Hodgkin's lymphoma (Hodgkin's disease)

Hodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the body's germ-fighting immune system. In Hodgkin's lymphoma, white blood cells called lymphocytes grow out of control, causing swollen lymph nodes and growths throughout the body.

Hodgkin's lymphoma, which used to be called Hodgkin's disease, is one of two general categories of lymphoma. The other is non-Hodgkin's lymphoma.

Advances in diagnosis and treatment of Hodgkin's lymphoma have helped give people with this disease the chance for a full recovery. The prognosis continues to improve for people with Hodgkin's lymphoma.

Symptoms

Signs and symptoms of Hodgkin's lymphoma may include:

• Painless swelling of lymph nodes in your neck, armpits or groin
• Persistent fatigue
• Fever
• Night sweats
• Losing weight without trying
• Severe itching
• Pain in your lymph nodes after drinking alcohol

When to see a doctor

Make an appointment with your health care provider if you have any persistent signs or symptoms that worry you.

Causes

Doctors aren't sure what causes Hodgkin's lymphoma. They know that it begins when infection-fighting white blood cells called lymphocytes develop changes in their DNA. A cell's DNA contains the instructions that tell a cell what to do.

The DNA changes tell the cells to multiply rapidly and to continue living when other cells would naturally die. The lymphoma cells attract many healthy immune system cells to protect them and help them grow. The extra cells crowd into the lymph nodes and cause swelling and other Hodgkin's lymphoma signs and symptoms.

There are multiple types of Hodgkin's lymphoma. Your type is based on the characteristics of the cells involved in your disease and their behavior. The type of lymphoma you have helps determines your treatment options.

Classical Hodgkin's lymphoma

Classical Hodgkin's lymphoma is the more common type of this disease. People diagnosed with this type have large lymphoma cells called Reed-Sternberg cells in their lymph nodes.

Subtypes of classical Hodgkin's lymphoma include:

• Nodular sclerosis Hodgkin's lymphoma
• Mixed cellularity Hodgkin's lymphoma
• Lymphocyte-depleted Hodgkin's lymphoma
• Lymphocyte-rich Hodgkin's lymphoma

Nodular lymphocyte-predominant Hodgkin's lymphoma

This much rarer type of Hodgkin's lymphoma involves lymphoma cells that are sometimes called popcorn cells because of their appearance. Nodular lymphocyte-predominant Hodgkin's lymphoma is usually diagnosed at an early stage and may require less intensive treatments compared to the classical type of the disease.

Risk factors

Factors that can increase the risk of Hodgkin's lymphoma include:

• Your age. Hodgkin's lymphoma is most often diagnosed in people in their 20s and 30s and those over age 55.
• A family history of lymphoma. Having a blood relative with Hodgkin's lymphoma increases your risk of developing Hodgkin's lymphoma.
• Being male. People who are assigned male at birth are slightly more likely to develop Hodgkin's lymphoma than are those who are assigned female.
• Past Epstein-Barr infection. People who have had illnesses caused by the Epstein-Barr virus, such as infectious mononucleosis, are more likely to develop Hodgkin's lymphoma than are people who haven't had Epstein-Barr infections.
• HIV infection. People who are infected with HIV have an increased risk of Hodgkin's lymphoma.

Diagnosis

Tests and procedures used to diagnose Hodgkin's lymphoma include:

• A physical exam. Your health care provider may ask about your symptoms and conduct a physical exam. This might involve checking for swollen lymph nodes, including in your neck, underarm and groin, as well as a swollen spleen or liver.
• Blood tests. A sample of your blood is examined in a lab to understand your general health and look for signs of cancer.
• Imaging tests. Imaging tests are used to look for signs of Hodgkin's lymphoma in other areas of your body. Tests may include X-ray, CT and positron emission tomography (PET).

• A procedure to remove a lymph node. Your provider may recommend a lymph node biopsy procedure to remove a lymph node for laboratory testing that looks for signs of cancer.

  Other lab tests will analyze the lymphoma cells for markers on the surface of the cells that can tell your health care team exactly what type of Hodgkin's lymphoma you have and which treatments are best for your particular cancer.

• A procedure to remove a sample of bone marrow. A bone marrow biopsy and aspiration procedure involves inserting a needle into your hipbone to remove a sample of bone marrow. The sample is analyzed to look for Hodgkin's lymphoma cells.

Other tests and procedures may be used depending on your situation.

Hodgkin's lymphoma stages

Your health care team uses the results of your tests to assign your Hodgkin's lymphoma a stage. Your stage is helpful for understanding the seriousness of your condition and determining which treatments are most likely to help you.

Hodgkin's lymphoma staging uses the numbers 1 to 4 to indicate the stage. A lower number indicates an earlier stage cancer that's more likely to be cured. A higher number means the cancer is more advanced.

Sometimes Hodgkin's lymphoma stages also include the letters A and B. The letter A means that you don't have worrying symptoms of cancer. The letter B means that you have some signs and symptoms, such as a persistent fever, unexplained weight loss and night sweats.

Treatment

The goal of Hodgkin's lymphoma treatment is to destroy as many of the lymphoma cells as possible and bring the disease into remission. Which treatments are right for you depends on the type and stage of your cancer, your overall health, and your preferences.

Chemotherapy

Chemotherapy is a drug treatment that uses chemicals to kill lymphoma cells. Chemotherapy drugs travel through your bloodstream and can reach nearly all areas of your body. Chemotherapy drugs can be taken in pill form or through a vein in your arm, or sometimes both methods of administration are used.

Classical Hodgkin's lymphoma treatment usually begins with chemotherapy. It may be the only treatment needed or it may be combined with radiation therapy.

For nodular lymphocyte-predominant Hodgkin's lymphoma, chemotherapy is often combined with drugs that target the cancer cells (targeted therapy) and radiation therapy.

Side effects of chemotherapy depend on the drugs you're given. Common side effects are nausea and hair loss. Serious long-term complications can occur, such as heart disease, lung damage, fertility problems and other cancers.

Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays and protons, to kill cancer cells. During radiation therapy, you lie on a table and a large machine moves around you, directing the energy beams to specific points on your body.

For Hodgkin's lymphoma treatment, radiation can be aimed at affected lymph nodes and the nearby areas where the disease might spread. It's usually used with chemotherapy. For people with early-stage nodular lymphocyte-predominant Hodgkin's lymphoma, radiation therapy may be the only treatment needed.

Radiation therapy side effects include fatigue and skin redness at the site where the radiation is aimed. Other side effects depend on where the radiation is aimed. For instance, radiation to the neck can cause dry mouth and thyroid problems, such as an underactive thyroid (hypothyroidism). Radiation to the chest can cause heart and lung problems.

Bone marrow transplant

Bone marrow transplant, also known as stem cell transplant, is a treatment to replace your diseased bone marrow with healthy stem cells that help you grow new bone marrow. A bone marrow transplant may be an option if Hodgkin's lymphoma returns or doesn't respond to other treatments.

During a bone marrow transplant, your own blood stem cells are removed, frozen and stored for later use. Next you receive high-dose chemotherapy and radiation therapy to destroy cancerous cells in your body. Finally your stem cells are thawed and put back in your body where they help build healthy bone marrow.

Side effects of a bone marrow transplant include the side effects that might be caused by the chemotherapy or radiation you undergo before your transplant. In addition, you may have an increased risk of infection after your transplant.

Other drug therapy

Other drugs that are sometimes used to treat Hodgkin's lymphoma include:

• Targeted therapy. Targeted drug treatments focus on specific weaknesses present within cancer cells. By blocking these weaknesses, targeted drug treatments can cause cancer cells to die. Targeted therapy is often combined with chemotherapy for treating nodular lymphocyte-predominant Hodgkin's lymphoma. For classical Hodgkin's lymphoma it might be an option in certain situations.
• Immunotherapy. Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that help them hide from the immune system cells. Immunotherapy works by interfering with that process. For Hodgkin's lymphoma, immunotherapy might be considered in certain situations, such as if the disease doesn't respond to other treatments.

Alternative medicine

No alternative medicines have been found to treat Hodgkin's lymphoma. But alternative medicine may help you cope with the stress of a cancer diagnosis and the side effects of cancer treatment. Talk with your health care provider about your options, such as:

• Art therapy
• Exercise
• Meditation
• Music therapy
• Relaxation exercises
• Spirituality

Coping and support

A Hodgkin's lymphoma diagnosis can be challenging. The following strategies and resources may help you cope with your diagnosis:

• Learn about Hodgkin's lymphoma. Learn enough about your cancer to feel comfortable making decisions about your treatment and care. In addition to talking with your health care team, look for information in your local library and on the internet. Start your information search with the Lymphoma Research Foundation and the Leukemia & Lymphoma Society.
• Maintain a strong support system. Having a support system can help you cope with any issues, pain and anxieties that might occur. Although friends and family can be your best allies, they sometimes may have trouble dealing with your illness. If so, the concern and understanding of a formal support group or others coping with cancer can be especially helpful.
• Set reasonable goals. Having goals helps you feel in control and can give you a sense of purpose. But avoid setting goals you can't possibly reach. You may not be able to work full time, for example, but you may be able to work at least part time. In fact, many people find that continuing to work can be helpful.
• Take time for yourself. Eating well, relaxing and getting enough rest can help combat the stress and fatigue of cancer. Also, plan for the downtimes when you may need to rest more or limit what you do.
• Stay active. Receiving a diagnosis of cancer doesn't mean you have to stop doing the things you enjoy or usually do. For the most part, if you feel well enough to do something, go ahead and do it. It's important to stay active and involved as much as you can.

Preparing for an appointment

Make an appointment with your health care provider if you have any signs or symptoms that worry you. If your provider suspects that you have a type of lymphoma, he or she may refer you to a doctor who specializes in diseases that affect the blood cells (hematologist).

Because appointments can be brief, and because there's often a lot of information to discuss, it's a good idea to be well prepared. Here's some information to help you get ready.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet before testing.
• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements you're taking.
• Consider taking a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask.

Your time with your health care provider is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important, in case time runs out. For Hodgkin's lymphoma, some basic questions to ask include:

• Do I have Hodgkin's lymphoma?
• What type of Hodgkin's lymphoma do I have?
• What stage is my condition?
• Will I need more tests?
• Will I need treatment?
• What are my treatment options?
• What are the potential side effects of each treatment?
• How will treatment affect my daily life? Can I continue working?
• How long will treatment last?
• Is there one treatment you feel is best for me?
• If you had a friend or loved one in my situation, what advice would you give that person?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Do you have brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you've prepared, don't hesitate to ask additional questions.

What to expect from your provider

Your health care provider is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your provider may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Has anyone in your family had cancer, including Hodgkin's lymphoma?
• Have you or has anyone in your family had conditions affecting the immune system?
• Have you had infections in the past?
• Have you or your family been exposed to toxins?

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