Hodgkin Lymphoma, Adult

Treatment and Diagnosis:

Types of Hodgkin Lymphoma

If you have swollen lymph nodes or another symptom that suggests Hodgkin lymphoma, your doctor will try to find out what's causing the problem. Your doctor may ask about your personal and family medical history.

You may have some of the following exams and tests:

• Physical exam: Your doctor checks for swollen lymph nodes in your neck, underarms, and groin. Your doctor also checks for a swollen spleen or liver.
• Blood tests: The lab does a complete blood count to check the number of white blood cells and other cells and substances.
• Chest x-rays: X-ray pictures may show swollen lymph nodes or other signs of disease in your chest.
• Biopsy: A biopsy is the only sure way to diagnose Hodgkin lymphoma. Your doctor may remove an entire lymph node (excisional biopsy) or only part of a lymph node (incisional biopsy). A thin needle (fine needle aspiration) usually cannot remove a large enough sample for the pathologist to diagnose Hodgkin lymphoma. Removing an entire lymph node is best.

The pathologist uses a microscope to check the tissue for Hodgkin lymphoma cells. A person with Hodgkin lymphoma usually has large, abnormal cells known as Reed-Sternberg cells. They are not found in people with non-Hodgkin lymphoma. See the photo of a Reed-Sternberg cell.

Types of Hodgkin Lymphoma

When Hodgkin lymphoma is found, the pathologist reports the type. There are two major types of Hodgkin lymphoma:

• Classical Hodgkin lymphoma: Most people with Hodgkin lymphoma have the classical type. The Reed-Sternberg cell looks like the photo.
• Nodular lymphocyte-predominant Hodgkin lymphoma: This is a rare type of Hodgkin lymphoma. The abnormal cell is called a popcorn cell. It may be treated differently from the classical type.

Staging

Your doctor needs to know the extent (stage) of Hodgkin lymphoma to plan the best treatment. Staging is a careful attempt to find out what parts of the body are affected by the disease.

Hodgkin lymphoma tends to spread from one group of lymph nodes to the next group. For example, Hodgkin lymphoma that starts in the lymph nodes in the neck may spread first to the lymph nodes above the collarbones, and then to the lymph nodes under the arms and within the chest.

In time, the Hodgkin lymphoma cells can invade blood vessels and spread to almost any other part of the body. For example, it can spread to the liver, lungs, bone, and bone marrow.

Staging may involve one or more of the following tests:

• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your chest, abdomen, and pelvis. You may receive an injection of contrast material. Also, you may be asked to drink another type of contrast material. The contrast material makes it easier for the doctor to see swollen lymph nodes and other abnormal areas on the x-ray.
• MRI: A powerful magnet linked to a computer is used to make detailed pictures of your bones, brain, or other tissues. Your doctor can view these pictures on a monitor and can print them on film.
• PET scan: You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Lymphoma cells use sugar faster than normal cells, and areas with lymphoma look brighter on the pictures.
• Bone marrow biopsy: The doctor uses a thick needle to remove a small sample of bone and bone marrow from your hipbone or another large bone. Local anesthesia can help control pain. A pathologist looks for Hodgkin lymphoma cells in the sample.

Other staging procedures may include biopsies of other lymph nodes, the liver, or other tissue.

The doctor considers the following to determine the stage of Hodgkin lymphoma:

• The number of lymph nodes that have Hodgkin lymphoma cells
• Whether these lymph nodes are on one or both sides of the diaphragm (see picture)
• Whether the disease has spread to the bone marrow, spleen, liver, or lung.

The stages of Hodgkin lymphoma are as follows:

• Stage I: The lymphoma cells are in one lymph node group (such as in the neck or underarm). Or, if the lymphoma cells are not in the lymph nodes, they are in only one part of a tissue or an organ (such as the lung).
• Stage II: The lymphoma cells are in at least two lymph node groups on the same side of (either above or below) the diaphragm. Or, the lymphoma cells are in one part of a tissue or an organ and the lymph nodes near that organ (on the same side of the diaphragm). There may be lymphoma cells in other lymph node groups on the same side of the diaphragm.
• Stage III: The lymphoma cells are in lymph nodes above and below the diaphragm. Lymphoma also may be found in one part of a tissue or an organ (such as the liver, lung, or bone) near these lymph node groups. It may also be found in the spleen.
• Stage IV: Lymphoma cells are found in several parts of one or more organs or tissues. Or, the lymphoma is in an organ (such as the liver, lung, or bone) and in distant lymph nodes.
• Recurrent: The disease returns after treatment.

In addition to these stage numbers, your doctor may also describe the stage as A or B:

• A: You have not had weight loss, drenching night sweats, or fevers.
• B: You have had weight loss, drenching night sweats, or fevers.

Treatment

• Chemotherapy
• Radiation Therapy
• Stem Cell Transplantation

Your doctor can describe your treatment choices and the expected results. You and your doctor can work together to develop a treatment plan that meets your needs.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat Hodgkin lymphoma include hematologists, medical oncologists, and radiation oncologists . Your doctor may suggest that you choose an oncologist who specializes in the treatment of Hodgkin lymphoma. Often, such doctors are associated with major academic centers. Your health care team may also include an oncology nurse and a registered dietitian.

The choice of treatment depends mainly on the following:

• The type of your Hodgkin lymphoma (most people have classical Hodgkin lymphoma)
• Its stage (where the lymphoma is found)
• Whether you have a tumor that is more than 4 inches (10 centimeters) wide
• Your age
• Whether you've had weight loss, drenching night sweats, or fevers.

People with Hodgkin lymphoma may be treated with chemotherapy, radiation therapy, or both.

If Hodgkin lymphoma comes back after treatment, doctors call this a relapse or recurrence. People with Hodgkin lymphoma that comes back after treatment may receive high doses of chemotherapy, radiation therapy, or both, followed by stem cell transplantation.

You may want to know about side effects and how treatment may change your normal activities. Because chemotherapy and radiation therapy often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them. The younger a person is, the easier it may be to cope with treatment and its side effects.

You may want to talk to your doctor about taking part in a clinical trial, a research study of new treatment methods. See the Taking Part in Cancer Research section.

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Chemotherapy

Chemotherapy for Hodgkin lymphoma uses drugs to kill lymphoma cells. It is called systemic therapy because the drugs travel through the bloodstream. The drugs can reach lymphoma cells in almost all parts of the body.

Usually, more than one drug is given. Most drugs for Hodgkin lymphoma are given through a vein (intravenous), but some are taken by mouth.

Chemotherapy is given in cycles. You have a treatment period followed by a rest period. The length of the rest period and the number of treatment cycles depend on the stage of your disease and on the anticancer drugs used.

You may have your treatment in a clinic, at the doctor's office, or at home. Some people may need to stay in the hospital for treatment.

The side effects depend mainly on which drugs are given and how much. The drugs can harm normal cells that divide rapidly:

• Blood cells: When chemotherapy lowers the levels of healthy blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team gives you blood tests to check for low levels of blood cells. If levels are low, there are medicines that can help your body make new blood cells.
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may be somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Ask your health care team about medicines and other ways to help you cope with these problems.

Some types of chemotherapy can cause infertility:

• Men: Chemotherapy may damage sperm cells. Because these changes to sperm may be permanent, some men have their sperm frozen and stored before treatment (sperm banking).
• Women: Chemotherapy may damage the ovaries. Women who may want to get pregnant in the future should ask their health care team about ways to preserve their eggs before treatment starts.

Some of the drugs used for Hodgkin lymphoma may cause heart disease or cancer later on. See the Follow-up Care section for information about checkups after treatment.

Radiation Therapy

Radiation therapy (also called radiotherapy) for Hodgkin lymphoma uses high-energy rays to kill lymphoma cells. It can shrink tumors and help control pain.

A large machine aims the rays at the lymph node areas affected by lymphoma. This is local therapy because it affects cells in the treated area only. Most people go to a hospital or clinic for treatment 5 days a week for several weeks.

The side effects of radiation therapy depend mainly on the dose of radiation and the part of the body that is treated. For example, radiation to your abdomen can cause nausea, vomiting, and diarrhea. When your chest and neck are treated, you may have a dry, sore throat and some trouble swallowing.

In addition, your skin in the area being treated may become red, dry, and tender. You also may lose your hair in the treated area.

Many people become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise people to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, they can usually be treated or controlled. You can talk with your doctor about ways to ease these problems.

It may also help to know that, in most cases, the side effects are not permanent. However, you may want to discuss with your doctor the possible long-term effects of radiation treatment. After treatment is over, you may have an increased chance of developing a second cancer. Also, radiation therapy aimed at the chest may cause heart disease or lung damage.

Radiation therapy aimed at the pelvis can cause infertility. Loss of fertility may be temporary or permanent, depending on your age:

• Men: If radiation therapy is aimed at the pelvic area, the testes may be harmed. Sperm banking before treatment may be a choice.
• Women: Radiation aimed at the pelvic area can harm the ovaries. Menstrual periods may stop, and women may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger women. Women who may want to get pregnant after radiation therapy should ask their health care team about ways to preserve their eggs before treatment starts.

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Stem Cell Transplantation

If Hodgkin lymphoma returns after treatment, you may receive stem cell transplantation. A transplant of your own blood-forming stem cells (autologous stem cell transplantation) allows you to receive high doses of chemotherapy, radiation therapy, or both. The high doses destroy both Hodgkin lymphoma cells and healthy blood cells in the bone marrow.

Stem cell transplants take place in the hospital. Before you receive high-dose treatment, your stem cells are removed and may be treated to kill lymphoma cells that may be present. Your stem cells are frozen and stored. After you receive high-dose treatment to kill Hodgkin lymphoma cells, your stored stem cells are thawed and given back to you through a flexible tube placed in a large vein in your neck or chest area. New blood cells develop from the transplanted stem cells.

Second Opinion

Before starting treatment, you might want a second opinion about your diagnosis and your treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it.

It may take some time and effort to gather your medical records and see another doctor. In most cases, a brief delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Sometimes people with Hodgkin lymphoma need treatment right away.

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