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LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Discuss the underlying pathophysiologic mechanisms of the lymphomas and how they relate to presenting symptoms of the disease.

  2. Differentiate the pathologic findings of Hodgkin lymphoma (HL), follicular indolent non-Hodgkin lymphoma (NHL), and diffuse aggressive NHL and how this information yields a specific diagnosis.

  3. Describe the general staging criteria for the lymphomas and how it relates to prognosis; evaluate the role of the prognostic systems such as the International Prognostic Score for HL, the Follicular Lymphoma International Prognostic Index (IPI), and the IPI for diffuse, aggressive NHL.

  4. Compare and contrast the treatment algorithms for early and advanced stage disease for HL.

  5. Assess the role of autologous hematopoietic stem cell transplantation for relapsed lymphomas.

  6. Delineate the clinical course of follicular indolent and diffuse aggressive NHL and the implications for disease classification schemes and treatment goals.

  7. Outline the general treatment approach to follicular indolent and diffuse aggressive NHL for localized and advanced disease.

  8. Interpret the current role for monoclonal antibody therapy in NHL.

INTRODUCTION

The malignant lymphomas are a clonal disorder of hematopoiesis with the primary malignant cells consisting of lymphocytes of B-, T-, or natural killer (NK) cell origin. Lymphoma cells predominate in the lymph nodes; however, they can infiltrate lymphoid and nonlymphoid tissues, such as the bone marrow, central nervous system (CNS), gastrointestinal (GI) tract, liver, mediastinum, skin, and spleen. An overview of the lymph node regions is depicted in Figure 97–1. Image not available. There are two broad classifications of lymphoma, Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), and both contain numerous histologic subtypes that are pathologically distinct disease entities.

FIGURE 97–1.

Representation of the anatomic regions used in the staging of Hodgkin disease. (From Rosenberg SA. Staging of Hodgkin disease. Radiology. 1966;87:146.)

The clinical course varies widely among histologies of lymphoma. More aggressive subtypes are highly proliferating cells that require aggressive therapeutic intervention with chemotherapy, radiation therapy, or both. By contrast, certain subtypes of NHL are characterized by a disease course that flares and remits intermittently over a period of years regardless of treatment.

HODGKIN LYMPHOMA

EPIDEMIOLOGY AND ETIOLOGY

Approximately 8500 new cases of HL were estimated to be diagnosed in the United States in 2018, with 1050 deaths attributed to the disease.1 The incidence of HL is bimodal, with peaks occurring in the third decade of life and in patients over 50 years of age.2 The precise cause of HL is unknown, but certain associations have been reported and provide insight about possible etiologic factors. Epstein-Barr virus (EBV) has been associated with HL, its viral genome is detected in Reed-Sternberg (RS) cells in up to 40% of cases in developed countries. Other viruses (cytomegalovirus, human herpes viruses, human immunodeficiency virus ...

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