Hodgkin’s Disease – The Healing Space Clinic

Hodgkin's Disease

BASICS

DESCRIPTION

A malignant disease of the lymphoid tissue, caused by the transformation of an uncertain progenitor cell to the pathognomonic Reed-Sternberg cell. Disease spreads to contiguous lymphoid tissue, and eventually to non-lymphoid tissue.

Rye classification-based on pathologic findings (frequency by percent):
- Lymphocyte predominant (2-10)
- Mixed cellularity (20-40)
- Lymphocyte depleted (2-15)
- Nodular sclerosis (40-80)
System(s) affected: Hemic/Lymphatic/Immunologic
Genetics:
- First degree relatives - 3 times risk
- Siblings of younger patients - 7 times risk
Incidence/Prevalence in USA:
- 3.1/100000
- About 7200 new cases expected in 1999
- Incidence is lower in underdeveloped countries
Predominant age:
- Bimodal age distribution
  - Early peak in mid to late 20s
  - Later peak around 60-70
- Rare under age 5
Predominant sex: Male > Female (1.4:1)

SIGNS AND SYMPTOMS

Asymptomatic lymphadenopathy (usually cervical or supraclavicular)
Fever (Pel-Ebstein pattern)
Night sweats
Weight loss
Fatigue
Anorexia
Unexplained itching
Alcohol-induced pain

CAUSES

Unknown; EB virus may play a role

RISK FACTORS

Immunodeficiency (inherited or acquired)
Autoimmune disorders
HIV infection

DIAGNOSIS

LABORATORY

CBC
Chemistry profile
ESR
Liver function tests
Renal function tests
HIV (if risk factors present)

Drugs that may alter lab results: Phenytoin may produce pseudolymphoma
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Reed-Sternberg (RS) cell
- Abundant cytoplasm
- Two or more nuclei or nuclear lobes, each with a prominent nucleoli
Background infiltrate of lymphocytes, histiocytes, granulocytes, plasma cells and fibroblasts

SPECIAL TESTS

N/A

IMAGING

Chest X-ray
Thoracic CT scan
Abdominal and pelvic CT scan (or possibly MR scan)
Lymphangiography
Bone scan, gallium scan, abdominal ultrasound (used infrequently)

DIAGNOSTIC PROCEDURES

Excisional lymph node biopsy (needle biopsy not sufficient)
Exploratory laparotomy with splenectomy - only if treatment will be altered by results
Bone marrow biopsy - especially with systemic symptoms
Liver biopsy (in selected cases)

TREATMENT

APPROPRIATE HEALTH CARE

Initial staging is critical to therapy
Cotswold classification
- Stage I - single lymph node group
- Stage II - two or more node groups on same side of diaphragm
- Stage III - Node groups on both sides of diaphragm
- Stage IV - dissemination involving extra-nodal organs (not the spleen which is considered lymphoid tissue)
- Subclass designations: A = no symptoms; B = systemic symptoms (fever, night sweats, weight loss >10% body weight); X = bulky disease (widened mediastinum > 1/3 intrathoracic diameter or > 10 cm nodal mass); E = single extra-nodal site involvement in proximity with known nodal site

GENERAL MEASURES

Treatment aimed for cure with minimum toxicity, including treatment-induced late mortality
Treatment can be radiation therapy (RT), chemotherapy, or combined radiation and chemotherapy (CMT), based on stage and tumor burden
- Stage IA, IIA, nonbulky - usually RT alone; chemotherapy for selected high risk patients
- Stage IB, IIB, nonbulky - RT, if staging laparotomy is done: otherwise, CMT
- Stage IIAX, IIBX (bulky disease) - CMT
- Stage IIIA - possibly RT for carefully selected patients (minimal disease limited to upper abdomen); otherwise, CMT
- Stage IIIB, IV - CMT
Autologous bone marrow transplant for selected patients who fail conventional therapy

SURGICAL MEASURES

N/A

ACTIVITY

As tolerated

DIET

No restrictions

PATIENT EDUCATION

Reproductive impact
- Spermatogenesis often impaired prior to therapy
- Gonadal side effects of therapy
- Sperm banking option for males
- Oophoropexy in premenopausal female if pelvic RT contemplated
Risks of secondary malignancy
Careful oral and dental care during therapy
Patient education material
- Leukemia Society of America, 733 3rd Avenue, New York, NY 10017

FOLLOW UP

PREVENTION/AVOIDANCE

Pneumococcal vaccine, if splenectomy is planned for staging
Consider vaccines for Haemophilus and Neisseria species as well

POSSIBLE COMPLICATIONS

Secondary malignancies following therapy
Sterility, gonadal dysfunction
Hypothyroidism
Bone marrow suppression
Immunosuppressed infections, including herpes zoster
Anemia
ITP, TTP
Coronary artery disease, cardiomyopathy
Radiation pneumonitis, pulmonary fibrosis
Transient radiation myelopathy (Lhermitte's sign)

EXPECTED COURSE AND PROGNOSIS

Overall 5 year survival 82%
75% long term survival
10 year survival rates correlate with stage at diagnosis
- Stage IA, IB, IIA nonbulky 85-95%
- Stage IIA bulky, IIB 80-85%
- Stage IIIA 75-90%
- Stage IIIB 60-65%
- Stage IV 55-60%
Unfavorable prognostic factors in advanced disease
- Sed rate > 70
- Age > 45
- Male gender
- Albumin < 4
- Hemoglobin < 10.5
- Lymphopenia < 600

MISCELLANEOUS

ASSOCIATED CONDITIONS

T lymphocyte defects, which persist after successful treatment
Patients with HIV tend to present with more advanced disease

AGE-RELATED FACTORS

Pediatric: Increased risk for males
Geriatric: Usually presents in more advance stage and shows unfavorable histology
Others: N/A

PREGNANCY

Pregnancy not known to affect course of disease
Hodgkin's disease not known to affect pregnancy or fetus IF therapy can be postponed until delivery
Normal pregnancy can occur after treatment, if fertility is maintained
Risk of disease progression during pregnancy is variable. Management must be individualized

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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