Hodgkin lymphoma in the elderly
Introduction
Introduction to elderly Hodgkin's lymphoma Hodgkin's lymphoma is a unique malignant disease of the lymphatic system that begins to occur in a group of lymph nodes and then spreads to other lymph nodes or extranodal organs and tissues. Its histopathological features are malignant Reed- The appearance of Sternberg cells and the appropriate number of cell backgrounds can be divided into four histological types according to their appearance and the relative proportion of RIS-cells, lymphocytes and fibrosis: lymphocyte-based, nodules Sclerosing, mixed cell type and lymphocyte depletion type. Histological subtypes are a major factor in determining a patient's clinical performance, prognosis, and appropriate treatment. basic knowledge The proportion of sickness: 0.002%-0.003% Susceptible people: the elderly Mode of infection: non-infectious Complications: leukemia
Cause
The cause of Hodgkin's lymphoma in the elderly
(1) Causes of the disease
The cause of Hodgkin's lymphoma is unknown, and the etiology of Epstein-Barr virus is the most concerned. Epstein-Barr virus genome fragments can be detected in RS cells of about 50% of patients. Hodgkin's lymphoma is known to have immunodeficiency and autoimmune diseases. The risk of neoplasia is increased. The risk of siblings in homozygous twins Hodgkin's lymphoma is 99 times higher, probably due to the same genetic susceptibility and/or the same immune abnormality to the cause, and the etiology of the disease. The pathogenesis remains to be further studied.
(two) pathogenesis
Pathological histology
The main manifestations of Hodgkin's lymphoma histopathology:
(1) The normal lymphoid tissue such as lymph nodes in the lesion is completely or partially destroyed.
(2) presenting a variety of non-tumor reactive cellular components, mostly lymphocytes, and visible plasma cells, eosinophils, neutrophils, tissue cells, fibroblasts and fibrous tissue, in a variety of reactive cells Typical RS cells with different amounts in the background of the composition and their variants (Fig. 1), typical RS cells are binuclear or multinucleated giant cells, nucleoli eosinophilic, large and obvious, cytoplasm rich, if the cells show symmetric dual-nuclear scale "Mirror cells", RS cells and atypical (variant) RS cells are true tumor cells of Hodgkin's lymphoma. Recently, single-cell microscopy combined with immunophenotypic and genotypic assays have shown that RS cells are derived from lymphocytes. Mainly derived from B lymphocytes.
2. Histopathological classification
In the past 30 years, the Rye classification scheme of Hodgkin's lymphoma developed in 1965 has been widely used internationally. The newly proposed WHO classification classifies Hodgkin's lymphoma into nodular lymphocyte-predominant (NLPHL). And classic Hodgkin's lymphoma (classical HL), nodular lymphocyte-based histological manifestations are mostly nodular growth. The background is mostly lymphocytes and epithelioid tissue cells, typical RS cells are rare, large Most of the mutated lymphocytes and histiocytes are called L/H (lymphocytic/histocytic) cells. The nucleus is pleomorphic and vacuolated. The nucleolus is small, and the nucleus is near the nucleus. It is called "popcorn" and is also called popcorn. Popcorn cells, L/H cells express B cell-associated antigen (CD19, CD20, CD22, CD79a) positive, epithelial membrane antigen (EMA) positive and CD15 and CD30 are negative, clinical manifestations of cervical lesions, local treatment efficacy Good, good prognosis, classic Hodgkin's lymphoma is divided into nodular sclerosis, lymphocyte-rich classical lob, lymphocyte-rich classical HL, mixed cellularity HL) and lymphocyte depletion (HL) four subtypes, similar to Rye classification, developed in Europe and the United States with nodular sclerosis type, China has more mixed cell types, WHO classification better reflects different organizations The relationship between the type of school and its course of disease, clinical biological characteristics and prognosis, is currently promoting the application of WHO classification in China.
Prevention
Elderly Hodgkin's lymphoma prevention
Major measures for the prevention of malignant diseases of the blood system, including malignant lymphoma, should be taken to avoid causing the disease.
1. Prevent viral infections, such as Epstein-Barr virus, adult T-lymphocyte virus, HIV, etc., prevent colds in the spring and autumn, strengthen self-protection, and overcome bad habits.
2. Remove environmental factors, such as avoiding exposure to various rays and some radioactive materials, and avoid contact with related toxic substances such as benzene, vinyl chloride, rubber, arsenic, gasoline, organic solvent coatings, etc.
3. Prevention and treatment of autoimmune deficiency diseases, such as low immune status after various organ transplants, autoimmune deficiency diseases, various cancers after chemotherapy, etc., because graft-versus-host disease or immunosuppressive agents can activate the virus and promote lymphatic induction. The proliferative effect of the tissue.
4. Maintain an optimistic, confident and healthy mentality, appropriate physical exercise, help the stability of the body's immune function, and promptly eliminate the invasion of external factors.
5. For early-stage diagnosis and early comprehensive treatment for dangerous people or those who find risk factors.
The treatment of this disease should be comprehensive, in addition to the treatment of the cause, including nutritional supplements, if necessary, for central venous intubation and parenteral nutrition, supplement blood products as needed, the success or failure of complication prevention often The prognosis of the disease has a major impact, especially the prevention and treatment of opportunistic infections in the immunosuppressive phase. In China, special attention should be paid to tuberculosis, fungal infection, hepatitis and cytomegalovirus infection.
Complication
Elderly Hodgkin's lymphoma complications Complications leukemia
Mainly complicated by multiple organ damage, individual can be converted to leukemia.
Symptom
Elderly Hodgkin's lymphoma symptoms Common symptoms Weak weight loss, high heat, night sweats, itching, abdominal mass, intermittent hot neck, lymph node enlargement, low heat nodules
Lymph node enlargement
Lymph node enlargement is the most common clinical manifestation of Hodgkin's lymphoma. 90% of patients have lymph node enlargement, about 70% have cervical lymphadenopathy, 50% have mediastinal lymphadenopathy, and lymphadenopathy is often painless. , progressive swelling.
2. Clinical manifestations of involvement of extranodal organs
Hodgkin's lymphoma is rare in primary organs or tissues (<10%). Primary or extranodal involvement of extranodal organs can cause anatomical and dysfunction of the corresponding organs, resulting in a variety of clinical manifestations (see Non Clinical manifestations of Hodgkin's lymphoma).
3. Systemic symptoms
Most patients have no obvious systemic symptoms at the time of initial diagnosis. 20% to 30% of patients have fever, night sweats, weight loss, fever can be low fever, sometimes intermittent high fever (Pel-Ebstein fever), in addition to itching, fatigue and so on.
4. Clinical manifestations of different histological types
Nodular lymphocytes dominated 4% to 5% of HL, and the median age of onset was 35 years old. Men were more common. The ratio of male to female was 3:1. The lesion usually involved peripheral lymph nodes. Most of the initial diagnosis was early limitation. Sexual lesions, about 80% belong to stage I and II, the natural course is slow, the prognosis is good, the complete response rate of treatment can reach 90%, and the 10-year survival rate is about 90%, but the patients with advanced stage (III, IV) have poor prognosis. Lymphocyte-type classical Hodgkin's lymphoma accounts for about 6%, and the average age is larger. It is more common in men. The clinical features are between nodular lymphocyte-based and classic Hodgkin's lymphoma. Early limited lesions, rare massive lesions, mediastinal lesions and B symptoms, have a good prognosis, but the survival rate is lower than NLPHL. The nodular sclerosis of classical Hodgkin's lymphoma is the most common in developed countries, accounting for 60%-80. %, more common young adults and adolescents, slightly more women, often showing mediastinal and other parts of the lymph nodes lesions, prognosis is good, mixed cell type in Europe and the United States accounted for 15% to 30%, can be affected by different ages, clinical manifestations of abdominal cavity Lymph node and spleen disease are common changes, about half of the patients at the time of treatment The patient has been in advanced stage (III, IV), the prognosis is poor, lymphopenia is rare, about 1%, more common in the elderly and human immunodeficiency virus (HIV) infection, often involving abdominal lymph nodes, spleen, liver and bone marrow At the time of diagnosis, it is usually widely spread, prone to hematogenous spread, often accompanied by systemic symptoms, rapid progression of the disease, and poor prognosis.
5. Clinical staging and dissemination
(1) Clinical staging: The lesion range (staging) of Hodgkin's lymphoma is performed by the Ann Arbor/Cotswords staging system. The clinical stage is determined according to systemic symptoms, physical examination, laboratory examination and imaging examination. Staging, CS); on the basis of clinical staging, the necessary biopsy of the lesions (affected lymph nodes and organs), as well as exploratory laparotomy, splenectomy to further determine the extent and nature of the lesion as pathologic staging (PS), accurate staging It is an important basis for the development of a correct treatment plan. Due to recent reports, there is no significant difference between the clinical staging and the efficacy of expanded field irradiation based on the pathological staging of laparotomy, as well as the early application of chemotherapy and the complications and delayed treatment caused by laparotomy. It is no longer the usual method of instalment inspection.
(2) Dissemination method: Hodgkin's lymphoma usually shows the regular spread of the primary tumor along the lymphatic pathway to the adjacent lymph nodes, and the bloodstream spreads in the late stage.
Examine
Examination of elderly Hodgkin's lymphoma
1. Blood and biochemical examination
Anemia is more common in patients with advanced disease, positive pigment, positive cell anemia, occasionally hemolytic anemia, 2% to 10% of patients with positive Coombs test, neutrophil enlargement in a few cases, peripheral blood lymphocyte reduction (<1.0× 109 / L), increased erythrocyte sedimentation rate, elevated serum lactate dehydrogenase can be used as a disease detection index.
2. Immunological examination
The disease has cellular immunodeficiency, which shows that the delayed skin immune response is low. The expression of CD15 and CD30 antigen in RS cells of classical Hodgkin's lymphoma is an important immunological marker for identifying RS cells.
When there is a suspected mediastinal, hilar lymph node and lung lymphoma, it can be used for anterior and lateral X-ray of the chest, and radiographic scanning of the bone X-ray.
Diagnosis
Diagnosis and identification of elderly Hodgkin's lymphoma
diagnosis
Unexplained progressive lymphadenopathy, mediastinal mass, abdominal mass and long-term fever or intermittent heat of unknown cause should be considered in the possibility of Hodgkin's lymphoma. Live tissue examination such as lymph nodes should be performed in time to obtain histopathological diagnosis.
Differential diagnosis
The differential diagnosis of this disease often needs to be differentiated from lymphatic tuberculosis, viral infections such as infectious mononucleosis, sarcoidosis and non-Hodgkin's lymphoma, and should be differentiated from metastatic cancer. Cervical lymphadenopathy should exclude nasal discharge. Throat cancer, thyroid cancer, etc., mediastinal mass need to exclude lung cancer, thymoma, axillary lymph node enlargement should be differentiated from breast cancer.
The identification of the above diseases mainly depends on histopathological examination. Histopathological diagnosis is the main basis for the diagnosis of Hodgkin's lymphoma. It is essential that the pathological diagnosis usually has typical RS cells and needs to bind lymphocytes and plasma cells. The overall tissue image of various reactive cellular components such as eosinophils, as well as reference to CD15, CD30 and other immune markers for pathological diagnosis, clinicians should comprehensively diagnose the patient's clinical manifestations and pathological findings, including Hodge Pathological type and clinical stage of gold lymphoma.
