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Hodgkin Lymphoma

(Hodgkin’s Disease)

by Carol S. Portlock, MD

Hodgkin lymphoma is a localized or disseminated malignant proliferation of cells of the lymphoreticular system, primarily involving lymph node tissue, spleen, liver, and bone marrow. Symptoms include painless lymphadenopathy, sometimes with fever, night sweats, unintentional weight loss, pruritus, splenomegaly, and hepatomegaly. Diagnosis is based on lymph node biopsy. Treatment is curative in about 75% of cases and consists of chemotherapy with or without radiation therapy.

In the US, about 9000 new cases of Hodgkin lymphoma are diagnosed annually. The male:female ratio is 1.4:1. Hodgkin lymphoma is rare before age 10 and is most common between ages 15 and 40; a 2nd peak occurs in people > 50 to 60.

Pathophysiology

Hodgkin lymphoma results from the clonal transformation of cells of B-cell origin, giving rise to pathognomic binucleated Reed-Sternberg cells. The cause is unknown, but genetic susceptibility and environmental associations (eg, occupation, such as woodworking; history of treatment with phenytoin, radiation therapy, or chemotherapy; infection with Epstein-Barr virus, Mycobacterium tuberculosis, herpesvirus type 6, HIV) play a role. Risk is slightly increased in people with certain types of immunosuppression (eg, posttransplant patients taking immunosuppressants); in people with congenital immunodeficiency disorders (eg, ataxia-telangiectasia, Klinefelter syndrome, Chédiak-Higashi syndrome, Wiskott-Aldrich syndrome); and in people with certain autoimmune disorders (RA, celiac sprue, Sjögren syndrome, SLE).

Most patients also develop a slowly progressive defect in cell-mediated immunity (T-cell function) that, in advanced disease, contributes to common bacterial and unusual fungal, viral, and protozoal infections. Humoral immunity (antibody production) is depressed in advanced disease. Death often results from sepsis.

Symptoms and Signs

Most patients present with painless cervical adenopathy. Although the mechanism is unclear, pain may occur in diseased areas immediately after drinking alcoholic beverages, thereby providing an early indication of the diagnosis.

Other manifestations develop as the disease spreads through the reticuloendothelial system, generally to contiguous sites. Intense pruritus may occur early. Constitutional symptoms include fever, night sweats, and unintentional weight loss (> 10% of body weight in previous 6 mo), which may signify involvement of internal lymph nodes (mediastinal or retroperitoneal), viscera (liver), or bone marrow. Splenomegaly is often present; hepatomegaly may be present. Pel-Ebstein fever (a few days of high fever regularly alternating with a few days to several weeks of normal or below-normal temperature) occasionally occurs. Cachexia is common as disease advances.

Bone involvement is often asymptomatic but may produce vertebral osteoblastic lesions (ivory vertebrae) and, rarely, pain with osteolytic lesions and compression fracture. Intracranial, gastric, and cutaneous lesions are rare and when present suggest HIV-associated Hodgkin lymphoma.

Local compression by tumor masses often causes symptoms, including

  • Jaundice secondary to intrahepatic or extrahepatic bile duct obstruction

  • Leg edema secondary to lymphatic obstruction in the pelvis or groin

  • Severe dyspnea and wheezing secondary to tracheobronchial compression

  • Lung cavitation or abscess secondary to infiltration of lung parenchyma, which may simulate lobar consolidation or bronchopneumonia

Epidural invasion that compresses the spinal cord may result in paraplegia. Horner syndrome and laryngeal paralysis may result when enlarged lymph nodes compress the cervical sympathetic and recurrent laryngeal nerves. Neuralgic pain follows nerve root compression.

Diagnosis

  • Chest x-ray

  • CT of chest, abdomen, and pelvis

  • CBC, alkaline phosphatase, LDH, liver function tests, albumin, Ca, BUN, and creatinine

  • Lymph node biopsy

  • PET for staging and MRI if neurologic symptoms are present

  • Sometimes bone marrow biopsy

Hodgkin lymphoma is usually suspected in patients with painless lymphadenopathy or mediastinal adenopathy detected on routine chest x-ray. Similar lymphadenopathy can result from infectious mononucleosis, toxoplasmosis, cytomegalovirus infection, non-Hodgkin lymphoma, or leukemia. Similar chest x-ray findings can result from lung cancer, sarcoidosis, or TB (for evaluation of a mediastinal mass, see Mediastinal Masses : Diagnosis).

A chest x-ray is obtained if not already done. X-ray is usually followed by lymph node biopsy if findings are confirmed with CT or PET scan of the chest. If only mediastinal nodes are enlarged, mediastinoscopy or Chamberlain procedure (a limited left anterior thoracostomy allowing biopsy of mediastinal lymph nodes inaccessible by cervical mediastinoscopy) may be indicated. CT-guided biopsy may also be considered, but results of fine-needle aspiration are often inaccurate, so node core biopsy is needed. CBC, alkaline phosphatase, and kidney and liver function tests are generally done. Other tests are done depending on findings (eg, MRI for symptoms of cord compression).

Biopsy reveals Reed-Sternberg cells (large, binucleated cells) in a characteristically heterogeneous cellular infiltrate, consisting of histiocytes, lymphocytes, monocytes, plasma cells, and eosinophils. Classic Hodgkin lymphoma has 4 histopathologic subtypes (see Histopathologic Subtypes of Hodgkin Lymphoma (WHO Classification)); there is also a lymphocyte-predominant type. Certain antigens on Reed-Sternberg cells may help differentiate Hodgkin lymphoma from non-Hodgkin lymphoma, and classic Hodgkin lymphoma from the lymphocyte-predominant type.

Histopathologic Subtypes of Hodgkin Lymphoma (WHO Classification)

Histologic Type

Morphologic Appearance

Tumor Cell Immunophenotype

Incidence

Classic

Nodular sclerosis

Dense fibrous tissue* surrounding nodules of Hodgkin tissue

CD15+, CD30+, CD20–

67%

Mixed cellularity

A moderate number of Reed-Sternberg cells with a mixed background infiltrate

CD15+, CD30+, CD20–

25%

Lymphocyte-rich

Few Reed-Sternberg cells

Many B cells

Fine sclerosis

CD15+, CD30+, CD20–

3%

Lymphocyte-depleted

Numerous Reed-Sternberg cells

Extensive fibrosis

CD15+, CD30+, CD20–

Rare

Nodular lymphocyte-predominant

Few neoplastic cells (lymphocytic or histiocytic cells or both)

Many small B cells

Nodular pattern

CD15–, CD30–, CD20+, EMA+

3%

*Shows characteristic birefringence with polarized light.

EMA = epithelial membrane antigen.

Other test results may be abnormal but are nondiagnostic. CBC may show slight polymorphonuclear leukocytosis. Lymphocytopenia may occur early and become pronounced with advanced disease. Eosinophilia is present in about 20% of patients, and thrombocytosis may be present. Anemia, often microcytic, usually develops with advanced disease. In advanced anemia, defective iron reutilization is characterized by low serum iron, low iron-binding capacity, and increased bone marrow iron. Pancytopenia is occasionally caused by bone marrow invasion, usually by the lymphocyte-depleted type. Hypersplenism (see Hypersplenism) may occur in patients with marked splenomegaly. Elevated serum alkaline phosphatase levels may be present, but elevations do not always indicate bone marrow or liver involvement. Increases in leukocyte alkaline phosphatase, serum haptoglobin, and other acute-phase reactants usually reflect active disease.

Staging

After diagnosis, stage is determined to guide therapy. The commonly used Ann Arbor staging system (see Cotswold Modification of Ann Arbor Staging of Hodgkin Lymphoma and Non-Hodgkin Lymphoma) incorporates symptoms; physical examination findings; results of imaging tests, including chest x-ray, CT of the chest, abdomen, and pelvis, and PET; and less frequently, unilateral bone marrow biopsy. Laparotomy is not required for staging. Other staging tests include cardiac and pulmonary function tests in anticipation of therapy. The Cotswold modifications of the Ann Arbor staging system incorporate the prognostic implications of tumor bulkiness and disease sites.

Cotswold Modification of Ann Arbor Staging of Hodgkin Lymphoma and Non-Hodgkin Lymphoma

Stage*

Criteria

I

In 1 lymph region only

II

In 2 lymph regions on the same side of the diaphragm

III

In the lymph nodes, spleen, or both and on both sides of the diaphragm

IV

Extranodal involvement (eg, bone marrow, lungs, liver)

*Subclassification E indicates extranodal involvement adjacent to an involved lymph node (eg, disease of mediastinal nodes and hilar adenopathy with adjacent lung infiltration is classified as stage IIE). Stages can be further classified by A to indicate the absence or B to indicate the presence of systemic symptoms (weight loss, fever, or night sweats). Systemic symptoms usually occur in stages III and IV (20 to 30% of patients). The suffix X is used to denote bulky disease, which is > 10 cm in maximum dimension or involves more than one third of the chest diameter (seen on chest x-ray).

Designation of the letter A to any stage means that no systemic symptoms are being experienced. Designation of the letter B means that at least one systemic symptom is experienced. The presence of symptoms correlates with response to treatment.

Prognosis

In classic Hodgkin lymphoma, disease-free survival 5 yr after therapy is considered a cure. Relapse is very rare after 5 yr. Chemotherapy with or without radiation therapy achieves cure in 70 to 80% of patients. Increased potential for relapse depends on many factors, including male sex, age > 45 yr, involvement of multiple extranodal sites, and presence of constitutional symptoms at diagnosis. Patients who do not achieve complete remission or who relapse within 12 mo have a poor prognosis.

Treatment

  • Chemotherapy

  • Radiation therapy

  • Surgery

  • Sometimes hematopoietic stem cell transplantation

The choice of treatment modality is complex and depends on the precise stage of disease. Before treatment, men should be offered sperm banking, and women should discuss fertility options with their oncologists.

Stage IA, IIA, IB, or IIB disease is generally treated with an abbreviated chemotherapy regimen of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine (ABVD) plus radiation therapy or with longer-course chemotherapy alone. Such treatment cures about 80% of patients. In patients with bulky mediastinal disease, chemotherapy may be of longer duration or of a different type, and radiation therapy is typically used.

Stage IIIA and IIIB disease is usually treated with ABVD combination chemotherapy alone. Cure rates of 75 to 80% have been achieved in patients with stage IIIA disease, and rates from 70 to 80% in patients with stage IIIB disease.

For stage IVA and IVB disease, ABVD combination chemotherapy is the standard regimen, producing complete remission in 70 to 80% of patients; > 50% remain disease-free at 5 yr. Other effective drugs include nitrosoureas, ifosfamide, procarbazine, cisplatin or carboplatin, and etoposide. Other drug combinations are bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone (known as BEACOPP), and melchlorethamine, doxorubicin, vinblastine, vincristine, etoposide, bleomycin, and prednisone (known as Stanford V). Standford V incorporates involved field irradiation for consolidation.

Hodgkin Lymphoma Posttreatment Surveillance

Evaluation

Schedule

History and physical examination, CBC, platelets, electrolytes, BUN, creatinine, liver function tests

First 2 yr, q 3‒4 mo

Yr 3‒5, q 6 mo

> 5 yr, q 12 mo

Chest x-ray at each visit if chest CT is not done

First 2 yr, q 3 mo

Yr 3‒5, q 6 mo

Chest CT

First 2 yr, q 6 to 8 mo

Yr 3‒5, annually

Abdomen and pelvis CT

Stages I and II: First 5 yr, annually

For other stages: First 2 yr, q 6 mo

Yr 3‒5, annually

Thyroid-stimulating hormone levels

Every 6 mo after radiation to neck

Mammography

Annually beginning at yr 7 if radiation above the diaphragm began at age < 30 yr

Annually beginning at age 37 if radiation above the diaphragm began at age 30 yr

Breast MRI

For high-risk patients (those who received radiation above the diaphragm before age 30 yr), alternating every 6 mo with mammography (one test every 6 mo)

Autologous transplantation using peripheral stem cell products should be considered for all physiologically eligible patients with relapsed or refractory Hodgkin lymphoma who respond to salvage chemotherapy.

Complications of treatment

Chemotherapy, particularly with drugs such as mechlorethamine, vincristine, procarbazine, and prednisone, increases the risk of leukemia, which typically develops after > 3 yr. Both chemotherapy and radiation therapy increase the risk of malignant solid tumors (eg, breast, GI, lung, soft tissue). Mediastinal radiation increases the risk of coronary atherosclerosis. Breast cancer risk is increased in women beginning about 7 yr after they have received radiation treatment to adjacent nodal regions.

Posttreatment surveillance

Routine testing is done to identify recurrence. For a schedule of posttreatment surveillance, see Hodgkin Lymphoma Posttreatment Surveillance.

Key Points

  • Hodgkin lymphoma is of B cell origin.

  • Patients usually present with painless lymphadenopathy or with incidental mediastinal adenopathy discovered on chest x-ray.

  • Biopsy shows pathognomic, binucleated Reed-Sternberg cells.

  • Cure rate overall is 70 to 80% using combination chemotherapy and sometimes radiation therapy.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • DILANTIN
  • CYTOXAN (LYOPHILIZED)
  • No US brand name
  • IFEX
  • PLATINOL
  • MARQIBO KIT
  • ETOPOPHOS
  • MATULANE
  • RAYOS
  • DTIC-DOME
  • MUSTARGEN

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