Hodgkin’s lymphoma is Case Study Report
Name
Department of Medical science
ABCD University
State, United States
Mail
Abstract-
Key Words:
1. INTRODUCTION
Hodgkin’s lymphoma is rarer of the two types of cancers of the lymphatic system. It has an incidence rate of 2.6 people per one hundred thousand individuals in the United States in a year. National Cancer Institute shows that about 215,531 people had the disease in United States in 2017. The lifetime risk of developing Hodgkin’s lymphoma is nearly 0.2 percent in all genders. American Cancer Society approximates that almost 8,480 cases of Hodgkin’s lymphoma will be diagnosed in 2020 with cases among men and women expected to be 4690 and 37090, respectively. The disease affects both children and adults however, it is more prevalent in early adulthood specifically in twenties after which its risks increases again among older adults with the peak beginning at fifty-five years. Therefore, this case of a fifty-two-year-old male patient is a rare case as seen because majority of cases are among the adolescents (15-19 years) and then risk picks up again from age fifty-five. Also, the testicular involvement is a rare happening in Hodgkin’s lymphoma. The current advances in treatment have made increased the survival rate of Hodgkin’s lymphoma to eighty-six percent currently. The yearly death rate for Hodgkin’s lymphoma has
reduced significantly and presently at 0.3 deaths per 100000 people. ABVD (Adriamycin, bleomycin, vinblastine, dacarbazine) is the standard treatment for Hodgkin’s lymphoma. A research by Zhang and colleagues show that ABVD has a higher survival rate, better efficacy and are often less myelotoxic compared to other interventions such as MOPP (mechlorethamine, vincristine, procarbazine, and prednisone) and BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) [4]. Similarly, according to American Society Clinical journal, ABVD is more tolerable compared to BEACOPP. A research by Demircioğlu, Baştürk and Bilgin confirm that treatment of Hodgkin’s lymphoma involving testis using ABVD was successful after six cycles [1]. The case shows a rare scenario and where a patient-oriented decision was made regarding the mode of treatment to ensure that the outcome is not only maximal but also satisfies the patient.
II. CASE PRESENTATION
I present a case of a fifty-two-year-old male patient. He is a non-smoker and with no known underlying medical condition and had been referred from some healthcare facility to the pulmonary clinic having a history of chronic cough with sudden onset about a month ago. The cough was initially dry but later became productive and white with a mid-moderate amount. The patient had about four to five episodes of hemoptysis in a small amount. He has no history of chest pain, wheezing, fever, night sweating, but reports that he has lost about ten kilograms in four months and suffers a decrease in appetite.
The vital obtained from occupational biochemistry were stable; however, the patient seemed underweight. There was no lymphadenopathy; splenomegaly, hepatomegaly, skin rash, and other examination were unremarkable. Laboratory test revealed WBC: 15 HGB: 13 PLT: 435 Neutrophils % 84% Eosinophil % 0.1% Lymphocytes % 9.4% PT: 14 PTT:37 INR:1.1 creat:50 Urea:3 ca:2.6 ESR:82 albumin: 42 Sodium: 138 Potassium:3.73 Chloride:101 Bicarbonate:23. A CT scan was done outside the hospital, which revealed mediastinal and right hilar lymphadenopathy suspicious for malignancy as described for histopathologic correlation. Focal areas of septal thickening in the right upper and right middle lobe with no definite suspicious lung masses were noted. The patient received tuberculosis workup, which was negative as follows, sputum AFB & PCR MTB DNA COMPLEX not detected sputum for culture and sensitivity: normal respiratory flora. The Endo-bronchial Ultrasound-Guided FNA for Lower Para-tracheal Lymph Node “Station 4r”: *Intraoperative Adequacy Statement revealed: – Scattered binucleated/multinuclear single large lymphocytes with prominent large macronuclei. Besides, a background of polymorphic lymphocytes and occasional bronchial cells were seen.
General Diagnostic Category: – Malignant cells identified. * Cytology Diagnosis shows findings that are highly suggestive of Hodgkin’s Lymphoma. Besides, the cell block reveals large atypical binucleated cells with positive CD30, CD15, and PAX5. The cells are negative for CD20, CD3. CT NECK POST IV CONTRAST of 09-MAR-2020 shows Left level IV, central compartment, and upper mediastinal lymphadenopathy. CT CHEST POST IV CONTRAST of 09-MAR-2020: Almost interval stability of the mediastinal and hilar lymphadenopathy. Interval improvement in previously seen septal thickening in the right upper lobe and right middle lobes were revealed. Ct Abdomen and Pelvis Post IV. CONTRAST of 09-MAR-2020 shows sub-centimetric lymph nodes in the gastrohepatic ligament. The largest is 0.7 cm, which necessitates further follow-up by Pet CT scan. Left-sided varicocele is noted. Standard PET of the whole body was performed and revealed ta diffuse mediastinal LAP with greed FDG uptake, consistent with lymphoma diagnosis. Spleen focal uptake is a noted indication for spleen involvement. Bone marrow involvement is highly considered. Assessment: Hodgkin Lymphoma IV SB Plan of management: to start ABVD cycle one as inpatient Today since there is no slot for the patient in OUT and scheduled appointment monthly before each cycle.
III. DISCUSSION
The case is special in some notable aspects. According to diagnostic examinations, it is noted that cancer has spread to various body organs above and below the diaphragm. As noted, there is spleen involvement, as shown by the spleen focal uptake. Also, there is notable left-sided varicocele with possible show a testicular involvement. While most of the malignant lymphoma of the testis accounts for about five percent of the testicular malignancy, about one percent generates lymphoma [1]. The three researchers further show that testicular involvement in Hodgkin’s lymphoma is rare but has been reported in about five patients diagnosed with Hodgkin’s lymphoma. This is a very rare case and would attract attention and more research regarding what could have stimulated such far and rare involvement in a patient without history of any chronic disease. Therefore, possibly, the case presents a stage III adult Hodgkin’s lymphoma.
Now, the greatest challenge was on deciding the initial management of the condition based on the current debate whether to use ABVD or BEACOPP and various studies comparing their efficacies. Using a case follow-up of 1,195 patients with Hodgkin’s lymphoma, shows that BEACOPP escalated is more effective than the BEACOPP baseline and the ABVD [2]. However, the management using BEACOPP was found to cause al lot of hematologic toxicity, infections as well as secondary leukemia leading to a controversy regarding its usage. Most patients who were treated with BEACOPP escalated suffered grade 3 and 4 leucopenia and some thrombocytopenia while approximately twenty-two percent developed infectious disease. While Engert research shows that these side effects did not result in higher treatment-related mortality with BEACOPP escalated when compared to BEACOPP baseline and ABVD, it is better to be patient-oriented than result-oriented and start a patient on a standard treatment that is safe, tolerable and approved to be effective.
Engert reports the outcomes from an Italian randomized study that involved 3017 patients with Hodgkin’s lymphoma aiming to compare the efficacy of ABVD, BEACOPP, and COPP-EBV-CAD [2]. The result was thirteen secondary neoplasms following the management with the three therapies. There was one secondary neoplasm with ABVD, six after BEACOPP and other six after COPP-EBV-CAD. These results led to the researchers leaving the follow up because they could not confirm the superiority of BEACOPP over ABVD. This confirms that ABVD is safer while still efficient. Similarly, Zhang and colleagues proves that ABVD is efficient and has fewer adverse effects [4]. It is the first time the patient is diagnosed with Hodgkin’s lymphoma, and therefore it is better to start with the safest therapy. Then ensure close supervision, possibly via appointment after every cycle and do interim PET tests to confirm the outcomes of ABVD treatment then change appropriately to a combination of BEACOPP escalated regimen and BEACIPP baseline regimen as necessary while considering patient safety, toxicity and outcome. In other words, the patient should be the focus since this is long term care, and it is the first care he is receiving for Hodgkin’s lymphoma.
Lastly, often while the risk for Hodgkin’s lymphoma is among the younger adults and older adults, adults above twenty years and below fifty-five years are as well affected by the disease. The case confirms a diagnosis is a man with fifty-two years. Similarly, this patient did not show any other symptoms suggestive of Hodgkin lymphoma apart from the sudden loss of weight over a short period and the sudden onset of dry cough, which progressed to productive cough with mild-moderate sputum. Often patients will present with some painless swelling around the neck, armpit, and grown. According to Cancer Research UK, about seven out of every ten patients diagnosed with Hodgkin lymphoma have enlarged lymph nodes around the neck, which translated to about seventy percent.
1V. CONCLUSION
It was appropriate to start the patient on ABVD and not BEACOPP escalated because though some studies support that it is a more effective regimen, particularly in a patient with advanced-stage Hodgkin’s lymphoma, BEACOPP leads to more toxicity compared to ABVD research paper writing service which is more tolerable and effective. The case represents a rare case not only on the aspect of its asymptomatic nature but also based on the cancer spread. The choice of management represents a patient-based approach to ensure the safest treatment that will achieve the best patient outcome in the long term. This is why, despite the evidence supporting the effectiveness of BEACOPP, ABVD was chosen due to reduced toxicity, tolerability, and efficacy.
REFERENCES
[1] Demircioğlu, S., Baştürk, A., & Bilgin, A. U. (2016). Testicular Involvement in Relapsed Hodgkin Lymphoma. Balkan medical journal, 33(5), 581.
[2] Engert, A. (2016). ABVD or BEACOPP for advanced Hodgkin lymphoma. J Clin Oncol, 34(11), 1167-1169.
[3] Zaucha, J. M., Małkowski, B., Chauvie, S., Subocz, E., Tajer, J., Kulikowski, W., … & Dziuk, M. (2017). The predictive role of interim PET after the first chemotherapy cycle and sequential Assessment of response to ABVD in Hodgkin’s lymphoma patients—the Polish Lymphoma Research Group (PLRG) Observational Study. Annals of Oncology, 28(12), 3051-3057.
[4] Zhang, T., Yao, Y., Feng, F., Zhao, W., Tian, J., Zhou, C., … & Sun, C. (2018). Comparative effectiveness of different chemotherapy regimens of advanced-stage hodgkin lymphoma in adults: a network meta-analysis. Cancer management and research, 10, 6017.
