Hodgkin’s lymphoma


Overview

Hodgkin’s lymphoma is also known as Hodgkin's disease. It is a type of lymphoma where cancer originates from the white blood cells called lymphocytes. It was named after Thomas Hodgkin, who first described abnormalities in the lymph system in 1832.

In Hodgkin's lymphoma, cancer cells spread from one lymph node group to another.

When the cancer cells are observed through a microscope, we get to see multiple RS Cells. The RS Cell, in other words, known as Reed-Sternberg cells which are distinctive, giant cells, found when the patient suffers from Hodgkin’s Lymphoma. The cells usually give the tissues surrounding it, a moth-eaten appearance.

Symptoms

The various symptoms of Hodgkin’s Lymphoma are:

  • Swollen lymph nodes in the neck, armpits or groin
  • Pain in lymph nodes after drinking alcohol
  • Itching throughout the body (Pruritus)
  • Persistent fatigue
  • Coughing, difficulty in breathing, or chest pain arising due to the swollen lymph nodes in the chest pressing        the windpipe.
  • Unexplained weight loss
  • Persistent fever
  • Drenching night sweats

The last three symptoms are classified as 'B symptoms’ which requires aggressive treatment. It is important to note that patients with Hodgkin's disease may not experience any symptoms or the symptoms may not appear until the advanced stages of cancer.

Causes

Hodgkin lymphoma is caused by a mutation in the DNA of a type of white blood cell called B lymphocytes, although the exact reason why this happens isn't known. The mutation in the DNA causing them to multiply uncontrollably. The abnormal lymphocytes usually begin to multiply in one or more lymph nodes in a particular area of the body, such as the neck or groin. Over time however, it's possible for the abnormal lymphocytes to spread into other parts of the body, such as the bone marrow, spleen, skin, lungs and the liver.

Some of the common risk factors identified with Hodgkin's lymphoma are:

  • Males tend to be at a higher risk than females to suffer the disease.
  • The people in the age group of 15–40 years and over 55 years have a higher chance of the cancer.
  • A family history of Hodgkin’s Lymphoma.
  • Glandular fever, also known as infectious mononucleosis caused by the EBV virus which is directly associated with Hodgkin’s Lymphoma.
  • Weakened immune system due to HIV or AIDS.
  • Prolonged use of human growth hormone.

Diagnosis

Physical Examination:

During diagnosis, the doctor takes into account the medical history of the patient and conducts a physical examination. Here, the doctor checks for swollen lymph nodes in the neck, underarm, groin, spleen and liver. If swelling in the lymph nodes is detected, then some additional tests may be needed to confirm the presence of cancer and determine the extent to which it has spread.

Blood Tests:

Blood tests are performed to check the presence of cancer cells in the blood.  Another variant of the standard blood test is conducted to check the erythrocyte sedimentation rate (ESR). In this procedure, blood is collected in a test tube and observations are made to see how quickly red blood cells settle at the bottom of the test tube. Generally, red blood cells settle slowly. A faster rate may indicate the possibility of cancer.

Imaging Techniques:

A chest X-rays shows the lymph nodes in the chest and neck area, which is also known as the starting point for Hodgkin's Lymphoma. The technique is also used to detect enlarged lymph nodes.

Computer Tomography (CT):

CT scans are generally more accurate than x-rays. They can detect abnormalities in the chest and neck area, as well as reveal the extent of cancer. CT scans are used to evaluate symptoms, understand the stage of cancer and consistently monitor the response to treatment. A CT scan is also often used in detecting lymphomas in the brain, abdominal and pelvic areas.

Positron Emission Tomography (PET):

PET scans combined with CT scans can help doctors clarify the location of cancer. It can also provide information on whether or not an enlarged lymph node is benign or cancerous. PET scans may also help doctors determine how well a patient has responded to treatment, determining if there is any residue of cancer after treatment and if the patient has achieved remission.

Biopsy:

A biopsy of the suspicious lymph node is the most definitive way to diagnose Hodgkin's disease. A pathologist examines the lymph node sample for the presence of Reed-Sternberg cells or other abnormal features. The type of biopsy performed depends on the location of cancer and how accessible the lymph node is. The doctor may engage in surgery and remove the entire lymph node or a small part of it.

In some cases, the doctor may use fine needle aspiration to withdraw a small amount of tissue from the lymph node to check for cancer cells. Biopsies of bone marrow may also be performed in patients with existing Hodgkin's disease specifically to determine if cancer has spread to the bone marrow.  In such cases, it is termed as Advanced Hodgkin’s Lymphoma.

Stages of Hodgkin’s Lymphoma:

Hodgkin’s Lymphoma can broadly be classified into four stages.

Stage I: In this stage, cancer affects only one lymph node region. There are chances that the cancer has invaded an extra-lymphatic organ but not another lymph node region. Such cases are quite rare in Hodgkin’s Lymphoma.

Stage II: Here, cancer has spread to 2 or more lymph node regions located on the same side of the diaphragm. It is possible that another organ and its regional lymph nodes may also be affected. There are instances when a tumour mass may develop in the chest. In such cases, the size of the tumour can be larger than one-third the diameter of the chest or larger than 10 centimetres.

Stage III: The cancer in the lymph node areas has spread to both sides of the diaphragm.

Stage IV: Here the lymphoma is in its advanced stage where it has spread to 1 or more organs beyond the lymph nodes such as cerebrospinal fluid, liver, bone marrow or lungs.

The treatment depends on the stage of cancer and how far it has spread across the organs. However one of the common symptoms observed is acute pain in the lymph nodes.

Prognostic factors:

In addition to staging, doctors use other prognostic factors to help plan the best treatment and predict how well a treatment will work. For patients with Hodgkin’s lymphoma, several factors can predict the recurrence of cancer and what treatment works best.

The Prognostic factors include:

  • The sex of the patient.
  • Age of the patient.
  • A low blood albumin (a type of protein) level where it is less than 4 grams per litre.
  • Low haemoglobin (red blood cell count), defined as less than 10.5 grams per decilitre.
  • If White blood cell count is more than 15,000 per cubic millimetre.
  • If Lymphocyte count is less than 600 per cubic millimetre or less than 8% of the total white blood cell count.

Treatment

Treatment options depend on the:

  • Type of Hodgkin’s disease
  • Tumour stage, size, and location
  • Patient’s age and overall health status
  • Presence or absence of "B symptoms" (weight loss, persistent fever and night sweats)

Chemotherapy, Radiation, or a combination of both is the primary treatment options for Hodgkin's disease. Stem cell transplantation may be recommended for patients who have recurring cancer. During such a stage, high-dose of chemotherapy (along with radiation) is given.

Preparing for Side Effects before Treatment

One of the common side effects is the suppression of the immune system which increases the risk of infections.  It is a common practice for patients to be vaccinated against three bacteria namely pneumococci, meningococci and Haemophilus influenza before the actual treatment.

Another side effect is infertility.  Patients who may wish to have children in the future should be aware of the risk of infertility after treatment. Men with Hodgkin's disease may want to consider sperm freezing and assisted reproductive techniques. Women should ask their doctors about the possibility of preserving fertility by taking hormonal drugs called GnRH analogues (responsible for fertility and sex steroids) before undergoing chemotherapy.

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