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• W2059722511 abstract "To the Editor: A 96-year-old woman presented to the hospital with fever and progressive shortness of breath. She had been asymptomatic until 4 months earlier, when she had been admitted on three occasions because of acute bronchitis and self-limited fever. She and her family had declined further investigation and treatment previously, but during the last admission, she was experiencing cardiac failure because of fast atrial fibrillation in the context of a relapsing evening fever. Her Barthel Index was 60 points, and she had a history of hypertension, hiatal hernia, and recurrent syncope. On physical examination, she was febrile (38.9°C) and moderately dehydrated, her pulse rate was 133 beats per minute, and blood pressure was 112/62 mmHg. She had bilateral leg edema and a distended jugular vein. Breath sounds were bilaterally diminished. Palpation detected no enlargement of the superficial lymph nodes, spleen, or liver. She had no neurological deficits, and abdominal examination disclosed no significant abnormalities. Chest X-ray showed bilateral pleural effusion, and laboratory analysis revealed creatinine, blood urea nitrogen, thyroid hormone, immunoglobulin, and tumor marker levels within normal limits. Autoimmunity was negative. Leukocyte count was 4,400/μL with 1,100 monocytes (25%), hematocrit was 30.6%, and platelet count was 157,000/μL. Finally, because of the relapsing episodes of fever, she and her family agreed to undergo several diagnostic tests. Thoracoabdominal computed tomography showed mild hepatosplenomegaly and enlargement of the retroperitoneal and mediastinal lymph nodes. Bone scintigraphy was normal. Blood and urine cultures and serological determinations for various microorganisms (Coxiella sp., Brucella sp., Salmonella sp., herpes virus, Epstein–Barr virus (EBV), cytomegalovirus) and sputum culture and examination (Ziehl–Neelsen for mycobacteria) were performed and were all negative. Bone marrow aspiration indicated refractory cytopenia with multilineage dysplasia. Finally, thoracoabdominal computed tomography was repeated, and indicated progressive enlargement of the lymph nodes; new nodes were found in the left inguinal area. An inguinal lymph node biopsy was performed, and a diagnosis of nodular sclerosis classical Hodgkin lymphoma (HL) was made. Tumoral cells revealed their typical immunophenotype, showing epithelial membrane antigen, CD30, CD15, and EBV immunopositivity. After the findings were explained to the woman and family, they decided to undergo symptomatic treatment. Naproxen was started, and her fever improved, so she was discharged home for palliative care and died 1 month later. Hodgkin lymphoma is one of the most curable malignancies in the vast majority of individuals younger than 60, but it has been aptly described as an orphan disease in elderly adults,1 who have poorer survival than younger individuals because of comorbidities, toxic effects of treatment, and lower treatment intensity.2 The incidence of HL seems constant at two to three cases per 100,000 people, and as diagnostic hematopathology has improved, it appears that the previously identified second peak of HL in middle to old age is no longer so evident. Because the majority of studies and randomized controlled trials have excluded older adults on the basis of age or fitness rating, the most accurate assessments appear to come from population-based studies.3 It has been suggested that HL in elderly adults might represent a different disease.4 Elderly adults differ in clinical presentation from younger individuals. They seem to present more often with B-symptoms (fever, night sweats, and weight loss), poorer functional status, mixed cellularity, advanced stage, and small tumor mass. HL is often associated with EBV in older adults, which confers a worse prognosis. Furthermore, older age has proven a consistent adverse prognostic factor for HL survival. One of the most commonly used prognostic tools in advance-stage HL is the International Prognostic Score (IPS), which identifies seven adverse prognostic factors, including aged 45 and older. Only 9% of participants in the study that established the IPS were aged 55 and older, and none aged 65 and older included.5 HL in elderly adults has no standard treatment recommendations. Moreover, elderly adults are underrepresented in HL prospective clinical studies, and survival rates in this population are disproportionately inferior to those of younger individuals. Generally, treatment of HL in elderly adults should be given with curative intent, but more-effective, more-tolerable therapeutic regimens are needed. This woman is an example of the diagnostic and therapeutic challenges in the decision-making process. When making decisions in the clinic, a comprehensive geriatric assessment and not just the number of years an individual has lived, need to be taken into account. Assessment of comorbidities, quality of life, and performance status should be actively incorporated when designing studies and during planning of treatment. Conflict of Interest: None. Author Contributions: All authors participated fully in the preparation of the manuscript. Martínez-Velilla, Pena-Carbo: management of subject during hospitalization. Idoate-Saralegui: imaging. Martínez-Penuela: pathological study. Ayestarán: surgical procedure. Sponsor's Role: None." @default.
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• W2059722511 date "2014-06-01" @default.
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• W2059722511 title "Hodgkin's Lymphoma in a 96-Year-Old Woman: A Diagnostic, Therapeutic, and Prognostic Dilemma" @default.
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• W2059722511 doi "https://doi.org/10.1111/jgs.12862" @default.
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