Chapter 29: The pretty medical student

A pretty 22-year-old medical student on her first clinical attachment noticed a swelling in her neck. She felt very well. She asked the houseman what it was. He did not have a clue but asked her out for a drink. So she asked the firm registrar what he thought it was. After also asking her out for a date, he suggested glandular fever. As it persisted and she did not have a fever, she went to see her (female) GP. She did not ask her out but referred her to an ENT surgeon. She had an excision biopsy that revealed nodular sclerosing Hodgkin Disease.

• 1. What virus is implicated in the pathogenesis of HD?

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  Correct answer:
  The Epstein-Barr virus (EBV) genome may be found incorporated within Reed-Sternberg (RS) cells, and about half of the cases of ‘s lymphoma in the United Kingdom are linked to EBV. The Reed-Sternberg cell is pathognomonic for the diagnosis and is thought to originate from lymphocytes affected by EBV. There is a threefold increased risk of Hodgkin‘s disease following infectious mononucleosis (glandular fever).

An FDG-PET and CT scan were performed as staging investigations.

• 2. What do the FDG-PET and CT show?

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  Correct answer:
  
  FDG-PET and CT images confirm left supra-clavicular lymph node mass of Hodgkin‘s lymphoma that is FDG avid.

As she is <40 years old she has a breast ultrasound, core biopsy of the mass and fine needle aspirate (FNA) of the right axilla.

• 3. What further information is required to complete the staging?

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  Correct answer:
  Presence of B symptoms
  B symptoms include: (i) profound night sweating, sufficient to drench bedclothes, (ii) fevers greater than 38°C and (iii) weight loss exceeding 10% of body mass. These constitutional symptoms are prognostically important and designated as B symptoms.

She was treated with two cycles of ABVD chemotherapy followed by involved field radiotherapy for favourable stage IA nodular sclerosing Hodgkin‘s lymphoma. She has wisely decided that she wants to become a medical oncologist.

• 4. What would you advise her about pregnancy?

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  Correct answer:
  The chemotherapy (two cycles of ABVD) will not significantly reduce her fertility but it is advised that she should not get pregnant within 2 years of completing systemic chemotherapy.