Hodgkin's lymphoma
Lymphoma or cancer of the lymphatic system develops at the expense of lymphocytes, the cells of the family of white blood cells which play an essential role in immune defense reactions. Lymphoma is a cancer in the lymph organs (lymph nodes, spleen, thymus, tonsils...) and can also occur at the level of non-lymphoid territories (digestive tract, bone, testicle, breast, eye, thyroid...).
Hodgkin's lymphomas are placed in France at the 20th of human cancers and the 21st highest in women's cancers in terms of incidence (2.2 cases for 100 000 men and 2.5 cases for 100 000 women). It occurs among young adults (aged 20 to 30) and in the elderly (over 60 years).
Progression of Hodgkin's lymphoma
The immune system that causes lymphoma
The immune system is made up of different organs, tissues, cells that protect us from external aggression by controlling and eliminating foreign bodies. The lymphatic system contributes to the protection of the body in the face of diseases and infections, it represents the most important part of the immune system. It consists of a set of small vessels that cross the whole body and in which circulates the lymph, and lymphocytes. These cells have a major role in the functioning of the immune system. Within this network we also find lymph nodes as well as different organs like spleen, tonsils, bone marrow and thymus that will filter the lymph. The lymph nodes are spread throughout the body especially in the neck, armpits and groin.
Lymphocytes are part of the white blood cell family and fight against foreign organisms and abnormal cells. They are made in the lymph nodes, the bone marrow, the spleen and then circulate in the lymphatic system but also the blood vessels.
There are two types of lymphocytes, B lymphocytes and T lymphocytes. B lymphocytes can become plasma and make antibodies that target bacteria and cancer cells to eliminate them. The action of B lymphocytes is supplemented by T lymphocytes which will recognize and remove infected cells that may have escaped B lymphocytes.
Lymphoma is the most common disease of the blood and lymphatic system. It is a cancer of the lymphatic system that occurs when the production of lymphocytes becomes abnormal. These cancerous lymphocytes can proliferate by dividing faster or living longer than normal lymphocytes.
There are 2 different types of lymphoma:
Hodgkin's lymphoma (LH) or Hodgkin's disease characterized by specific cell development (Sternberg cells).
Non-Hodgkin's lymphoma (NHL), which groups different categories according to microscopic, molecular and immunological criteria.
Hodgkin's lymphoma (or Hodgkin's disease)
Definition
Hodgkin's lymphoma is a cancer that results from the abnormal proliferation of a B lymphocyte. This disease comes from the name of the British doctor who discovered it in 1832, the Doctor Thomas Hodgkin.
This lymphoma is characterized by the presence of specific B lymphocytes, the Reed-Sternberg cells found in the affected organs. The Sternberg cell is perfectly recognizable under a microscope, it is a giant cell with several nuclei. It proliferates from a group of lymph nodes or a lymphoid organ and evolves slowly. The cancer cells then propagate through the lymph vessels to the nearby lymph nodes. They can also affect a body adjacent to the lymph nodes through the blood vessels such as bone marrow, spleen, intestines, liver or lungs. We are talking about extra-ganglionic interference: This development is rarer and occurs in the most advanced forms.
This cancer is usually located at the level of a ganglion or even an organ, with a good prognosis and can be cured in about 95% of cases. However, it must be confirmed by a anatomopathologic examination of cells from a ganglionic biopsy.
The exact causes of this disease are not identified and the risk factors are few. People who have contracted the human immunodeficiency virus (HIV) also have more risks. The hereditary factor is not discarded either because data suggest that a patient's family members have a higher than average risk of developing this disease.
To know! Anatomopathologic Examination: This examination consists of studying all the characteristics of the tumor at the macroscopic and microscopic level and helps to specify the stage of cancer.
Signs of illness
The occurrence of Hodgkin's lymphoma most often results in a persistent increase in the volume of one or more lymph nodes, which is referred to as lymphadenopathy. Adenopathies refers to swelling of lymph nodes that can be found in ganglion areas such as the neck, armpits. They can also cause facial edema, respiratory or abdominal discomfort, back pain or bloating. The disease is accompanied by other signs such as fever, severe fatigue, itching and slimming.
In all cases, persistence for more than 3 weeks of lymph nodes with a larger volume, without inflammatory character and outside an infectious episode, should result in a complete clinical examination.
Further reviews and analysis
If the doctor suspects the presence of lymphoma after discarding any other cause, he may prescribe different tests to confirm the diagnosis.
It is generally practiced:
A biopsy: It consists of taking a piece of ganglion by surgery under local or general anesthesia either at the neck, or by endoscopy, laparotomy or thoracotomy depending on the location. The study of the biopsy under the microscope allows to make an initial diagnosis and to differentiate the type of lymphoma notably by the characterization of the cells of Reed-Sternberg.
Medical imaging: It is used to determine the extension of Hodgkin's lymphoma.
The chest X-ray is used to assess the size and eventual impairment of the mediastinum.
The scanner and possibly ultrasound of the neck, thorax, abdomen and pelvis can be used to specify lesions and their extension at the level of the lymph nodes and certain organs.
PET (positron emission tomography) to assess the localization of cancer cells and ganglion activity through the use of a fluorinated radioelement-labelled sugar. It is also useful for monitoring the treatment in order to visualize the disappearance of tumors.
To know! The mediastinum corresponds to the central region of the rib cage, between the lungs. It contains the heart, the esophagus and the trachea.
Blood tests: The blood count is used to check the white blood cells and platelets in terms of appearance and number. The analysis can determine a decrease in lymphocytes, anemia, the rate of hémoglobuline, the fall of serum iron, the rate of sedimentation which are signs of evolution of the disease.
Bone marrow Examination: In some cases, Hodgkin's lymphoma develops at the bone marrow level. A biopsy of the pelvis bone may be performed to collect bone marrow and to check for tumor cell presence.
Other tests: abdominal lymphography, spleen and liver scan, skeletal x-rays.
To know! The bone marrow contains stem cells that can evolve into three kinds of mature cells, red blood cells, white blood cells and platelets.
Stage of evolution and category
The tests will help to determine the extent of the disease's spread with its stage and type. The evolution of Hodgkin's lymphoma is divided according to the Ann Arbor classification in 4 clinical stages:
Stage I: Attainment of a single contiguous ganglion group on the same side of the diaphragm;
Stage II: Attainment of two non-contiguous ganglion territories but on the same side of the diaphragm;
Stage III: Attainment of ganglion SUS and sub-diaphragmatic groups;
Stage IV: Associated visceral impairment: liver, heart, lung, digestive tract, marrow, bone, nervous system.
Each of these stages is accompanied by a letter with the two main sub-categories A and B. They are defined according to the general symptoms felt by the patient at the time of diagnosis: fever, sweats, slimming...
Subcategory A: Patients have no symptoms;
Subcategory B: Patients exhibit general or systemic symptoms such as fever, night sweats and weight loss;
Sub-category E: This category is used for patients whose lymphoma has developed from a lymph node to a single surrounding tissue;
Sub-category X: This category is used when the patient has a tumor mass at the mediastinum or lymph nodes.
Prognosis
The prognosis of Hodgkin's disease is generally good and all the better as the disease is little spread. For stages I and II, chronic remission is obtained in 95% of cases. In the most extensive forms (stages III and IV), chronic remission is obtained in 70% of cases. For each stage, the speed and quality of the therapeutic response are the best prognostic criteria.
Treatment
The treatment of Hodgkin's lymphoma has improved significantly and in most cases today allows for remission or recovery with decreased adverse effects. The treatment is based on chemotherapy used alone or in combination with radiation therapy. Several elements are considered for the choice of treatment:
The stage of disease evolution
The volume of the tumor
The presence of inflammation
The rate of lymphocytes;
The number of lymph nodes affected;
Age;
General health status.
Chemotherapy
Chemotherapy or polychemotherapy is a treatment based on various associated medications to strengthen their effect. It is a systemic or general treatment that will destroy the cancer cells in all the places of the body where they are. The combination of these different medications makes it possible to combine their different mechanisms of actions and to alter or destroy cancer cells in several ways. Doses are generally lower and reduce the risk of drug resistance.
The combination of several medications is called chemotherapy protocol. They are usually named according to the initials of the molecules used. For Hodgkin's lymphoma, the protocols used are:
Protocol ABVD: doxorubicin, Bleomycine, Vinblastine, Dacarbazine.
Protocol BEACOPP: Bleomycine, Etoposide, doxorubicin, Cyclophosphamide, Vincristine, Procarbazine, prednisone.
The treatment takes place with repeated doses in order to obtain better result in the destruction of cancer cells. Chemotherapy is administered in the form of cures that alternate treatment and recovery phase according to a predetermined schedule. The number of cycles and duration of treatment are predetermined and can be adapted according to factors such as the type of lymphoma, the stage, the medications used, the tolerance and the response to treatment.
ABVD protocol: The most common, it is administered every two weeks. Each cure lasts 28 days with an administration on Day 1 and 15
For stages I and II, the oncologist usually proposes between 2 and 4 chemotherapy treatments 2 to 4 months, sometimes associated with radiation therapy in the affected areas.
For stages III and IV, the doctor usually offers 6 to 8 chemotherapy treatments spread over 6 to 8 months.
BEACOPP protocol: More rarely used, each cure lasts 21 days with administration on days 1, 2, 3 and 8.
Administration can be done in different forms, orally (pill or tablet), intravenous or intramuscular injection or subcutaneous. To facilitate intravenous injections, the doctor may recommend setting up a percutaneous implantable chamber (CIP).
Radiotherapy
Radiation is a local therapy that involves using very high-energy X-rays to destroy cancer cells and reduce tumors. It only affects cancer cells in the treated area. Radiation is concentrated on some of the lymph nodes and surrounding areas or region of origin in the case of extra-ganglion lymphomas.
Radiotherapy is associated with chemotherapy to consolidate these effects, because only it exposes the patient to a risk of relapse too high. It is generally proposed for lymphomas located above the diaphragm. The radiation fields are determined on a case by case basis and depend on the type of tumor as well as the stage of the disease.
The number of radiotherapy sessions and the dose of radiation needed are defined according to each patient depending on the extent of the disease and the efficacy of the chemotherapy. The initial dose generally issued to the ganglion regions is in the order of 30 Gy.
To know! The radiotherapy Ray dose is expressed in Gray (Gy). It corresponds to the energy quantity of 1 joule absorbed by a mass of 1 kilo.
Radiation therapy is usually performed 1 month after the end of chemotherapy. They take place five days a week. The total duration is usually 3 to 4 weeks.
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