The changing pattern of hodgkin lymphoma in adults at Chris Hani Baragwanath academy hospital
Hodgkin lymphoma (HL) is a malignancy of lymphoid cells that was first described by Thomas Hodgkin in 1832. It is recognized histologically by the presence of the characteristic Reed Sternberg cells, bathed in a reactive cellular background of inflammatory cells. Hodgkin lymphoma is less common than Non-Hodgkin Lymphoma (NHL) and accounts for approximately 10-20 % of all the lymphomas encountered. It is most often seen in young adults, with a peak frequency in the third decade of life. Hodgkin lymphoma is characterized by the orderly spread of disease from one lymph node group to another (contiguous spread and centripetal distribution) and by the development of systemic symptoms, particularly with advanced stage disease. True extra nodal disease is uncommon. Pathologically, Hodgkin lymphoma is categorized into two groups: Nodular lymphocyte predominant Hodgkin lymphoma which accounts for about 5% and Classical Hodgkin lymphoma which accounts for 95%. Classical Hodgkin lymphoma is further subdivided into four subtypes: Nodular sclerosis classical Hodgkin lymphoma, Mixed cellularity classical Hodgkin lymphoma, Lymphocyte rich classical Hodgkin lymphoma and Lymphocyte depleted classical Hodgkin lymphoma. Once the diagnosis is confirmed on a lymph node or tissue biopsy, a complete work up is done, which includes blood investigations, a bone marrow aspirate and biopsy and appropriate radiological investigations. Following on this, the treatment is individualized and includes both supportive care and specific therapy. The specific initial treatment of Hodgkin lymphoma involves combination chemotherapy and where necessary involved field radiotherapy. Cure is a realistic goal in more than 90% of patients with early stage disease. A delicate balance exists vi between optimal initial treatment and the development of late complications of the disease, mainly related to treatment. The last decade has witnessed the emergence of Hodgkin lymphoma occurring with increasing frequency in association with the Human Immunodeficiency virus (HIV) infection. The relative risk is 10-20 fold higher with HIV seropositivity, compared to the general population. HIV associated Hodgkin lymphoma is generally more aggressive, presents with advanced stage disease, frequent ‘B’ symptoms, less favorable histology, more frequent bone marrow involvement and overall a poorer prognosis compared to Hodgkin lymphoma in HIV seronegative individuals. This study was aimed at exploring and defining the changing pattern of Hodgkin lymphoma at Chris Hani Baragwanath Academic Hospital (CHBAH) from January 2005 to December 2012. Other objectives were to review: (i) the impact of HIV on the clinical pattern of disease and (ii) the different treatment options and the outcome of the patients. Patients and Methods This was a retrospective review of all adult patients with Hodgkin lymphoma seen at the Clinical Hematology Unit, Department of Medicine from January 2005 to December 2012 at CHBAH. Descriptive analysis was conducted through the computation of frequency tables for categorical variables and appropriate measures of central tendency i.e. mean ± SD/median (IQR) for continuous variables. Kaplan Meier survival curves were plotted to determine the survival probability of the patients based on demographic and clinical characteristics. vii Results A total of 150 patients with a confirmed diagnosis were included in the study. Ninety three percent of the patients were of black ethnicity. There were 84 males (56%) and 66 females (44%), with a male to female ratio of 1.27:1. The median age of the patients was 37 years, with a peak frequency in the third and fourth decades of life. HIV seropositivity was noted in 90 patients (60%), with the remaining 60 patients (40%) being seronegative. For the whole group of 150 patients, lymphadenopathy was the most common presenting feature (92.7%). ‘B’ symptoms were present in 74.7% of the patients. Advanced stage disease was noted in 74% of the patients and a performance status of ≥2 was evident in 66.7% of the patients. A comparison of the HIV seropositive and HIV seronegative patients shows that there is a statistically significant difference between the histological subtypes (mixed cellularity with HIV seropositivity and nodular sclerosis with HIV seronegativity), TB association (higher with HIV seropositivity) and more bone marrow involvement with HIV seropositivity. However, the median survival was shorter in HIV seropositive compared to HIV seronegative individuals. Conclusion As compared to the current literature on Hodgkin lymphoma (particularly from the developed world), our study showed a high prevalence of HIV and TB, in association with Hodgkin lymphoma. There is a paradigm shift at our institution, from an early period in the 1980’s with no HIV seropositivity in association with HL, to <50% in the 1990’s and early 2000’s, to > 50% in the last decade. The association between HIV and HL has an impact on the clinical presentation and outcome of the patients. Therefore, health care workers need to be aware of this emerging and increasing association between HIV and Hodgkin lymphoma.
A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine (Internal Medicine)