Dr Garrick Laudin helps us understand the disease process of Hodgkin lymphoma and the available treatments thereof.
What is Hodgkin lymphoma?
Hodgkin lymphoma is a disease process typically confined to the lymph nodes and lymphatic structures throughout the body.
Lymph nodes are collections of tissue distributed strategically throughout the head, neck, chest, armpits, abdomen and groin that contain soldier cells (lymphocytes) which are primed to fight invading organisms.
In lymphomas, lymphocytes multiply uncontrollably even in the absence of an intruder and spread to different lymph node groups via special lymphatic channels. If untreated, your disease may spread to tissues (bone marrow) and organs outside of the lymph nodes.
The two sub-groups of Hodgkin lymphoma are classic Hodgkin lymphoma (CHL) and the rarer sub-group is nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL).
What are common symptoms?
Swelling of various lymph node groups in the neck, armpits or groin are often the first symptoms. Other classic symptoms, referred to as B-symptoms, include unexplained fevers, drenching night sweats and unintentional weight loss. Additionally, you may notice itchy skin (pruritus) and lymph node pain when you consume alcohol.
How is a diagnosis made?
Sampling of tissue from enlarged or swollen lymph nodes is essential for diagnosing Hodgkin lymphoma. The entire node may be removed (excisional biopsy) or part of a lymph node group is removed by means of an incisional biopsy or by core biopsy in which a large bore needle removes part of the node through the skin.
Fine needle aspirate (FNA) makes use of a smaller needle and syringe to draw up (aspirate) lymph node tissue through the skin and is a useful tool to exclude the presence of tuberculosis in lymph nodes. A fine needle aspirate specimen is unfortunately not sufficient to diagnose Hodgkin lymphoma with certainty.
Characteristic owl-eye cells (Reed-Sternberg cells) may be seen when lymph node tissue is examined under a microscope.
Classic owl-eye cells (Reed-Sternberg cells) of lymph node tissue when examined by microscope.
The stages of Hodgkin lymphoma
Hodgkin lymphoma has four stages which are numbered according to lymph node regions affected by the cancer. Staging has value in understanding how aggressive the disease is and may dictate how best to treat the lymphoma.
Radiological investigations, like positron emission tomography (PET) and computerised tomography (CT), assist your doctor in taking multiple images of your body to determine the exact lymph nodes involved and to serve as a baseline for monitoring response to therapy. Your doctor may also wish to take a sample of your bone marrow to examine for the presence of cancer cells.
What are the options for treatment?
Treatment takes two forms namely supportive and specific therapies. Supportive treatments are added to your main therapy and may include blood transfusions, pain medications as well as psychosocial support.
Prior to commencing definitive therapy, you may wish to discuss fertility options with your doctor.
Specific therapies are those that are targeted towards the lymphoma with systemic therapies generally favoured. Systemic therapies, usually given through a drip in a vein, are given at fixed times (cycles) with intervening days of rest which allows your body and bone marrow cells to recover.
Chemoimmunotherapy (CIT) is an example of a systemic treatment option. Chemotherapy regimens use tried and tested drug combinations to induce killing of the lymphoma cells.
Immunotherapies are newer drugs that aim to increase the immune system and its ability to fight cancer cells.
Radiation therapy uses high-energy X-rays targeted against specific lymph node groups and can be used in emergency situations to target focal lymph swelling in the case of spinal cord compression or when localised lymph nodes remain despite chemoimmunotherapy.
After completion of your therapy, your doctor will continue to monitor your overall health for signs of relapse through physical examinations, blood investigations and scheduled radiological scans.
Disease relapse
Hodgkin lymphoma is a highly curable disease and most patients will achieve complete response with first-line therapies. Though, up to one third of patients will not completely respond to first-line therapies or their disease will eventually re-occur (disease relapse).
Although there are no concrete factors that predict disease relapse, factors such as patient age, biological sex, disease stage and histology have been postulated to play a role.
If your Hodgkin lymphoma doesn’t get better with treatment (refractory disease) or comes back after completing treatment, you may require further courses of chemotherapy (second-line therapy).
Eligible patients who respond to second-line chemoimmunotherapy or the administration of novel agents may require a stem cell transplant. It’s also important to ask your doctor about the possibility of accessing newer (novel) medications through enrolment in clinical trials.
MEET THE EXPERT – Dr Garrick Laudin
Dr Garrick Laudin is a specialist physician and clinical haematologist affiliated with the University of the Witwatersrand, who currently practices at Chris Hani Baragwanath Academic Hospital. His special interests are the hyperinflammatory syndromes associated with haematological malignancies, the haemolytic anaemias and bone marrow failure syndromes.
