Hodgkin Lymphoma

Epidemiology

Incidence - approx. 8,920 cases in 2026

Deaths- approx. 1,100

Less common than non-Hodgkin lymphoma

Death rate declining

Slightly higher incidence in Non-Hispanic whites and blacks

Why is there a decrease in deaths?

Lower incidence, advanced tx., improved survival for HIV- associated lymphoma

Peak incidence in what ages?

20-34 and 55+

Median age at dx

39

___ of cases involve children under age 17, rare in those under age 5

12%

Slightly more prevalent in which gender?

Male

Etiology

Cause unknown

Epstein-Barr virus

Infectious mononucleosis

Family history (siblings of patients with Hodgkins at higher risk)

Reed Sternberg cells

An individual’s genetic makeup

Environmental exposures

Infectious agents

Known risk factors

Severely altered immune function:

◦ Immunosuppressants given for organ transplant patients

◦ Autoimmune disorders: Sjögren syndrome, systemic lupus, rheumatoid arthritis

◦ HIV (due to weakening the immune system)

◦ Helicobacter pylori (by continuously activating the immune system)

◦ Hepatitis C

Prognostic Indicators

Stage at diagnosis

Age

B symptoms

Preservation of fertility in both females and males

Clinical presentation

Most present with painless lymphadenopathy and are asymptomatic

Painless mass is most often discovered in supraclavicular, cervical, and mediastinal lymph node areas (can include lumps in the neck, underarm, or groin)

◦ Chest pain

◦ Shortness of breath

◦ Abdominal fullness

◦ Loss of appetite

◦ Itching

◦ Night sweats

◦ Fatigue

◦ Unexplained weight loss

◦ Intermittent fever

What is the most common sign?

A painless mass found by the patient, above the diaphragm

What are “B” symptoms?

Specific symptoms associated with Hodgkin lymphoma

1. Unexplained weight loss of more than 10% of body weight in the 6 months before

2. Frequent, drenching night sweats

3. Unexplained fevers higher than 100.4 degrees

• Generalized pruritis and pain with alcohol ingestion

• Shortness of breath, cough, or chest discomfort

How many patients experience B symptoms before diagnosis?

1/3

Detection and Diagnosis

H&P

Radiographic examinations

• Chest x-ray (mediastinal masses are often found on routine chest x-rays)

• CT

• MRI

• PET

Laboratory studies

• CBC

• Complete platelet count

• Liver and renal functions

What conditions can indicate bone marrow involvement?

Anemia, leukopenia, thrombocytosis, and lymphopenia

Bone marrow biopsies are reserved for which patients? Why

Later-stage disease and subdiaphragmatic disease

Because few patients with Hodgkin lymphoma have bone marrow involvement

Abnormal laboratory studies that may indicate Hodgkin lymphoma

• Low blood albumin level below 4

• High erythrocyte sedimentation rate

• High white blood cell count above 15,000

• Low red blood cell count, hemoglobin level below 10.5

• Low blood lymphocyte count below 600

The WHO classification system divides Hodgkin into two main categories:

Classic Hodgkin lymphoma - (approx. 95%)

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) - (5%)

4 subcategories of Classic Hodgkin lymphoma

• Nodular Sclerosing Hodgkin lymphoma*

• Mixed Cellularity Hodgkin lymphoma*

• Lymphocyte –rich Hodgkin lymphoma

• Lymphocyte-depleted Hodgkin lymphoma (rarest of 4 types)

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)

Characterized by variants of Reed-Sternberg cells called popcorn cells

Presents with disease in the lymph nodes of neck and axilla

80% 10-year survival for stages I and II

Staging system

Ann Arbor Staging System:

A The patient does not have B symptoms.

B The patient has B symptoms.

E Extranodal disease is present.

S Disease is found in the spleen.

Routes of Spread

Predictable, contiguous pattern of spread that mimics the route of the lymphatic system

◦ If outside of lymph system, it is next to the involved sites

◦ Rate of progression not predictable

◦ In advanced stages, may spread to viscera, spleen, bone marrow, or other organs

Primary treatment modality for early-stage disease?

Chemotherapy

Pts with adverse reactions to chemo are given which treatment?

EBRT alone

ABVD is the standard treatment today (proven more effective and less toxic than MOPP)

doxorubicin (Adriamycin), bleomycin, vincristine, and dacarbazine

Patients diagnosed with advanced stages are treated with ________ because combined modality yields better results

Chemotherapy regimen and adjuvant radiation therapy

Mantle field

Disease above diaphragm

Field includes the cervical, submandibular, axillary, supraclavicular, infraclavicular, mediastinal, and hilar lymph nodes

Large fields needed to encompass nodes in neck, chest, and axilla, but sparing healthy tissue

Mantle field borders

Sup: lower mandible and mastoid tips (chin hyperextended)

Inf: T9 to interspace

Lat: flash beyond axillary nodes

Abdominal or Paraaortic Fields

The spleen, paraaortic, and retroperitoneal nodes are treated

Treatment of the mantle and abdominal fields without the pelvic portion is termed subtotal nodal irradiation

A spinal block may be added superiorly on the abdominal field to protect the spinal cord from overdose

Why must the left kidney be protected if the spleen is treated?

Because the right kidney receives dose

Abdominal/Paraaortic field borders

Sup: Mid T10-T11

Inf: L4-L5

Lat: 9-10 cm wide midline

Pelvic Irradiation (Inverted Y field)

Shielding blocks are used to protect bone marrow, the bowel, and the bladder

Can cause concern for patients who desire to preserve fertility

Pelvic field borders

Sup: L5, Inf: 2 cm below ischial tuberosity

Lat: 2 cm beyond pelvic inlet

Total nodal radiation

Encompasses both mantle and inverted Y fields

Patients receiving multiple treatment fields usually undergo ________ treatment for better tolerance

Sequential

Treatment areas that only encompass the areas of known disease are called

Involved field radiation therapy

When the field includes areas of known disease and contiguous uninvolved lymph nodes is called

Extended field radiation therapy

For patients with a favorable prognosis, treatment to the pelvic region is avoided. Why?

To preserve fertility

If chemo and radiation therapy fail, patients may undergo ________

Autologous bone marrow and peripheral blood stem cell transplants

Involved-Node Radiotherapy field volumes

Include only the initially involved nodes with a 1cm margin and modifications to block organs at risk

Involved-Site Radiotherapy field volumes

Include all initial disease sites after chemotherapy, If treated with EBRT alone, the ISRT field margins should increase by 2–5cm superiorly and inferiorly, accounting for OARs

Doses of EBRT alone

30-36 Gy to involved sites with 6-MV to 10-MV

Doses of sites with potential subclinical involvement

25-30 Gy

Doses for EBRT with chemo

20-30 Gy for non-bulky disease

30-36 Gy for bulky sites

Radiation Side Effects

◦ Fatigue

◦ Alopecia

◦ Skin erythema

◦ Esophagitis

◦ Altered taste

◦ Dysphagia

◦ Dry cough

◦ Nausea

◦ Vomiting

◦ Diarrhea

Late Complications from EBRT

◦ Hypothyroidism

◦ Cardiac disease

◦ Radiation pneumonitis

◦ Increased dental caries

◦ Xerostomia

◦ Secondary cancer

◦ Infections

◦ Thyroid issues

◦ Lung damage

◦ Lhermitte syndrome - numbness/electrical sensations that run down the body to the limbs

◦ Second malignancies

◦ Xerospermia - loss of sperm

Hodgkin lymphoma is one of the most curable types of cancer and has been proven to respond to chemotherapy and radiation therapy at a lower dose than other types of tumors

True

Overall 5-year survival

89%

Factors that may decrease survival/ be a cause for more aggressive treatment

◦ Male gender

◦ Age 45 years old or older

◦ B symptoms

◦ Markedly abnormal laboratory results

Extranodal disease

Rare