Hodgkin's+Disease+(adult+and+child)

More common in developed countries1 Approximately one half of Hodgkin’s lymphomas are diagnosed in patients younger than 40 years of age1 Median age=38 y.o Rare in children younger than 10 y.o || There seems to be an increased frequency in patients with AIDS. In these patients1 Another risk factor for Hodgkin's is defective T-cell functioning.1 || Medistinal masses detected with chest x-rays1 Most disease is above the diaphragm1 1/3 of patients experience B Symptoms1 Unexplained fevers Drenching night sweats Weight loss of 10% of their body weight within 6 months May experience a cough, shortness of breath or chest discomfort1 Enlarged spleen or abdomen, bony tenderness and pleural effusion indicate a later stage of Hodgkin’s disease1 || > Posteroanterior and lateral chest radiographs are needed with measurements of the tumor mass: thoracic ratio at either T5-6 or at the diaphragm and Computed Tomography (CT) scans of the chest, abdomen and pelvis. In reviewing the chest CT scan, evaluation of the mediastinal disease extent, axillary involvement, pericardial nodal involvement and chest wall invasion are completed. The baseline nuclear medicine scan used is F-fluorodeoxyglucose positron emission tomographic (FDG-PET) scanning (more sensitive to both initial staging and follow-up of Hodgkin’s disease. 2 > > - Pathological evaluation: Bone marrow biopsies are limited to patients with advanced stage disease and/or constitutional symptoms. Excisional biopsies are done, depending upon location of the disease. 2 > > -Pretreatment baseline evaluation: Patients receiving Adriamycin need a baseline MUGA scan. Patients receiving bleomycin need baseline pulmonary tests.2 > || I - Single lymph node region (I) or one extralymphatic site (IE). II - Two or more lymph node regions, same side of the diaphragm (II) or local extralymphatic extension plus one or more lymph node regions or same side of the diaphragm (IIE) <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">III - Lymph node regions on both sides of the diaphragm (III), which may be accompanied by local extralymphatic extension (IIIE). <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">IV - Diffuse involvement of one or more extralymphatic organs or sites. <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Bulky tumor || Preauricular Field2 Subdiaphragmatic Fields2 3-D Treatment Planning2 ||
 * **Epidemiolgy:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Slightly more common in males than females1
 * **Etiology:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">No known specific causes1Although no specific pathogen has been identified to help in the diagnosis of Hodgkin's, the best candidate is Epstein-Barr virus (EBV). 1
 * **Signs & Symptoms:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Usually appears as a painless mass that the patient discovers1Most common sites of presentation are in the neck and supraclavicular regions1
 * **Diagnostic Procedures:** || * A complete physical examination that include any documentation of any B symptoms and other symptoms such as pruritus intolerance, fatigue, respiratory problems and alcohol intolerance.
 * An evaluation of all nodal sites.
 * For patients that will receive radiation therapy it is recommended to have a dental exam.
 * Laboratory tests: a complete differential blood count, erythrocyte sedimentation rate (ESR), serum electrolytes, liver and renal function tests, serum alkaline phosphatase, and beta2-lactate dehydrogenase. Optional but useful tests include: serum copper, microglobulin, and various surface cytogenetic analyses. 2
 * Radiology procedures:
 * **Histology:** || There are four histological subtypes of Hodgkin's disease:
 * lymphocyte-predominant (LPHD) (most favorable)
 * nodular-sclerosing (NSHD)(most common and less favorable than LPHD)
 * mixed-cellularity (MCHD)( less favorable than NSHD)
 * lymphocyte-depleted (LDHD) (worst prognosis) ||
 * **Lymph node drainage:** || The most common symptom of Hodgkin's is the painless enlargement of one or more lymph nodes. The nodes may also feel rubbery and swollen when examined. The most frequently involved (80–90% of the time) are the nodes of the neck and shoulders (cervical and supraclavicular). The lymph nodes of the chest are often affected, and these may be noticed on a chest radiograph. 2 ||
 * **Metastatic spread:** || 90% of patients with Hodgkin’s disease present with contiguous sites of involvement. 3 Visceral involvement may be secondary to direct extension (especially lung, bone of soft tissue) or hematogenous spread (such as liver to multifocal bone). 3 It uncommonly involves other organ systems such as the upper aerodigestive tract, central nervous system, skin, and gastrointestinal tract. 3 Nearly all patients with hepatic or bone-marrow involvement have (or had) extensive involvement in the spleen. 3 ||
 * **Grading:** || <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">There is no formal grading system for Hodgkin's disease. Prognosis is based on histologic subtype. ||
 * **Staging:** || **<span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Modified Ann Arbor Staging System for Hodgkin's Lymphoma ** 4
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Stage and Involvement **
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">A -No B symptoms
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">B - Presence of at least one of the following symptoms:
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Unexplained weight loss >10% baseline during 6 months before staging
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Recurrent unexplained fever >38°C
 * <span style="color: #800080; font-family: Arial,Helvetica,sans-serif;">Recurrent night sweats
 * **Radiation side effects:** || * Radiation pneumonitis develops in less than 5% of patients within 6 to 12 weeks after completion of mantle irradiation.
 * Radiation pericarditis is seen in less than 5% of patients.
 * Subclinical hypothyroidism
 * Lhermitte's sign develops in approximately 10% to 15% of patients.
 * The most important long-term hazards are secondary malignancies and cardiovascular disease.
 * Long-term cardiovascular side effects include coronary artery disease, pericarditis, pancarditis, and valvular disease.2 ||
 * **Prognosis:** || * Patients are considered favorable if the have no B symptoms or bulky mediastinal disease
 * Unfavorable prognosis stage I and II patients usually have either B symptoms or a large mediastinal mass.2 ||
 * **Treatments:** || Mantle2
 * The full mantle is rarely treated.
 * In addition to luch blocks, blocks can be placed over the occipital region and spinal cord posteriorly, the larynx anteriorly, and the humeral heads both anteriorly and posteriorly.
 * Spinal cord shielding may not be necessary with compensated fields if the prescribed tumor dose is only 36 Gy but should be used when the prescribed dose is more than 40 Gy.
 * After a dose of 30 Gy has been delivered, a block is placed in the subcarinal region (approximately 5 cm below the carina), shielding the pericardium and myocardium.
 * Bolus can be used if disease extends to the anterior chest wall.
 * The preauricular field can be treated with opposed lateral or unilateral photons or, preferably, with a unilateral 6- to 9-MeV electron field to spare the contralateral parotid.
 * The classic subdiaphragmatic irradiation field for HD is the "inverted-Y", which includes the paraaortic (retroperitoneal) and pelvic lymph nodes.
 * If the spleen is intact, the entire spleen, not just the splenic hilar region, is included in the field.
 * Sequential treatment to a mantle field and inverted-Y field is referred to as total lymphoid irradiation. When the subdiaphragmatic field does not included the pelvis, the term subtotal lymphoid irradiation is used.
 * Low-dose hepatic irradiation may be used for involvement if irradiation alone is being used as primary treatment, or in combined-modality programs, when the liver is involved. A 50% transmission block delivers 20 to 22 Gy to the liver during the same period in which the paraaortic nodes would receive 40 to 44 Gy.
 * In men, use of a double-thickness midline block and specially constructed testicular shield can reduce testicular dose from 10% to between 0.75 and 3.0% (40, 41).
 * Planning with three-dimensianal (3-D) simulation allows the use of more tailored treatment fields to limit late effects (29).
 * The GTV is defined as palpable nodes, nodes enlarged on CT, or nodes avid on PET.
 * The CTV is the GTV plus the entire involved lymph node region and possibly the inclusion of adjacent uninvolved nodal regions (extended CTV)
 * The PTV includes the CTV (or extended CTV) plus a 1.0- to 1.5-cm margin. ||
 * **TD 5/5:** || Due to the nature of both Non Hodgkins and Hogkins lymphoma to be located and spread anywhere lymph travles I have encluded a table that is sued at my clinical site that refrences RTOG Trials for current dose tolerances
 * **References:** || # <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Green S. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MI: Mosby. 2010: 610-611.
 * 1) Chao KC, Perez CA, Brady LW. // Radiation Oncology Management Decisions // . 2nd ed. Philadelphia, PA; Lippincott Williams & Wilkins. 2011: 575-587
 * 2) <span style="color: purple; font-family: 'Arial','sans-serif'; font-size: 13px;">Hoppe RT, Phillips TL, Mack III M. //Leibel and Phillips Textbook of Radiation Oncology//. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010
 * 3) <span style="color: purple; font-family: 'Arial','sans-serif'; font-size: 13px;">Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG. //Abeloff's Clinical Oncology//. 4th ed. Philadelphia, PA: Churchill Livingstone; 2008 ||

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