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Hodgkin Lymphoma

  • "I don't think I've ever sat down with the family of a child with newly diagnosed lymphoma and talked about "controlling" their child's Hodgkin lymphoma. With Hodgkin lymphoma, we talk about a cure. It's not even a question."

    - Amy L. Billet, MD, Director of Lymphoma Program

    Learning that your child has Hodgkin lymphoma, a cancer of the lymph system,is a scary and life-altering experience for any parent. We are here to work with you, your child and your family through every moment of the journey.

    As difficult as coping with your child’s cancer can be, it’s important to remember that there is cause for hope: Hodgkin lymphoma is a very treatable form of cancer, and more than 90 percent of children with the condition who are treated at the Dana-Farber/Boston Children’s are cured.

    • The two main types of Hodgkin lymphomaare classical Hodgkin lymphoma and nodular lymphocyte predominant Hodgkin lymphoma.
    • Both classical and nodular lymphocyte predominant are highly curable.  Classical Hodgkin lymphoma usually requires more treatment. It’s a rare disease, with only 12 cases per million children in the United States.
    • It accounts for 8 percent of pediatric cancers.
    • It is most common in people between ages 15 and 34 and in people older than 55.
    • Hodgkin lymphoma always produces Reed-Sternberg cells; while non-Hodgkin lymphoma rarely produces Reed-Sternberg cells.

    How the Dana-Farber/Boston Children's approaches Hodgkin lymphoma

    Patients with Hodgkin lymphoma are treated through Dana-Farber/Boston Children's Cancer and Blood Disorders Center, an integrated pediatric hematology and oncology partnership between Dana-Farber Cancer Institute and Boston Children’s Hospital. Our Lymphoma Program utilizes the expertise of both Boston Children's Hospital and Dana-Farber Cancer Institute to treat children and adolescents with newly diagnosed and recurrent Hodgkin lymphoma.

    Through the David B. Perini, Jr. Quality of Life Clinic at Dana-Farber Cancer Institute, childhood cancer survivors receive a comprehensive follow-up evaluation from their cancer care team.

    We also offer the following services:

    • patient and family education
    • psychosocial assessment
    • genetic counseling
    • opportunities to speak with other childhood cancer survivors

    From Rwanda to Boston

    Sibo Tuyishmire is a Rwandan teen who received life-saving care for Hodgkin lymphoma at the Dana-Farber/Children’s Cancer Center in 2011. After going through two rounds of successful chemotherapy, he returned to school, where teachers and students of Concord Middle School welcomed him. Learn more about this Sibo’s story.

    Hodgkin lymphoma: Reviewed by Amy Billet, MD © Children’s Hospital Boston, 2012

    Boston Children's Hospital 
    300 Longwood Avenue
    Boston MA 02115

    Call: 888-733-4662

  • We focus on providing innovative family centered care. From your first visit, our team of professionals will be there to support your family’s physical and psychosocial needs. We understand you want to know more about Hodgkin lymphoma, and will have many questions including:

    • What is it?
    • What can we do about it?
    • How will it affect my child long-term?

    We’ve provided some answers to these questions here, and when you meet with our experts, we can talk with you more about your child’s diagnosis and treatment.

    What is the lymphatic system?

    Hodgkin lymphoma arises from the body’s lymphatic tissue. This tissue is found in parts of the body that are part of the lymph system, including:

    • lymph
    • fluid that carries lymphocytes, also known as white blood cells
    • lymphocytes
    • white blood cells that fight infections and tumor growth
    • lymph vessels
    • vessels that carry the lymph through the body, and back into the bloodstream
    • lymph nodes
    • small, bean-shaped structures that can be found anywhere in the body, such as in the groin, abdomen, neck, pelvis and underarm
    • filters the lymph and store lymphocytes
    • spleen
    • located on the left side of the abdomen near the stomach
    • makes lymphocytes, filters blood, stores blood cells, and destroys old blood cells
    • gastrointestinal system
    • stores lymphocytes that help protect the body against infection
    • includes the stomach, colon, small intestine, appendix, cecum and anus
    • thymus
    • located in the behind the breastbone of the chest
    • grows lymphocytes
    • tonsils
    • two small masses of lymph tissue located behind the back of the throat
    • makes lymphocytes
    • bone marrow
    • located in the center of large bones
    • makes platelets, white blood cells and red blood cells

    Hodgkin lymphoma causes the cells in the lymphatic system to abnormally reproduce causing swelling in the lymph nodes or other lymph tissue.

    Hodgkin lymphoma cells can spread to other organs and tissue. A cancer cell that has spread to other organs and tissue is said to have "metastasized." With different treatment options available, the cure rate is not changed if the Hodgkin lymphoma does metasize.

    How does Hodgkin lymphoma differ from other lymphomas?

    Hodgkin lymphoma is distinguished from other types of lymphomas by:

    • the presence of a particular type of abnormal cell,called the Reed-Sternberg cell (named for the scientists who discovered and studied this type of cell)
    • the way it progresses—Hodgkin lymphoma usually begins in the lymph nodes of one part of your child’s body, usually in the head, neck or chest. It then tends to spread in a predictable manner from one part of the lymph system to the next, and, in advanced stages, to the lungs, liver, bone marrow, bones or other organs.

    What is the difference between Hodgkin and non-Hodgkin lymphoma?

      There are different kinds of lymph cells in the lymph system and each can give rise to specific lymphomas.  The Reed-Sternberg  is a malignant cell that is always seen in Hodgkin lymphoma but rarely in non-Hodgkin lymphoma  There are more non-Hodgkin lymphoma subtypes than Hodgkin lymphoma subtypes. Each kind of lymphoma tends to present and spread in different ways.

    What are the factors that separate the different subtypes of Hodgkin lymphoma?

    • appearance of cells under a microscope. 
    • In addition, pathologists can do special testing on the tissue to help them distinguish different subtypes of Hodgkin lymphoma.

    What is the difference between classical Hodgkin lymphoma and nodular lymphocyte predominant Hodgkin lymphoma?

    Nodular lymphocyte predominant Hodgkin lymphoma is a very rare form, rarely it can be treated just with surgery. Generally, children with this kind may need less intensive treatment than classical Hodgkin lymphoma. Children with the nodular lymphocyte predominant form usually don’t have noticeable symptoms such as fever, night sweats and weight loss. With classical Hodgkin, B symptoms are more common.

    What are the different subtypes of classical Hodgkin lymphoma?

    Physicians categorize Hodgkin lymphoma based on how the individual cells look under a microscope and other characteristics of the cells. Diagnosis and treatment are similar for all of the following subtypes, although the stage (how far the cancer has progressed) may influence the specifics of your child's treatment:

    Nodular sclerosing

    • The most common subtype of Hodgkin lymphoma, it tends to occur in adolescents and young adults.
    • It accounts for more than half of all Hodgkin lymphoma cases.
    • This subtype typically begins in the lymph nodes of the chest and other places above the diaphragm.
    • Bulky tumors may arise in the mediastinum (the space in the chest between the lungs) and spread to lung tissue.

    Lymphocyte depleted

    • An extremely rare subtype accounting for less than 5 percent of people with Hodgkin lymphoma.
    • It usually begins in the lymph nodes of the abdomen and pelvis.

    Mixed cellularity

    • This subtype accounts for 15 to 30 percent of people with Hodgkin lymphoma.
    • It tends to arise in the lymph nodes of the abdomen and the spleen but can also arise in lymph nodes anywhere in the body.

    Causes

    What causes Hodgkin lymphoma?

    The specific cause of Hodgkin lymphoma is unknown. The risk of developing this condition may be associated with:

    • exposure to viral infections
    • a very slight risk of genetic predisposition (there is a slightly increased chance for Hodgkin lymphoma to occur in siblings and cousins)

    There has been much investigation into the association of Hodgkin’s lymphoma with:

    • the Epstein-Barr virus (EBV), which causes the infection mononucleosis (mono)
    • human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS)
    • immune suppressing medications
      • used prior to organ transplant

    Both of these viruses have been correlated with Hodgkin lymphoma, although the direct link is unknown. It’s important to note, however, that the vast majority of people who have infections related to EBV and HIV do not develop Hodgkin lymphoma.

    Signs and Symptoms

    What are the symptoms of Hodgkin lymphoma?

    Childhood Hodgkin lymphoma most commonly occurs in children age 15 or older. While each child may experience symptoms of Hodgkin lymphoma differently, some of the most common include:

    • painless swelling of the lymph nodes in neck, underarm, groin and chest
    • dyspnea (difficulty breathing) due to enlarged nodes in the chest
    • fever
    • night sweats
    • fatigue (tiring easily)
    • weight loss
    • pruritus (itching skin)

    The symptoms of Hodgkin lymphoma may resemble other blood disorders or medical problems. Always consult your child's physician for a diagnosis.

    FAQ

    We understand that you are an expert on your child, and can play an important role in the care of your child. Our team of professionals use your knowledge about your own child to help your child through treatment and on through recovery. By asking questions of your child’s doctor, you can help facilitate a conversation between you and your child’s care team. Sometimes, it’s helpful to write your questions down, so you can remember them for the appointment. There are several questions you can ask your child’s doctor, such as:

    • How do you decide treatment recommendations?
    • How long will treatment last?
    • What are the possible short and long-term complications of treatment? How will they be addressed?
    • How can I get my child eased back into normal social and school activities after treatment?
    • How could my child benefit from being part of a research study?
  • The first step in treating your child is forming an accurate and complete diagnosis. Your child’s medical history and a physical examination are the most important parts of forming the diagnosis. A patient’s medically relevant history may include information such as diet, everyday activities, past illnesses and past treatments. Additionally, a physical examination includes checking for swollen lymph nodes, which often affect the neck, underarm, groin, spleen and liver.

    In addition to a complete medical history and physical examination, the following tests help to establish a diagnosis and or stage the Hodgkin lymphoma:

    • blood tests
      • complete blood count test – count of red blood cells, white blood cells, platelets and amount of oxygen-carrying protein (hemoglobin)
      • sedimentation test – drawn blood is checked to see how fast it settles to the bottom of a test tube
      • c-reactive protein –  measures a protein made in the liver
    • x-rays of the chest - a diagnostic test which uses invisible electromagnetic energy beams to produce images of your child’s internal tissues, bones and organs onto film
    • biopsy - a sample of tissue is removed from a wherever the Hodgkin is located, such as a lymph node, and is examined under a microscope
    • computerized tomography scan (also called a CT or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat and organs. CT scans are more detailed than general x-rays.
    • Positron emission tomography (PET) scan –is a very sensitive technology that uses a radioactive material to measure chemical and functional changes within the body
    • bone marrow biopsy/aspiration - a procedure that involves a small amount of bone marrow fluid and tissue to be taken to look for abnormal cancerous cells

    How is Hodgkin lymphoma staged?

    Staging is the process of determining whether cancer has spread and, if so, how far. There are various staging systems that are used for Hodgkin lymphoma.

    One method of staging Hodgkin lymphoma is the following:

    • stage I - usually involves a single lymph node region or structure
    • stage II - involves two or more lymph node regions or structures on the same side of the body, specifically either below or above the space between the midsection and chest (diaphragm)
    • stage III - involves lymph node regions or structures on both sides of the body, above and below the diaphragm, and is further classified depending on the organs and areas involved
    • stage IV - involves disease that has spread to other areas (metastasized) such as the lungs, liver or bones, in addition to the lymphatic system

    Stages are also noted by the presence or absence of symptoms of the disease:

    • asymptomatic (A)
    • symptomatic (B)

    For example, if your child’s Hodgkin lymphoma is stage IIIB, it means that it is symptomatic, involves lymph node regions or structures on both sides of the body, and is further classified depending on the organs and areas involved.

    We meet with families multiple times to share information as it becomes available.  We describe an overview of the multifaceted treatment of Hodgkin before final information is available.  After all the information is available and has been reviewed, we meet with families to summarize all available data, proposed treatment options.   Additional discussions are often necessary if there is more than one reasonable treatment option, if the patient/family has additional questions, and to ensure the final choice is best tailored to each child and their family.

    Patients with Hodgkin lymphoma are treated through Dana-Farber/Boston Children's Cancer and Blood Disorders Center, an integrated pediatric hematology and oncology partnership between Dana-Farber Cancer Institute and Boston Children’s Hospital.

    Pediatric Stem Cell Transplant Program

    The Dana-Farber/Boston Children's Pediatric Stem Cell Transplant Program is one of the nation’s oldest and most experienced pediatric stem cell transplant programs.

  • We understand how difficult a diagnosis of Hodgkin lymphoma can be, both for your child and for your whole family. That's why our team of professionals is focused on family-centered care and committed to supporting all of your family's physical and psychosocial needs. We'll work with you to create a care plan that's best for your child.

    Treatment components may include the following (alone or in combination):

    Chemotherapy

    Chemotherapy is a drug treatment that works by interfering with the cancer cell's ability to grow or reproduce. There are several ways it can be given, such as:

    • as a pill to swallow
    • as an injection into the muscle or fat tissue
    • intravenously (directly to the bloodstream, also called IV)

    How is chemotherapy used?

    This depends on many factors. Some things to keep in mind:

    • A number of combinations of chemotherapy drugs are currently being used to shrink the cancer.
    • Depending on the type of cancer, chemotherapy drugs may be given in a specific order.
    • Chemotherapy may be used alone for some types of Hodgkin, or in conjunction with other therapy such as radiation.

    What are the side effects of chemotherapy?

    Chemotherapy is the use of strong drugs designed to kill cancer cells. Since chemotherapy travels throughout the blood stream, the side effects are systemic (affecting a child's whole body). Chemotherapy side effects commonly include nausea and vomiting, but also include sores in the mouth or gastrointestinal track. Another side effect is myelosuppression, which is when there are a low number of healthy blood cells, including red blood cells, white blood cells and platelets. Myelosuppression increases a child's risk for infection, anemia and low platelet levels which can lead to minor bleeding, such as nose bleeds or bleeding from brushing teeth.Being able to anticipate these side effects can help your child, family and your child's health care team prepare for and sometimes prevent these side effects from occurring.

    Radiation therapy

    Radiation therapy uses high-energy rays (radiation), such as x-rays, from a specialized machine to damage or kill cancer cells and shrink tumors. For children with classical Hodgkin lymphoma, radiation often used after chemotherapy, there are several other factors that may determine if radiation is safe and effective for an individual child.

    What are the side effects of radiation therapy?

    Radiation therapy kills cancer cells, but it also may damage healthy cells. Since radiation uses beams focused on a specific area, the side effects are isolated to that area being treated. For example, if your child's arm required radiation, the skin on his arm may feel itchy and irritated. Other side effects may include a sore throat, hair loss, nausea and vomiting.

    Long-term side effects mayoccur years after treatment.  Possible late effects include heart disease, thyroid problems, lung problems other cancers and very rarely, infertility. Infertility is especially rare side effect of radiation for Hodgkin lymphoma because very rarely are reproductive organs affected by Hodgkin lymphoma. 

    Surgery

    Although surgery may be used to biopsy Hodgkin lymphoma, it is not used to treat classical Hodgkin lymphoma.  It may be used in the treatment of nodular lymphocyte predominant Hodgkin lymphoma that is involves only one lymph node.

    Stem cell transplant

    Stem cell transplant is often used when the lymphoma progresses despite the initial treatment or when the cancer returns  (relapses) after the initial treatment is complete. The donor is usually the patient himself (autologous), so there is no risk for a mismatch of tissue type

    Supportive care

    Medications and other treatments may be given if your child experiences symptoms such as pain, fever, infection and nausea and/or vomiting.

    Continuous follow-up care

    Your child's health is closely monitored to determine response to treatment, detect recurrent disease and manage late effects of treatment.

    It's important for your child to visit a survivorship clinic every year to:

    • manage disease complications
    • screen for recurrence of cancer and/or secondary cancers
    • manage late effects of treatment

    A typical follow-up visit may include some or all of the following:

    • physical exam
    • laboratory testing
    • imaging scans

    Through the David B. Perini, Jr. Quality of Life Clinic at Dana-Farber Cancer Institute, childhood cancer survivors receive a comprehensive follow-up evaluation from their cancer care team.

    What is my child's quality of life like during treatment?

    Treatment is usually chemotherapy which can be exhausting physically, mentally and emotionally. That being said, a lot of children are resilient, and most patients being treated for Hodgkin lymphoma continue going to school and participating in social activities. Athletics may be difficult until your child regains his or her full strength. The quality of life during radiation treatment is the same as with chemotherapy.

    What is the long-term outlook for a child with Hodgkin lymphoma?

    As far as life expectancy, more than 90 percent of children treated for Hodgkin lymphoma at Dana-Farber/Children's Cancer Care are cured and are expected to live a full life. Once treatment is finished, the majority of children can resume a normal life, and are able to fully participate in sports, social activities and school.

    Coping and support

    Treatment and recovery for Hodgkin lymphoma may be especially challenging for your whole family, as well as for your child. Learn more about the patient and family resources available to your whole family at the Dana-Farber/Children's Cancer Center.

  • Learn about the lymphoma clinical trials and research underway at Dana-Farber/Boston Children’s.

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The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”
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