Hodgkin's disease and the malignant lymphomas

The unanticipated finding of a subcutaneous swelling, typically an enlarged lymph node in the neck, is legitimate cause for concern. After excluding benign or reactive conditions, this sign should initiate a series of investigations to characterize the neoplasm and, in the case of a lymphoma, lead to prompt treatment aimed at cure. The classic description of such cervical adenopathy is that by Thomas Hodgkin, who clearly recorded both the clinical behavior and the macroscopic findings evident at dissection. Subsequent histologic study revealed the multinucleate giant cells that characterize the tumor that now bears his name and linked it to those of Greenfield, Sternberg, and Reed. Initial debate centered on whether this entity was inflammatory or malignant, with the issue further clouded by the frequent coexistence of tuberculosis. Although a number of features exist in favor of both concepts, current consensus places it among the neoplastic processes. Hodgkin's disease was separated from other malignant lymphomas as agreement on diagnostic criteria emerged. The next major step forward was the demonstration, first by Vera Peters and then by Henry Kaplan, that adequate doses of radiotherapy were curative when delivered to treatment fields that encompassed the tumor. A further milestone was the introduction by Vincent DeVita, Jr., and his colleagues of combination chemotherapy that was effective in late stage of disseminated disease. The established cornerstones of managing these patients are accurate diagnosis; precise anatomic staging, modified as appropriate by associated factors known to have prognostic value; and selection of irradiation, chemotherapy, or whatever combination will result in the best possible patient survival. However, success is not universal, and death due to resistant or relapsing disease is encountered all too frequently. It is here that the benefits of a multidisciplinary approach are evident, because a substantial level of expertise coupled with sound judgment is needed to salvage these individuals, often by means of investigational programs. Some of the latter are limited by profound myelosuppression, and safety may center on the use of cytokines in the form of interleukins and growth factors, with or without bone marrow transplantation. In such situations, benefit must be balanced against risks in well-structured clinical trials that embody informed consent. Herein lies one of the major goals for the next decade. The non-Hodgkin's lymphomas can conveniently be considered in two broad categories. Some follow an indolent clinical course, in which the lymph node retains a follicular pattern with small component cells, and others are aggressive tumors, in which primitive blasts have diffusely effaced the glandular architecture.(ABSTRACT TRUNCATED AT 400 WORDS)