Treatment

Overview

Hodgkin lymphoma is a cancer of the lymphatic system marked by large abnormal cells called Reed–Sternberg cells. It is one of the most curable cancers: most patients are cured with first-line treatment.

It most often affects young adults (ages 15–40) and people over 55. Our goal is to cure the lymphoma while limiting long-term side effects on the heart, lungs and fertility.

Types of Hodgkin lymphoma

Classical Hodgkin lymphoma (about 95%) — nodular sclerosis, mixed cellularity, lymphocyte-rich and lymphocyte-depleted subtypes
Nodular lymphocyte-predominant Hodgkin lymphoma — a rare, slower-growing form treated differently

Symptoms

Painless swelling of lymph nodes, often in the neck or above the collarbone
Fever, drenching night sweats and weight loss (B symptoms)
Persistent itching
Cough, chest discomfort or breathlessness from enlarged nodes in the chest
Pain in lymph nodes after drinking alcohol (uncommon but typical)

Causes and risk factors

Previous Epstein–Barr virus infection (glandular fever)
A weakened immune system, such as HIV infection
A family history of Hodgkin lymphoma

Prognosis

With modern chemotherapy, with or without radiation, more than 85–90% of patients are cured. Even when the disease returns, many are cured with further treatment including stem cell transplantation.

Living with Hodgkin lymphoma

After treatment, regular follow-up checks for relapse and long-term effects. Fertility preservation is discussed before treatment starts, and survivors are supported to return to study, work and family life.

Diagnosing

Diagnosis needs a lymph-node biopsy, followed by staging to see how far the lymphoma has spread.

Physical exam and medical history

Your doctor checks all lymph-node areas, the liver and spleen, and asks about B symptoms.

Lymph node biopsy

Removing a whole node (excisional biopsy) or a core sample lets the pathologist find Reed–Sternberg cells and confirm the subtype with immunohistochemistry (CD30, CD15).

Blood tests

Blood count, ESR, liver and kidney function, albumin and screening for HIV and hepatitis are part of the risk assessment.

Imaging tests

PET-CT — the standard scan for staging and for checking response after two cycles of treatment
CT and MRI — in specific situations
Chest X-ray — to measure a large chest mass

Other tests before treatment

Heart (echocardiogram) and lung function tests, because some treatments can affect these organs.

Staging

Stages I–IV (Lugano), with letters for extra information: A (no B symptoms) or B (B symptoms present), E (spread to an organ next to a node) and bulky disease (a large mass). Stages are grouped into early favourable, early unfavourable and advanced disease.

Treatment is planned by stage and risk group, and adapted to the PET-CT response, so that each patient gets enough treatment to be cured with as few late effects as possible.

Chemotherapy

ABVD is the most widely used combination. Escalated BEACOPP or brentuximab vedotin with AVD (A-AVD) may be used for advanced disease.

Targeted therapy and immunotherapy

Brentuximab vedotin targets CD30 on the lymphoma cells. Checkpoint inhibitors (nivolumab, pembrolizumab) are effective in relapsed Hodgkin lymphoma and are increasingly used earlier.

Radiation therapy

Low-dose, highly targeted radiation to involved areas after chemotherapy for early-stage or bulky disease.

Bone marrow transplant

For relapsed or refractory Hodgkin lymphoma, high-dose chemotherapy with an autologous stem cell transplant cures a large proportion of patients. An allogeneic transplant is an option when the disease returns after that.