol/L 14.2 22-26
(HCO3)
Total CO2 mmol/L 15 19-25
Base Excess mmol/L -98 (-2)-(+2)
O2 Saturation % 98.5 95-100
LABORATORY STUDIES
Liver
Albumin g/dL 3.4 3.8-5.4
Carbohydrate metabolism
Blood glucose ad mg/dL 66.7 <200

random
Electrolyte
Natrium mEq/dL 132 135-155
Kalium mEq/dL 4.5 3.6-5.5
Chlorida mEq/dL 102 96-106

Chest X-Ray: November, 26th
2015
Histopathology: December, 7th 2015
Histopathology: December, 7th 2015
Macroscopic:
Received 1,5 cc of white, spongy tissue
Microscopic:
Found tumour mass of hypercellular cell, among them are binucleated,
multinucleated, and popcorn appearance cell, abnormal mitosis can be
found easily, between it found inflammated lymphocytes
Conclusion:
Hodgkin lymphoma
FOLLOW UP
33
Follow up
November, 26th 2015
S Patient was admitted to the non-infection unit at 26/11/15 12.15 pm.

Rahmat, male, 6 years 3 months OLD, came with:
Main complain : swelling on the right neck
Elaboration : the symptom occured 2 years ago before admission,

and worsen until admission. Cough (+) since a months ago, fever (-),
weight loss (+) about ±5 kg in 6 months.
History of previous treatment : the patient was a treated at
hematology division and was diagnosed with Hodgkin lymphoma.
History of drug usage : Not clear
Follow up
Physical examination:
O Sensorium: compos mentis Temp: 36,8 oC Weight: 16 kg Height: 116 cm Anemia (-)
dispnea (+) icteric (-) oedema (-), cyanosis (-)
Head: Eye: light reflex (+/+) pupil isochor, pale conjunctiva palpebrae inferior (-/-)
Ear/Nose/Mouth : within normal range
Neck : swelling 20x10 cm, well demarcated, pain (-)
Chest : symmetrical fusiform (+) chest wall retraction (-)
Heart rate : 88 x/i, regular, murmur (-)
Respiratory rate : 24 x/i, regular, rhales (-)
Abdomen : soft and palpable, peristaltic normal
liver/lymph/kidney is indeterminate
Extremities : Pulse rate 88 x/i, regular, pressure/volume is sufficient, warm, capillary
refill time < 3 seconds.
SaO2 : 95% Blood pressure : 120/60 mmHg
Follow up
Laboratory results:
O Hb/Ht/L/T : 9.7/29.9/7,300/347,000
pH/PCO2/PO2/HCO3/total CO2/BE/Sat:
7.369/25.3/124/14.2/15/-9.8/98.5
Albumin: 3.4
Blood Glucose Level: 87.7 g/dl
Na/K/Cl: 132/4.5/102
Follow up
A Hodgkin lymphoma
P •Bed rest
•IVFD Dextrose 5% + NaCl 0.45% (minimal)
•Planning for BMP
Follow up
November, 27th 2015
S Swelling on the right neck
O Physical examination:
Sensorium: compos mentis Temp: 37,0 oC Weight: 16 kg Height: 116 cm
Anemia (-) dispnea (+) icteric (-) oedema (-), cyanosis (-)
liver/lymph/kidney is indeterminate.
Extremities : Pulse rate 88 x/i, regular, pressure/volume is sufficient, warm,
capillary refill time < 3 seconds.
Follow up
A Hodgkin lymphoma
P • Bed rest
•Planning for BMP
•Refer to cardiology, oncology division
Follow up
November, 28th 2015 – 30th 2015
O
Head: Eye: light reflex (+/+) pupil isochor, pale conjunctiva palpebrae
inferior (-/-)
Follow up
A Hodgkin lymphoma
• Bedrest
P
•Planning for BMP
Follow up
December, 1st 2015
O
Follow up
O Laboratory results:
Hb/Ht/L/T : 10.9/32.9/7,680/428,000
pH/PCO2/PO2/HCO3/total CO2/BE/Sat:
7.396/25.6/132/14.2/15/-3.8/98.5
Albumin: 4.2
Blood Glucose Level: 72.6 g/dl
Na/K/Cl: 137/4.5/118
Follow up
A Hodgkin lymphoma
P • Bed rest
•Planning for elective incisional biopsy
Follow up
December, 2nd 2015
O
inferior (-/-)
Follow up
A Hodgkin lymphoma
• Bed rest
P
•Elective incisional biopsy
Follow up
December, 3rd 2015 – 8th 2015
S Swelling on the right neck, post incisional wound
O
inferior (-/-)
Follow up
A Hodgkin lymphoma
• Bed rest
P
•Inj. Ceftriaxone 500 mg/ 12 hrs/ IV
•Inj. Ranitidine 20 mg/ 12 hrs/ IV
•Paracetamol drips 200 mg/ 6 hrs/ IV
DISCUSSION
49
Discussion
EPIDEMIOLOGY EPIDEMIOLOGY
Hodgkin lymphoma is present The patient is male, 6 years
more in men than women, and and 3 months old
may happen as early as 5 years
old, with the highest incidence
range from 15-35 years
Discussion
CLINICAL HISTORY AND CLINICAL HISTORY AND
PHYSICAL EXAMINATION PHYSICAL EXAMINATION
•Most patient complaints are Patient complaints of swelling on
enlarged lymph nodes in the neck, the right neck, cough, and weight
axilla or groin, weight loss and loss.
sometimes accompanied by fever,
sweating and itching.
•Palpable enlarged lymph nodes,
spleen and liver
Discussion
TREATMENT TREATMENT
According to the staging, either - IVFD Dextrose 5% + NaCl
0.45% (minimal)
radiation therapy, chemotherapy, or
- Inj. Ceftriaxone 500 mg/ 12 hrs/
combination of both IV
- Inj. Ranitidine 20 mg/ 12 hrs/ IV
- Paracetamol drips 200 mg/ 6 hrs/
IV
SUMMARY
53
Summary
R, male, 6 years and 3 months of age was
admitted to the hospital on November, 26th
2015 with a chief complaint of swelling on
the right neck, and additional symptoms:
non productive cough and weight loss. The
patient was diagnosed with Hodgkin
lymphoma.
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HODGKIN

 Malignancy of lymphoreticular system

III Lymphocyte depletion

II 2 or more lymph region in one side of diaphragm

III 2 or more lymph region above and below diaphragm

IV Extra nodular involvement

Incidence and prevalence of HL in pediatric

HL In Indonesia, NHL>HL, and male>female

In USA, male>female, with peak incidence

Virus and Growth factor

Night sweating Fever

Weight loss Specific organ

B = Bleomisin 15 U 1-v- every week

C = Lomustin (CCNU) 80 mg/sqm p.o. every 6 weeks

D = Dakarbasin 800 mg/sqm i-v- every 3 weeks

C = Lomustin (CCNU) 80 mg/sqm p.o. day 1

E = Etoposid 100 mg/sqm p.o. day 1

P = Prednimustin 60 mg/sqm i.v.day 1, every 3-6 weeks

V = Vinkristin 2 mg/sqm i.v. day1

A = Adriamisin 20 mg/sqm i.v. day1, every 3 weeks

M = Metil-GAG 500 mg/sqm i.v. day 1-14

I = Ifosfamid 1 gram/sqm i.v. day1-5

M = Metotreksat 30 mg/sqm i.v. day3

E = Etoposid 100 mg/sqm i.v. day 1-4, every 3 weeks

E = Etoposid 100 mg/sqm day1-3 and 21-23

M = Metotreksat 30 mg/sqm p.o. day1,8,21,28, every 6

M = Metotreksat 30 mg/sqm i.v. every 6 h for 4 days from day 1

C = Siklofosfamid 750 mg/sqm i.v. day15

H = Doksorubisin 50 mg/sqm i.v. day15

O = Vinkristin 1 mg/sqm i.v. day15 and 22

P = Prednison 100 mg/sqm p.o. day 22-26, every 4 weeks

pH 7.369 7.35 – 7.45

Albumin g/dL 3.4 3.8-5.4

Blood glucose ad mg/dL 66.7 <200

Natrium mEq/dL 132 135-155

Kalium mEq/dL 4.5 3.6-5.5

Chlorida mEq/dL 102 96-106

S Patient was admitted to the non-infection unit at 26/11/15 12.15 pm.

Main complain : swelling on the right neck

Elaboration : the symptom occured 2 years ago before admission,

Blood Glucose Level: 87.7 g/dl

Blood Glucose Level: 72.6 g/dl

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