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Cervical lymphadenopathy

1.  What does this histological slide show?
2.  What is the diagnosis?

This histological slide shows a binucleate cell from a cervical lymph node biopsy.  It is a Reed-Sternberg cell and the diagnosis is that of Hodgkin's lymphoma.  The malignant lymphomas are divided into Hodgkin's and non-Hodgkin's groups.  Hodgkin's disease was first described by Sir Thomas Hodgkin in 1832.  The disease can present at any age but is more prevalent in adolescents and young adults. The male to female ratio is 2:1. It usually presents as painless rubbery lymphadenopathy involving the superficial lymph node groups.  The cervical, axillary and inguinal nodes are involved in 70%, 15% and 10% of patients respectively.  Splenomegaly occurs in 50% of patients. Mediastinal involvement occurs in about 10% of patients and this is characteristic of the nodular sclerosing type. Cutaneous involvement can occurs as a late complication.  Constitutional symptoms can develop in patients with widespread disease and these include a remitting fever (Pel-Ebstein fever), pruritus and alcohol-induced pain.  The diagnosis is confirmed by lymph node biopsy.

Four histological types are identified

  • Lymphocyte predominant (5%) - best prognosis
  • Nodular sclerosing (65%) - worst prognosis
  • Mixed cellularity (25%)
  • Lymphocyte depleted (5%)

The disease is staged by the use of chest x-ray, bone marrow biopsy and abdominal and thoracic CT scan.  Before the advent of CT, staging laparotomy was required but this has now been rendered obsolete. The following stages are recognised

  • Stage I        Confined to one lymph node group
  • Stage II       Disease confined to two or more nodal groups on one side of the diaphragm
  • Stage III      Disease involving nodes on both sided of the diaphragm
  • Stage IV      Extra-nodal disease - usually involving the liver and bone marrow

Patients with substage A disease have no constitutional symptoms.  Patients with substage B disease have constitutional symptoms that include an unexplained fever more than 38 deg C, night sweats and weight loss.

The treatment of Stage I and II disease is usually with radiotherapy.  Stage III and IV disease is often treated by both chemotherapy and radiotherapy.  Stage I disease has a 5-year survival of 90%.  Stage IV has a 5 year survival of 60%.

Recent papers

Mendenhall N P.  The role of radiation in the management of Hodgkin's disease: an update.  Cancer Invest 1999;  17:  47-55.

Potter R.  Paediatric Hodgkin's disease. Eur J Cancer 1999;  35:  1466-1477.

Wirth A,  Wolf M,  Prince H M.  Current trends in the management of early stage Hodgkin's disease.  Aust NZ J Med 1999;  29:  535-544.

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