General Information About Adult Hodgkin Lymphoma

Adult Hodgkin lymphoma is a disease in which malignant (cancer) cells form in the lymph system.

Adult Hodgkin lymphoma is a type of cancer that develops in the lymph system, part of the body's immune system.

The lymph system is made up of the following:

• Lymph: Colorless, watery fluid that travels through the lymph system and carries white blood cells called lymphocytes. Lymphocytes protect the body against infections and the growth of tumors.
• Lymph vessels: A network of thin tubes that collect lymph from different parts of the body and return it to the bloodstream.
• Lymph nodes: Small, bean-shaped structures that filter lymph and store white blood cells that help fight infection and disease. Lymph nodes are located along the network of lymph vessels found throughout the body. Clusters of lymph nodes are found in the underarm, pelvis, neck, abdomen, and groin.
• Spleen: An organ that makes lymphocytes, filters the blood, stores blood cells, and destroys old blood cells. It is located on the left side of the abdomen near the stomach.
• Thymus: An organ in which lymphocytes grow and multiply. The thymus is in the chest behind the breastbone.
• Tonsils: Two small masses of lymph tissue at the back of the throat. The tonsils produce lymphocytes.
• Bone marrow: The soft, spongy tissue in the center of large bones. Bone marrow produces white blood cells, red blood cells, and platelets.

There are two main types of Hodgkin lymphoma: classical and nodular lymphocyte-predominant.

Most Hodgkin lymphomas are the classical type. The classical type is broken down into the following four subtypes:

• Nodular sclerosing Hodgkin lymphoma.
• Mixed cellularity Hodgkin lymphoma.
• Lymphocyte depletion Hodgkin lymphoma.
• Lymphocyte-rich classical Hodgkin lymphoma.

Age, gender, and Epstein-Barr infection can affect the risk of developing adult Hodgkin lymphoma.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for adult Hodgkin lymphoma include the following:

• Being in young or late adulthood.
• Being male.
• Being infected with the Epstein-Barr virus.
• Having a first-degree relative (parent, brother, or sister) with Hodgkin lymphoma.

Pregnancy is not a risk factor for Hodgkin lymphoma.

Possible signs of adult Hodgkin lymphoma include swollen lymph nodes, fever, night sweats, and weight loss.

These and other symptoms may be caused by adult Hodgkin lymphoma. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems do not go away:

• Painless, swollen lymph nodes in the neck, underarm, or groin.
• Fever for no known reason.
• Drenching night sweats.
• Weight loss for no known reason.
• Itchy skin.
• Feeling very tired.

Tests that examine the lymph nodes are used to detect (find) and diagnose adult Hodgkin lymphoma.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's past illnesses and treatments will also be taken.
• Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
  • The number of red blood cells, white blood cells, and platelets.
  • The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.
  • The portion of the sample made up of red blood cells.
  Certain factors affect prognosis (chance of recovery) and treatment options.

  The prognosis (chance of recovery) and treatment options depend on the following:

  • The patient's symptoms.
  • The stage of the cancer.
  • The type of Hodgkin lymphoma.
  • Blood test results.
  • The patient's age, gender, and general health.
  • Whether the cancer is recurrent or progressive.

  For Hodgkin lymphoma during pregnancy, treatment options also depend on:

  • The wishes of the patient.
  • The age of the fetus.

  Adult Hodgkin lymphoma can usually be cured if found and treated early.

  Stages of Adult Hodgkin Lymphoma

  After adult Hodgkin lymphoma has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body.

  The process used to find out if cancer has spread within the lymph system or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For adult Hodgkin lymphoma, CT scans of the chest, abdomen, and pelvis are taken.
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
  • Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow, blood, and bone under a microscope to look for signs of cancer. Stages of adult Hodgkin lymphoma may include A, B, E, and S.

    Adult Hodgkin lymphoma may be described as follows:

    • A: The patient has no symptoms.
    • B: The patient has symptoms such as fever, weight loss, or night sweats.
    • E: "E" stands for extranodal and means the cancer is found in an area or organ other than the lymph nodes or has spread to tissues beyond, but near, the major lymphatic areas.
    • S: "S" stands for spleen and means the cancer is found in the spleen.
    The following stages are used for adult Hodgkin lymphoma:Stage I

    Stage I is divided into stage I and stage IE.

    • Stage I: Cancer is found in one lymph node group.
    • Stage IE: Cancer is found in an area or organ other than the lymph nodes.
    Stage II

    Stage II is divided into stage II and stage IIE.

    • Stage II: Cancer is found in two or more lymph node groups on the same side of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
    • Stage IIE: Cancer is found in an area or organ other than the lymph nodes and in lymph nodes near that area or organ, and may have spread to other lymph node groups on the same side of the diaphragm.
    Stage III

    Stage III is divided into stage III, stage IIIE, Stage IIIS, and stage IIIS+E.

    • Stage III: Cancer is found in lymph node groups on both sides of the diaphragm (the thin muscle below the lungs that helps breathing and separates the chest from the abdomen).
    • Stage IIIE: Cancer is found in lymph node groups on both sides of the diaphragm and in an area or organ other than the lymph nodes.
    • Stage IIIS: Cancer is found in lymph node groups on both sides of the diaphragm and in the spleen.
    • Stage IIIS+E: Cancer is found in lymph node groups on both sides of the diaphragm, in an area or organ other than the lymph nodes, and in the spleen.

    Stage III is also divided into stage III(1) and stage III(2) as follows:

    • Stage III(1): Cancer is found only in the upper abdomen above the renal vein.
    • Stage III(2): Cancer is found in lymph nodes in the pelvis and/or near the aorta.
    Stage IV

    In stage IV, the cancer either:

    • is found throughout one or more organs other than the lymph nodes and may be in lymph nodes near those organs; or
    • is found in one organ other than the lymph nodes and has spread to lymph nodes far away from that organ.
    Adult Hodgkin lymphoma may be grouped for treatment as follows:Early Favorable

    Early favorable adult Hodgkin lymphoma is stage I or stage II, without risk factors.

    Early Unfavorable

    Early unfavorable adult Hodgkin lymphoma is stage I or stage II with one or more of the following risk factors:

    • A tumor in the chest that is larger than 1/3 of the width of the chest or at least 10 centimeters.
    • Cancer in an organ other than the lymph nodes.
    • A high sedimentation rate (in a sample of blood, the red blood cells settle to the bottom of the test tube more quickly than normal).
    • Three or more lymph nodes with cancer.
    • Symptoms such as fever, weight loss, or night sweats.
    Advanced Favorable

    Advanced favorable adult Hodgkin lymphoma is stage III or stage IV with three or fewer of the following risk factors:

    • Having a low blood albumin (protein) level (below 4).
    • Having a low hemoglobin level (below 10.5).
    • Being male.
    • Being aged 45 years or older.
    • Having stage IV disease.
    • Having a high white blood cell count (15,000 or higher).
    • Having a low lymphocyte count (below 600 or less than 8% of the white blood cell count).
    Advanced Unfavorable

    Advanced unfavorable Hodgkin lymphoma is stage III or stage IV with four or more of the following risk factors:

    • Having a low blood albumin (protein) level (below 4).
    • Having a low hemoglobin level (below 10.5).
    • Being male.
    • Being aged 45 years or older.
    • Having stage IV disease.
    • Having a high white blood cell count (15,000 or higher).
    • Having a low lymphocyte count (below 600 or less than 8% of the white blood cell count).

    Recurrent Adult Hodgkin Lymphoma

    Recurrent adult Hodgkin lymphoma is cancer that has recurred (come back) after it has been treated. The cancer may come back in the lymph system or in other parts of the body.

    Treatment Option Overview

    There are different types of treatment for patients with adult Hodgkin lymphoma.

    Different types of treatment are available for patients with adult Hodgkin lymphoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

    Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

    For pregnant patients with Hodgkin lymphoma, treatment is carefully chosen to protect the fetus. Treatment decisions are based on the mother’s wishes, the stage of the Hodgkin lymphoma, and the age of the fetus. The treatment plan may change as the symptoms, cancer, and pregnancy change. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

    Patients with Hodgkin lymphoma should have their treatment planned by a team of doctors with expertise in treating lymphomas.

    Treatment will be overseen by a medical oncologist, a doctor who specializes in treating cancer. The medical oncologist may refer you to other doctors who have experience and expertise in treating adult Hodgkin lymphoma and who specialize in certain areas of medicine. These may include the following specialists:

    • Neurosurgeon.
    • Neurologist.
    • Rehabilitation specialist.
    • Radiation oncologist.
    • Endocrinologist.
    • Hematologist.
    • Other oncology specialists.
    Three types of standard treatment are used:Chemotherapy

    Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Combination chemotherapy is treatment with more than one anticancer drug.

    When a pregnant woman is treated with chemotherapy for Hodgkin lymphoma, it isn't possible to protect the fetus from being exposed to the chemotherapy. Some chemotherapy regimens may cause birth defects if given in the first trimester. Vinblastine is an anticancer drug that has not been linked with birth defects when given in the second half of pregnancy.

    Radiation therapy

    Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

    For pregnant patients with Hodgkin lymphoma, radiation therapy should be postponed until after delivery, if possible, to avoid any risk to the fetus. If immediate treatment is needed, patients may decide to continue the pregnancy and receive radiation therapy. However, lead used to shield the fetus may not protect it from scattered radiation that could possibly cause cancer in the future.

    Surgery

    Laparotomy is a procedure in which an incision (cut) is made in the wall of the abdomen to check the inside of the abdomen for signs of disease. The size of the incision depends on the reason the laparotomy is being done. Sometimes organs are removed or tissue samples are taken and checked under a microscope for signs of disease. If cancer is found, the tissue or organ is removed during the laparotomy.

    For pregnant patients with Hodgkin lymphoma, treatment options also include:Watchful waiting

    Watchful waiting is closely monitoring a patient’s condition without giving any treatment unless symptoms appear or change. Delivery may be induced when the fetus is 32 to 36 weeks old, so that the mother can begin treatment.

    Steroid therapy

    Steroids are hormones naturally produced in the body by the adrenal glands and by reproductive organs. Some types of steroids are made in a laboratory. Certain steroid drugs have been found to help chemotherapy work better and help stop the growth of cancer cells. Steroids can also help the lungs of the fetus develop faster than normal. This is important when delivery is induced early.

    New types of treatment are being tested in clinical trials. These include the following:High-dose chemotherapy and radiation therapy with stem cell transplant

    High-dose chemotherapy and radiation therapy with stem cell transplant is a way of giving high doses of chemotherapy and radiation therapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After therapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.

    Clinical trials comparing new methods of treatment

    This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

    Treatment Options for Adult Hodgkin Lymphoma

    Early Favorable Hodgkin Lymphoma

    Treatment of early favorable Hodgkin lymphoma may include the following:

    • Combination chemotherapy with or without radiation therapy to parts of the body with cancer.
    • Radiation therapy alone to areas of the body with cancer or to the mantle field (neck, chest, armpits).
    • Clinical trials of new combinations of chemotherapy and/or radiation therapy.

    This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

    Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I adult Hodgkin lymphoma and stage II adult Hodgkin lymphoma.

    Early Unfavorable Hodgkin Lymphoma

    Treatment of early unfavorable Hodgkin lymphoma may include the following:

    • Combination chemotherapy with or without radiation therapy to parts of the body with cancer.
    • Clinical trials of new combinations of chemotherapy and/or radiation therapy.

    This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

    Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I adult Hodgkin lymphoma and stage II adult Hodgkin lymphoma.

    Advanced Favorable Hodgkin Lymphoma

    Treatment of advanced favorable Hodgkin lymphoma may include the following:

    • Combination chemotherapy with or without radiation therapy to parts of the body with cancer.
    • Clinical trials of new combinations of chemotherapy.

    This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

    Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III adult Hodgkin lymphoma and stage IV adult Hodgkin lymphoma.

    Advanced Unfavorable Hodgkin Lymphoma

    Treatment of advanced unfavorable Hodgkin lymphoma may include the following:

    • Combination chemotherapy.
    • Clinical trials of new combinations of chemotherapy.
    • A clinical trial of high-dose chemotherapy and stem cell transplant using the patient's own stem cells.

    This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

    Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III adult Hodgkin lymphoma and stage IV adult Hodgkin lymphoma.

    Hodgkin Lymphoma During Pregnancy

    Hodgkin Lymphoma During the First Trimester of Pregnancy

    When Hodgkin lymphoma is diagnosed in the first trimester of pregnancy, it does not necessarily mean that the patient will be advised to end the pregnancy. Each patient's treatment will depend on the stage of the lymphoma, how fast it is growing, and the patient's wishes. For women who choose to continue the pregnancy, treatment of Hodgkin lymphoma during the first trimester of pregnancy may include the following:

    • Watchful waiting when the cancer is above the diaphragm and is slow-growing. Delivery may be induced when the fetus is 32 to 36 weeks old so the mother can begin treatment.
    • Radiation therapy above the diaphragm, with the fetus shielded.
    • Systemic chemotherapy using one or more drugs.

    Hodgkin Lymphoma During the Second Half of Pregnancy

    When Hodgkin lymphoma is diagnosed in the second half of pregnancy, most patients can delay treatment until after the baby is born. Treatment of Hodgkin lymphoma during the second half of pregnancy may include the following:

    • Watchful waiting, with plans to induce delivery when the fetus is 32 to 36 weeks old.
    • Systemic chemotherapy using one or more drugs.
    • Steroid therapy
    • Radiation therapy to relieve breathing problems caused by a large tumor in the chest.

    Recurrent Adult Hodgkin Lymphoma

    Treatment of recurrent Hodgkin lymphoma may include the following:

    • Combination chemotherapy.
    • Combination chemotherapy followed by high-dose chemotherapy and stem cell transplant with or without radiation therapy.
    • Radiation therapy with or without chemotherapy.
    • Chemotherapy as palliative therapy to relieve symptoms and improve quality of life.
    • A clinical trial of high-dose chemotherapy and stem cell transplant.

    This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site.

    Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent adult Hodgkin lymphoma.

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    Changes to This Summary (02/22/2008)

    The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

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