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<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
[[Category:Oncology]]
'''Original Editors '''- Ann Bedwell&nbsp;[[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
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'''Original Editors '''- [[User:Ann Bedwell|Ann Bedwell]] [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  


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== Definition/Description ==
== Introduction ==


[[Image:Reed-Sternberg cell.jpg|right|430x270px]]Hodgkin’s Lymphoma, also known as Hodgkin’s disease, is a “chronic, progressive, neoplastic disorder of lymphatic tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites such as the spleen and liver.”<ref name="DD">Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.</ref> It may also metastasize to bone marrow and other organs.<ref name="nlm">Zieve D, Chen Y.  Hodgkin’s Lymphoma.  http://www.nlm.nih.gov/medlineplus/ency/article/000580.htm. Updated March 3, 2010.  Accessed on February 27, 2011.</ref> The sites initially affected are the lymph glands in the neck or groin, usually on one side.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
[[Image:Reed-Sternberg cell.jpg|right|430x270px]]Hodgkin lymphoma or Hodgkin disease (HD) is a type of [[lymphoma]] and accounts for 1% of all cancers. 
* Hodgkin disease spreads contiguously and predictably along [[Lymphatic System|lymphatic]] pathways and is curable in 90% of cases, depending on its stage and sub-type<ref name=":0">Radiopedia [https://radiopaedia.org/articles/hodgkin-lymphoma Hodgkin Disease] .</ref>.
* This type of cancer is malignant and may travel to other parts of the body. As it progresses, it may compromise the body’s ability to fight infection since it is attacking the [[Immune System|immune system.]]<ref name="mayo">Mayo Clinic Staff.  [http://www.mayoclinic.com/health/hodgkins-disease/DS00186 Hodkgin’s lymphoma (Hodgkin’s Disease).]  Updated November 5, 2010.  </ref>
The disease is characterised by the presence of Reed-Sternberg cells (a cell that is part of the tissue macrophage system and have twin nuclei and nucleoli that give them the appearance of owl eyes,considered to be a type of B cell)<ref name="path">Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd edition. St. Louis, Missouri: Saunders Elsevier, 2009.</ref>. These cells however only occupy a very small proportion (<5%) of the overall cell population of the affected lymph node. Contiguous spread is another feature. EBV infection is present in 40-80% depending on subtype<ref name=":0" />


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <ref>Reed-Sternberg cell.  http://search.creativecommons.org/?q=reed-sternberg%20cells.  Accessed on February 27, 2011.</ref><br>
=== Subtypes ===
There are five recognised histological subtypes, subdivided into two groups:


This type of cancer is malignant and may&nbsp; travel to other parts of the body. As it progresses, it may compromise the body’s ability to fight infection since it is attacking the immune system.<ref name="mayo">Mayo Clinic Staff.  Hodkgin’s lymphoma (Hodgkin’s Disease).  http://www.mayoclinic.com/health/hodgkins-disease/DS00186.  Updated November 5, 2010.  Accessed on February 27, 2011.</ref><br>
'''Classical group'''
Positive for CD15/CD30 and negative for CD20/CD45/EMA:
* nodular sclerosing: ≈70%
* mixed cellularity: ≈25%
* lymphocyte-rich: 5%
* lymphocyte depleted: <5%
'''Non-classical group:'''


<br>  
Positive for CD 19, 20, 22, 79a/EMA and negative for CD15/CD30:
* nodular lymphocyte predominant (nodular paragranuloma)<ref name=":0" /><br>
{{#ev:youtube|jBzMp-pnfcA}}<ref>UCTV. Conversations with History: The Story of Hodgkin’s Disease.  http://www.youtube.com/watch?v=jBzMp-pnfcA.  Accessed on February 27, 2011.</ref>


Hodgkin’s lymphoma is differentiated from other cancers and [http://www.physio-pedia.com/index.php5?title=Non_Hodgkin_Lymphoma Non-Hodgkin’s lymphoma] by the type of cell involved. The Reed-Sternberg cell is “part of the tissue macrophage system and have twin nuclei and nucleoli that give them the appearance of owl eyes.”<ref name="path">Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd edition. St. Louis, Missouri: Saunders Elsevier, 2009.</ref> &nbsp; There are two subtypes of Hodgkin’s lymphoma, classic and nodular lymphocyte-predominant. Classic Hodgkin’s lymphoma is further divided into four categories based on what the cell looks like under a microscope. These are Lymphocyte-rich classical Hodgkin lymphoma, Nodular sclerosis Hodgkin lymphoma, Mixed cellularity Hodgkin lymphoma, Lymphocyte-depleted Hodgkin lymphoma.<ref name="nci">National Cancer Institute.  Hodgkin lymphoma.  http://www.cancer.gov/cancertopics/types/hodgkin.  Accessed on February 27, 2011.</ref><br>  
== Pediatric Hodgkin lymphoma ==
Hodgkin Lymphoma (HL) is uncommon in children below 4 years old, and among older children and adolescents, there are two distinct forms: childhood HL (affecting 10 to 14-year-olds, predominantly males, associated with larger family size and lower socioeconomic status) and adolescent/young adult HL (15 to 35 years old, with an equal gender incidence, linked to higher socioeconomic status, early birth order, and fewer siblings). Early contact with other children and infection with common childhood viruses are associated with a lower risk of adolescent/young-adult HL. Epstein Barr virus (EBV) infection plays a role, with higher proportions in patients under 10 years, showing male predominance as in pediatric HL. Recent primary EBV infection is a risk factor for childhood HL, while delayed EBV infection, especially with infectious mononucleosis, is associated with young-adult HL. The role of a yet-to-be-identified infectious agent is considered in EBV-negative young-adult cases. <ref name=":2">Hodgson DC, Hudson MM, Constine LS. [https://www.sciencedirect.com/science/article/pii/S1053429607000203 Pediatric hodgkin lymphoma: maximizing efficacy and minimizing toxicity]. Semin Radiat Oncol. 2007;17(3):230–42. </ref> Similar to adult Hodgkin Lymphoma (HL), painless lymphadenopathy is the predominant initial sign in pediatric cases. Around 80% of young children exhibit cervical lymphadenopathy, with a minority having mediastinal disease at presentation compared to adolescents and young adults. This discrepancy is attributed, in part, to the prevalence of mixed cellularity histology in young children. Overall, pediatric patients are more inclined to present with stage I/II disease and less likely to present with stage IV disease compared to adults. <ref name=":2" />


<br>
== Epidemiology  ==
It is estimated that HL accounts for approximately 10% of cases of newly diagnosed lymphoma in the United States (8260 of 80,500 cases), and the remainder are non‐Hodgkin lymphoma (NHL).
* Of 21,210 estimated deaths yearly because of lymphoma, about 1070 (or 5%) are from HL (accounting for about 0.5% of newly diagnosed cases of cancer in the United States and about 0.2% of all cancer deaths).
* Males are expected to comprise about 56% of patients newly diagnosed with HL in 2017
* The median age of diagnosis is 39 years; HL is most frequently seen in the group ages 20 to 34 years, which makes up almost one‐third of new diagnoses.


{{#ev:youtube|jBzMp-pnfcA}}<ref>UCTV. Conversations with History: The Story of Hodgkin’s Disease. http://www.youtube.com/watch?v=jBzMp-pnfcA. Accessed on February 27, 2011.</ref><br>  
=== The incidence rates ===
* Do not seem to vary between white and black Americans (3.1 new cases per 100,000 males)
* Are about one‐half as much in Asians/Pacific Islanders (1.6 new cases per 100,000 males) and American Indians/Alaskan Natives.
* Are lower in Hispanic Americans (2.6 new cases per 100,000 males) compared with white and black populations.
* HL have stayed flat since the mid‐1970s, but mortality rates have steadily declined from 1.3 cases per 100,000 in 1975 to 0.3 cases per 100,000 in 2014.
Across all stages of diagnosis, the relative 5‐year survival of patients with HL has improved from 70% to 85% during the same period<ref name=":1">Shanbhag S, Ambinder RF. [https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21438 Hodgkin lymphoma: a review and update on recent progress.] CA: a cancer journal for clinicians. 2018 Mar;68(2):116-32. </ref>


<br>
== Etiology ==
 
[[Image:Lymphatic sytem.png|right]]
== Prevalence  ==
 
In 2007, there were approximately 164,273 persons in the United States with a history of Hodgkin’s lymphoma. Based on rates from 2005-2007, “1 in 428 men and women will be diagnosed with Hodgkin lymphoma during their lifetime.”<ref name="seer">Altekruse et al.  SEER Stat Fact Sheet: Hodgkins lymphoma.  http://seer.cancer.gov/statfacts/html/hodg.html.  Updated 2009.  Accessed on February 27, 2011.</ref><br>
 
<br>
 
{| cellspacing="1" cellpadding="1" border="1" style="width: 398px; height: 150px;"
|+ Incidence Rates by Race<ref name="seer" />
|-
| Race/Ethnicity
| Male
| Female
|-
| All Races
| 3.2 per 100,000
| 2.5 per 100,000
|-
| White
| 3.4 per 100,000
| 2.7 per 100,00
|-
| Black
| 3.0 per 100,000
| 2.3 per 100,000
|-
| Asian/Pacific Islander
| 1.5 per 100,000
| 1.1 per 100,000
|-
| American India/Alaska Native
| <br>
| <br>
|-
| Hispanic
| 2.8 per 100,000
| 2.0 per 100,000
|}
 
<br>
 
Hodgkin’s can occur in children and adults at any age, but peaks around age 25-30 years and after 55 years. Men are typically diagnosed with Hodgkin’s more than women. “Children younger than 5 years rarely develop this disease, while only 10% of HL cases occur in children 16 years old and younger.”<ref name="path" /> The nodular lymphocyte-predominant Hodgkin’s lymphoma (LPHL), has a peak incidence around the fourth decade of life.
 
Approximately 7800 cases of HL are diagnosed in the United States each year.<ref name="path" />
 
“Estimated new cases and deaths from Hodgkin’s lymphoma in the United States in 2010:<br> New cases: 8490<br> Deaths: 1320”<ref name="nci" />
 
== Characteristics/Clinical Presentation<br>  ==
 
Signs:<br>
 
*&nbsp;Painless, unilateral, enlargement of nymph node usually in the neck, underarm or groin<ref name="DD" />
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o The lymph nodes should be examined based on the size, mobility, consistency and tenderness. A lymph node that is “over 1 centimeter in diameter and firm or rubbery consistency or tender are considered suspicious
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Lymph nodes that are soft and tender to touch are usually indicative of infection.<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Any changes in the shape, size, consistency, or mobility are red flags and should be reported to a physician immediately.


Symptoms<ref name="DD" />:<br>  
The etiology of HL is not well understood.
* The risk of developing EBV‐positive HL is significantly increased after an episode of infectious mononucleosis, also known as [[Epstein-Barr Virus]], with an estimated median incubation time of 4.1 year. However, the absolute risk of developing HL after infectious mononucleosis remains small at approximately 1 in 1000.
* Immunosuppression in a variety of medical conditions increases the risk of HL.
* The incidence of HL is significantly higher in the human immunodeficiency virus ([[Human Immunodeficiency Virus (HIV)|HIV]])‐infected population than in the general population (standardized rate ratio, 14.7 in a US study).
* The advent of highly [[Antiviral Drugs|active antiretroviral therapy]] (HAART) has indirectly led to the increase in rates of HL in HIV‐infected patients.Most cases are EBV‐positive and can occur in patients who have normal CD4 counts with a more aggressive histological phenotype; however, survival in HIV‐associated HL has improved significantly in the post‐HAART period.
* The incidence of HL also increases after solid organ transplantation and in patients with a history of [[Autoimmune Disorders|autoimmune conditions]], such as [[Rheumatoid Arthritis|rheumatoid arthritis]], [[Systemic Lupus Erythematosus|systemic lupus erythematosus]], and [[sarcoidosis]]<ref name=":1" />


*&nbsp;Fatigue
== Characteristics/Clinical Presentation  ==
*&nbsp;Fever and chills that come and go


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Typically peaks in the late afternoon<br>  
=== Signs ===
*Painless, unilateral, enlargement of nymph node usually in the neck, underarm or groin<ref name="DD">Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.</ref>
**The lymph nodes should be examined based on the size, mobility, consistency and tenderness. A lymph node that is “over 1 centimeter in diameter and firm or rubbery consistency or tender are considered suspicious
**Lymph nodes that are soft and tender to touch are usually indicative of infection.
**Any changes in the shape, size, consistency, or mobility are red flags and should be reported to a physician immediately.


*&nbsp;Itching all over the body that cannot be explained
=== Symptoms ===
 
*Fatigue <ref name="DD" />
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Itching occurs mostly at night<br>
*Fever and chills that come and go
 
**Typically peaks in the late afternoon
*&nbsp;Loss of appetite  
*Itching all over the body that cannot be explained
*&nbsp;Soaking night sweats  
**Itching occurs mostly at night  
*Loss of appetite  
*Soaking night sweats  
*Painless swelling of the lymph nodes in the neck, armpits, or groin (swollen glands)  
*Painless swelling of the lymph nodes in the neck, armpits, or groin (swollen glands)  
*&nbsp;Weight loss that cannot be explained
*Weight loss that cannot be explained


Other symptoms that may occur with this disease:<br>  
=== Other symptoms that may occur with this disease: ===
*Coughing, chest pains, or breathing problems if there are swollen lymph nodes in the chest <ref name="nlm">Zieve D, Chen Y.  [http://www.nlm.nih.gov/medlineplus/ency/article/000580.htm Hodgkin’s Lymphoma]. Updated March 3, 2010.</ref>
*Excessive sweating <ref name="nlm" />
*Pain or feeling of fullness below the ribs due to swollen spleen or liver <ref name="nlm" />
*Pain in lymph nodes after drinking alcohol <ref name="nlm" />
*Skin blushing or flushing <ref name="nlm" />
*Malaise <ref name="DD" />
*Anorexia <ref name="DD" />
*Symptoms may occur due to the obstruction or compression of structures by the enlarged lymph nodes. This may cause edema in the neck, face or right arm due to blockage of the superior vena cava or renal failure from blockage of the urethra <ref name="DD" />.
*Obstruction of bile ducts results in liver damage or jaundice, which will present as a yellowish color to the skin
*“Mediastinal lymph node enlargement with involvement of lung parenchyma and invasion of the pulmonary pleura progressing to the parietal pleura may result in pulmonary symptoms, including nonproductive cough, dyspnea, chest pain and cyanosis. <ref name="DD" />
*Nerve root pain and [[paraplegia]] could occur if the cancer spreads to the bones
*Invasion pericardium caused by enlarged “penetrating lymph nodes adjacent to the heart” <ref name="path" />
*Hepatosplenomegaly <ref name="path" />


*&nbsp;Coughing, chest pains, or breathing problems if there are swollen lymph nodes in the chest<ref name="nlm" />
Many of these signs and symptoms may be due to other health problems.  
*&nbsp;Excessive sweating<ref name="nlm" />
*&nbsp;Pain or feeling of fullness below the ribs due to swollen spleen or liver<ref name="nlm" />
*&nbsp;Pain in lymph nodes after drinking alcohol<ref name="nlm" />
*&nbsp;Skin blushing or flushing<ref name="nlm" />
*&nbsp;Malaise<ref name="DD" />
*&nbsp;Anorexia<ref name="DD" />
*&nbsp;Symptoms may occur due to the obstruction or compression of structures by the enlarged lymph nodes. This may cause edema in the neck, face or right arm due to blockage of the superior vena cava or renal failure from blockage of the urethra.<ref name="DD" />
*&nbsp;Obstruction of bile ducts results in liver damage or jaundice, which will present as a yellowish color to the skin
*&nbsp;“Mediastinal lymph node enlargement with involvement of lung parenchyma and invasion of the pulmonary pleura progressing to the parietal pleura may result in pulmonary symptoms, including nonproductive cough, dyspnea, chest pain and cyanosis.”<ref name="DD" />
*&nbsp;Nerve root pain and paraplegia could occur if the cancer spreads to the bones
*&nbsp;Invasion pericardium caused by enlarged “penetrating lymph nodes adjacent to the heart”<ref name="path" />
*&nbsp;Hepatoslenomegaly<ref name="path" />


Many of these signs and symptoms may be due to other health problems.<br><br>  
== Treatment  ==
[[Chemotherapy Side Effects and Syndromes|Chemotherapy]] and radiation therapy are the main treatments for HL.
* Depending on the case, one or both of these treatments might be used.
* Certain patients might be treated with immunotherapy or with a stem cell transplant, especially if other treatments haven’t worked. Except for biopsy and staging, surgery is rarely used to treat HL.<ref>ACS [https://www.cancer.org/cancer/hodgkin-lymphoma/treating.html Hodgkins Disease] Available from:https://www.cancer.org/cancer/hodgkin-lymphoma/treating.html (last accessed 1.8.2020)</ref>
Even in advanced‐stage disease, HL is highly curable with combination chemotherapy, radiation, or combined‐modality treatment.
* Although the same doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapeutic regimen has been the mainstay of therapy over the last 30 years, risk‐adapted approaches have helped de‐escalate therapy in low‐risk patients while intensifying treatment for higher risk patients.
* Even patients who are not cured with initial therapy can often be salvaged with alternate chemotherapy combinations, the novel antibody‐drug conjugate brentuximab, or high‐dose autologous or allogeneic hematopoietic stem cell transplantation.
* The programmed death‐1 inhibitors nivolumab and pembrolizumab have both demonstrated high response rates and durable remissions in patients with relapsed/refractory HL.
* Alternate donor sources and reduced‐intensity conditioning have made allogeneic hematopoietic stem cell transplantation a viable option for more patients.
* Future research will look to integrate novel strategies into earlier lines of therapy to improve the HL cure rate and minimize long‐term treatment toxicities<ref name=":1" />


== Associated Co-morbidities ==
== Diagnostic Tests/Lab Tests/Lab Values ==
Hodgkin’s lymphoma presents like many other disorders, so it is hard to differentiate and diagnose. The following tests and procedures are taken to positively diagnose Hodgkin’s lymphoma:


No associated co-morbidities were found although there are risks associated with chemotherapy and radiation therapy described further in the Medications section. <br>  
*“Physical exam: Your doctor checks for swollen lymph nodes in your neck, underarms, and groin. Your doctor also checks for a swollen spleen or liver.”<ref name="nci">National Cancer Institute.  [http://www.cancer.gov/cancertopics/types/hodgkin Hodgkin lymphoma].  </ref>
*Biopsy of lymph tissue that looks be involved and bone marrow. Once the sample is taken, it is checked for Reed-Sternberg cells that indicate Hodgkin’s lymphoma.<ref name="mayo" />
*[[Blood Tests|Blood Chemistry Tests]]: check protein levels, liver function tests, kidney function tests and uric acid levels<ref name="nlm" />


== Medications  ==
*[[CT Scans]]: chest, abdomen and pelvis<ref name="nlm" />
*[[X-Rays]]: show swollen lymph nodes<ref name="mayo" />
*PET Scan: glucose is injected in the patient’s veins and be will more concentrated around cancerous cells<ref name="mayo" />
*[[MRI Scans|MRI]]<ref name="mayo" />


There are several treatments used in patients with Hodgkin’s lymphoma which are discussed in the Medical Management section. Below is a list of medications that are used during chemotherapy.<br>  
Once tests reveal that a patient has Hodgkin’s lymphoma, additional tests will be done to see if the cancer has spread therefore finding out what stage the cancer is in.<ref name="nlm" /> Once the cancer stage has been found, future treatments can be planned and initiated.


<br>'''Chemotherapy'''<br>
== Physical Therapy Management  ==


<br>Chemotherapy is a mix of specific drugs that are introduced through the bloodstream to kill tumor cells. Most of the drugs are given intravenously, but some can also be given orally. Chemotherapy is given in cycles with a rest period. The amount of time spent in each cycle is determined by the type of drug used and stage of cancer.<ref name="seer" /><br>  
Physical therapy for patients with Hodgkin’s lymphoma focuses on [[Cardiovascular System|cardiovascular]] and pulmonary health, [[Strength and Conditioning|strength]], and [[flexibility]] in order to improve quality of life and reduce symptoms produced from cancer and treatments.  
 
* Most physical therapy sessions focus on [[Activities of Daily Living|activities of daily living]], but also focus on the ability to reduce fatigue.
*&nbsp;<u>Children</u>
* The ability to improve cardiovascular and pulmonary health along with strength and flexibility will allow patients the ability to help their tolerance to chemotherapy and radiation while maintaining or improving their ability to do everyday activities<ref name="CTCA">Cancer Treatment Centers of America.  [http://www.cancercenter.com/hodgkins-disease/complementary-alternative-hodgkins-disease-treatment.cfm Hodgkins Disease Treatments - Complementary and Alternative Medicines.] Updated October 3, 2007. </ref>.
 
* In a literature review by Courneya and Friedenreich, 24 empirical studies that were published between 1980 and 1997 showed that physical exercises and activity has a positive effect on quality of life in patients with cancer.
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Health professionals, such as oncologists, agree that the use of chemotherapy and radiation has different effects on children than it does on adults. Most all children patients are treated with chemotherapy with or without radiation unless the patient has “stage I, completely resected, nodular lymphocyte-predominant Hodgkin lymphoma, Hodgkin’s lymphoma.”<ref name="nci" /> These patients may receive surgery only. Radiation dosed for an adult can cause profound harm to musculoskeletal growth and increase risk for cardiovascular disease in children. There are also gender differences for treatment in children.<ref name="nci" /><br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; o Drugs that are used for children in childhood or adolescence are<ref name="nci" />:<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; •Alkylating Agents: Some have been “shown be to associated with an increased risk for therapy-related leukemia.” Therefore nonalkylating agents were developed, including ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine).<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; • Cyclophosphamide<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Mechlorethamine<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Procarbazine: causes long term gonadal toxicity in males<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; •&nbsp;Vinca Alkaloids&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<ref>Chemotherapy. http://www.dailymail.co.uk/news/article-1017418/Can-starving-help-combat-cancer.html. Accessed on March 24, 2011.</ref>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Vincristine[[Image:Chemo.jpg|right|200x250px|Chemotherapy]]<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Vinblastine<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; •&nbsp;Steriods<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Prednisone<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Dexamethasone<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Antimetabolites<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; • Methotrexate<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Cytosine arabinoside<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Other Agents<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Doxorubicin: associated with cardiac damage<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Bleomycin: associated with pulmonary fibrosis<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Dacarbazine<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp; • Etopside: developed to decrease male infertility&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br><br>  
* Physical activity is able to increase functional health as well as psychological and emotional welfare.<ref name="article">Courneya KS, Friedenreich CM.  Physical exercise and quality of life following cancer diagnosis: a literature review.  Ann Behav Med. 1999; 21: (2): 171-179.</ref>
 
* Research suggests that treadmill exercises (aerobic exercises) provide cardioprotective effects on the Doxorubicin-induced cardiotoxicity<ref>Yang HL, Hsieh PL, Hung CH, Cheng HC, Chou WC, Chu PM, Chang YC, Tsai KL. [https://pubmed.ncbi.nlm.nih.gov/32354131/ Early Moderate Intensity Aerobic Exercise Intervention Prevents Doxorubicin-Caused Cardiac Dysfunction Through Inhibition of Cardiac Fibrosis and Inflammation]. Cancers. 2020 May;12(5):1102.</ref>. 
{| cellspacing="1" cellpadding="1" border="1" style="width: 697px; height: 751px;"
<br>For an indepth look at studies and physiotherapy/exercise regimes&nbsp;see below
|+ Combination Chemotherapy Regimens Commonly Used for Children and Yound Adults with Hodgkin Lymphoma<ref name="nci" />  
{| style="width: 704px; height: 1700px;" border="1" cellspacing="1" cellpadding="1"
|-
| Title, Author and Year<br>
| Study Design<br>  
| Summary and Results<br>
|-
| Nelson JP. Perceived health, self-esteem, health habits, and perceived benefits and barriers to exercise in women who have and who have not experienced stage I breast cancer. 1991.<br><br>  
| Cross-sectional<br>
| Patients self reported exercises they did posttreatment. Healthy behaviors showed a positive relationship with self-esteem.<br>
|-
| Young-McCaughan S, Sexton DL. A retrospective investigation of the relationship between aerobic exercise and quality of life in women with breast cancer. 1991.<br>  
| Retrospective<br>
| Patients self reported exercise during or after treatment. Patients who exercised reported a higher QOL.<br>
|-
| Baldwin MK, Courneya KS. Exercise and self-esteem in breast cancer survivors: An application of the exercise and self-esteem model. 1997.<br>
| Cross-Sectional<br>
| Patients self reported mild, moderate or strenuous exercise during or after treatment. Strenuous physical activity related positively with self-esteem and physical competence.<br>
|-
| Bremer BA, Moore CT, Bourbon BM, Hess DR, Bremer KL. Perceptions of control, physical exercise, and psychological adjustment to breast cancer in South African women. 1997.<br><br>
| Cross-sectional<br>
| Patient’s self reported posttreatment exercises. No difference was found between patients that exercised and those that did not.<br>
|-
| Courneya KS, Friedenreich CM. Relationship between exercise pattern across the cancer experience and current quality of life in colorectal cancer survivors. 1997.<br><br>
| Retrospective<br>
| Patients self reported mild, moderate and strenuous exercise prediagnosis, during treatment and after treatment. “Survivors who permanently relapsed from pretreatment to posttreatment reported lowest QOL.”<br>
|-
| Courneya KS, Friedenreich CM. Relationship between exercise during cancer treatment and current quality of life in survivors of breast cancer. 1997.<br><br>  
| Retrospective<br>  
| Self reported mild, moderate and strenuous exerciseprediagnosis, during treatment and after treatment. Patients who maintained an exercise program from pre- to post-treatment reported the highest QOL.<br>
|-
| BuettnerLL. Personality changes and physiological changes of a personalized fitness enrichment program for cancer patients. 1980.<br><br>
| Quasi-experimental<br>  
| Exercise sessions with cardiovascular, strength and flexibility during post-treatment. Experimental group showed an increase in strength, functional capacity and personality.<br>
|-
| Winningham ML. Effects of a bicycle ergometry program on functional capacity and feelings of control in women with breast cancer. 1983.<br><br>  
| Quasi-experimental<br>  
| Patients exercised on a cycle ergometer during chemotherapy. Experimental group increased their functional capacity.<br>
|-
| Cunningham BA, Morris G, Cheney CL et al. Effects of resistance exercise on skeletal muscle in marrow transplant recipients receiving total parenteral nutrition. 1986.<br>  
| Experimental<br>  
| Exercise following bone marrow transplant. Experimental group maintained creatine exertion level.<br>
|-
| MacVicar MG, Winningham ML. Promoting the functional capacity of cancer patients. 1986.<br>  
| Quasi-experimental<br>  
| Exercise on cycle ergometer during chemotherapy. Experimental group increased functional capacity, where controls decreased.<br>
|-
| Winnginham ML, MacVicar MG. The effect of aerobic exercise on patient reports of nausea. 1988.<br>  
| Experimental<br>  
| Exercise on a cycle ergometer during chemotherapy. Experimental group had a larger decrease in nausea.<br>
|-
| Decker WA, Turner-McGlade K, Fehir KM. Psychosocial aspects and the physiological effects of a cardiopulmonary exercise program in patients undergoing bone marrow transplantation for acute leukemia. 1989.<br>
| Quasi-experimental<br>
| Home-based exercise program before and after bone marrow transplant. Patients exhibited a decreased aerobic capacity and weight loss.<br>
|-
|-
| Chemotherapy Regimen<br>  
| MacVicar MG, Winningham ML, Neckel JL. Effects of aerobic interval training on cancer patients’ functional capacity. 1989.<br>  
| Agents<br>
| Experimental<br>
| Exercise on a cycle ergometer during chemotherapy. Experimental group increased their functional capacity.<br>
|-
|-
| ABVD<br>  
| Winningham ML, MacVicar MG, Bondoc M, Anderson JL, Minton JP. Effect of aerobic exercise on body weight and composition in patients with breast cancer on adjuvant chemotherapy. 1989.<br>
| doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine<br>
| Experimental<br>  
| Exercise on a cycle ergometer during chemotherapy. Experimental group decreased their percent body fat and increased their lean body mass.<br>
|-
|-
| ABVE<br>  
| Pfalzer LA. The responses of bone marrow transplant patients to graded exercise testing prior to transplant and after transplant with and without exercise training. 1990.<br>  
| doxorubicin (Adriamycin), bleomycin, vincristine, etoposide<br>
| Quasi-experimental<br>
| Patient’s exercised on cycle ergometer after bone marrow transplant. Patient’s showed an increase in VO2, decreased depression and fatigue.<br>
|-
|-
| VAMP<br>  
| Peters C. Ausdauersport als rehabilitationsmassnahme in der krebs-nachsorge. 1992.<br>  
| vincristine, doxorubicin (Adriamycin), methotrexate, prednisone<br>
| Quasi-experimental<br>
| Patient’s exercised on a cycle ergometer. Patient’s showed an increase in natural killer cell activity.<br>
|-
|-
| OPPA+/-COPP (females)<br>  
| Seifert E, Ewert S, Werle J. Exercise and sports therapy for patients with head and neck tumors. 1992.<br>
| vincristine (Oncovin), prednisone, procarbazine, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine<br>
| Quasi-experimental<br>  
| Group exercise showed favor in the experimental group but there wasn’t a significant difference with the control group.<br>
|-
|-
| OEPA+/-COPP (males)<br>  
| Sharkey AM, Carey AB, Heise CT, Barber G. Cardiac rehabilitation after cancer therapy in children and adults. 1993.<br>
| vincristine (Oncovin), etoposide, prednisone, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine<br>
| Quasi-experimental<br>  
| Exercises showed an increase in peak oxygen uptake and ventilator anaerobic threshold.<br>
|-
|-
| COPP/ABV<br>  
| Mock V, Burke MB, Sheehan P, et al. A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy. 1994.<br>
| cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine, doxorubicin (Adriamycin), bleomycin, vinblastine<br>
| Experimental<br>  
| Walking program showed an increase in physical functioning and fewer symptoms than the control group.<br>
|-
|-
| BEACOPP (advanced stages)<br>  
| Nieman DC, Cook VD, Henson DA, et al. Moderate exercise training and natural killer cell cytotoxic activity in breast cancer patients. 1995.<br>
| bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), prednisone, procarbazine<br>
| Experimental<br>  
| Walking and weight training program during post-treatment showed an increase in the 6 minute walk test and a decrease in heart rate.<br>
|-
|-
| COP(P) with or without prednisone<br>  
| Dimeo F, Bertz H, Finke J, et al. An aerobic exercise program for patients with haemotological malignancies after bone marrow transplantation. 1996.<br>  
| cyclophosphamide, vincristine (Oncovin), ± prednisone, procarbazine<br>
| Quasi-experimental<br>
| Treadmill walking post-bone marrow transplant showed an increase in physical performance.<br>
|-
|-
| CHOP<br>  
| Dimeo F, Tilmann MHM, Bertz H, et al. Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. 1997.<br>  
| cyclophosphamide, doxorubicin (Adriamycin), vincristine (Oncovin), prednisone<br>
| Quasi-experimental<br>
| Treadmill walking showed an increase in maximum performance and hemoglobin levels while decreasing fatigue.<br>
|-
|-
| ABVE-PC<br>  
| Dimeo F, Fetscher S, Lange W, Mertelsmann R, Keul J. Effects of aerobic exercise on the physical performance and incidence of treatment-related complications after high-dose chemotherapy. 1997.<br>  
| doxorubicin (Adriamycin), bleomycin, vincristine, etoposide, prednisone, cyclophosphamide<br>
| Experimental<br>
| Biking by use of a bed ergometer showed an increase in functional capacity and a decrease in pain and length of hospital stay.<br>
|-
|-
| MOPP/ABV<br>  
| Mock V, Dow KH, Meares CJ, et al. Effects of exercise on fatigue, physical functioning and emotional distress during radiation therapy for breast cancer. 1997.<br>  
| mechlorethamine, vincristine (Oncovin), procarbazine, prednisone, doxorubicin (Adriamycin), bleomycin, vinblastine<br>
| Experimental<br>
| Home walking program during radiation increased patient’s functional capacity and decreased fatigue.<br>
|}
|}


*&nbsp;<u>Adults</u>:
== Treatment and prognosis ==
 
Prognosis depends on stage as well as several other factors such as age, serological markers (ESR), presence of B symptoms, and histological tumour subtype:
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Adults in early stages of Hodgkin’s lymphoma may receive chemotherapy, combined modality therapy or radiation therapy alone. Usually these patients “receive either four courses of ABVD or two courses of ABVD plus radiation.” Adults with stage III or IV Hodgkin’s lymphoma with favorable prognosis will receive six courses of ABVD while patients with unfavorable prognosis will receive BEACOPP.<ref name="path" /><br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Combinations of drugs used in chemotherapy for adults consist of:<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • ABVD: doxorubicin, bleomycin, vinblastine and dacarbazine<ref name="nci" /><br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • BEACOPP: bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisone9<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • MOPP: mechlorethamine, vincristine, procarbazine and prednisone.<ref name="nci" />
* Nodular lymphocyte-predominant: best prognosis
 
* Lymphocyte depleted: worse prognosis
<br><u>Pregnant Women</u>: Each patient must be looked individually when they present with Hodgkin’s lymphoma and are pregnant. If the HL is in the early stages and appears to be growing slowly, “patients can be followed carefully with plans to induce delivery early and proceed with definitive therapy.” These patients can also receive radiation therapy if shielded properly. “Investigators at M.D. Anderson reported no congenital abnormalities in 16 babies delivered after the mothers had received supradiaphragmatic radiation while shielding the uterus with five half-value layers of lead.” There are, however, risks that minimal scattered radiation could occur outside the radiation field and cause future malignancies in the baby.<ref name="nci" />
Treatment is dependant on the stage of the disease:
 
* Stage IIa and below: localised radiotherapy
<br>“Chemotherapy that is administered in the first trimester has been associated with congenital abnormalities in as many as 33% of infants. However, in one series, there were no adverse effects in 14 children of mothers who received a combination of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) or a combination of doxorubicin, plus bleomycin, plus vinblastine, and dacarbazine (ABVD) during gestation, five of whom began treatment during the first trimester.”<ref name="nci" />
* Stage IIb and above: chemotherapy +/- radiotherapy to sites of large tumour bulk<ref name=":0" />
 
<br>When a patient has HL in the 2nd half of their pregnancy, the cancer must be monitored carefully until they are induced into labor. If the patient is in a more advanced stage of cancer, vinblastine alone can be used because it has no associated fetal abnormalities with it. “Steroids are employed both for their antitumor effect and for hastening fetal pulmonary maturity.” Also, a combination of ABVD seems to be safe to use in the second half of the pregnancy. A combination of drugs is usually recommended over a single drug.<ref name="nci" />
 
<br>Side Effects of Chemotherapy<ref name="nlm" /><ref name="nci" />:<br>
 
*&nbsp;Increase risk for infection, bruising or bleeding
*&nbsp;Weakness and fatigue
*&nbsp;Hair loss
*&nbsp;Poor appetite
*&nbsp;Nausea and vomiting
*&nbsp;Diarrhea
*&nbsp;Mouth and/or lip sores
*&nbsp;Infertility
*&nbsp;Heart disease
*&nbsp;Bone marrow diseases
*&nbsp;Lung problems
*&nbsp;Other cancers&nbsp;
*Thyroid problems
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
[[Image:Lymph node exam.jpg|left]]Hodgkin’s lymphoma presents like many other disorders, so it is hard to differentiate and diagnose. The following tests and procedures are taken to positively diagnose Hodgkin’s lymphoma:
 
*“Physical exam: Your doctor checks for swollen lymph nodes in your neck, underarms, and groin. Your doctor also checks for a swollen spleen or liver.”<ref name="nci" />
*Biopsy of lymph tissue that looks be involved and bone marrow. Once the sample is taken, it is checked for Reed-Sternberg cells that indicate Hodgkin’s lymphoma.<ref name="mayo" />
*Blood Chemistry Tests: check protein levels, liver function tests, kidney function tests and uric acid levels<ref name="nlm" />
 
<ref>Head and Neck lymph nodes exam.  http://doctorsgate.blogspot.com/2010/05/head-and-neck-lymph-nodes-exam.html  Accessed on March 24, 2011.</ref>
 
*&nbsp;CT Scans: chest, abdomen and pelvis<ref name="nlm" />
*&nbsp;X-Rays: show swollen lymph nodes<ref name="mayo" />
*&nbsp;PET Scan: glucose is injected in the patient’s veins and be will more concentrated around cancerous cells<ref name="mayo" />
*&nbsp;MRI<ref name="mayo" />
 
Once tests reveal that a patient has Hodgkin’s lymphoma, additional tests will be done to see if the cancer has spread therefore finding out what stage the cancer is in.<ref name="nlm" /> Once the cancer stage has been found, future treatments can be planned and initiated.<br><br>
 
== Etiology/Causes  ==
 
[[Image:Lymphatic sytem.png|right]]
 
The exact cause of Hodgkin’s lymphoma is unknown.<ref name="nlm" /><ref name="mayo" /> HL begins with an abnormal B cell, which is a type of lymph cell that is important in the body’s response to foreign intruders. When these B cells become abnormal they are called Reed-Sternberg cells. This cell continues to divide and make copies, but unlike normal cells, it does not die.<ref name="path" /> “The genes have the ability to mimic transmembrane receptors and activate the transcription factor NF-кB. NF-кB, through its function of regulating dozens of genes within the cell, plays a key role in the proliferation and survival of the malignant clones.”<ref name="path" /> Products of these genes include cytokines and chemokines. Most cytokines, mostly interleukins produce an environment where the Reed-Sternberg cells can flourish. These interleukins may attract inflammatory cells to survive as it is shown in the lab that they cannot survive without the inflammatory cells. Other interleukins restrain the activation of T cells that are normally used to destroy any unusual cell, while others “act as growth factors, encouraging proliferation, metastasis and angiogensis.”<ref name="path" /> The abnormal B cell is unable to die due to a protein called c-FLIP that usually signals cell death but is not able to function in the circumstances. Therefore the abnormal B cell is undying.<ref name="path" />
 
The cells build up while attracting normal immune cells to cause tissue growth in the lymph nodes.<ref name="mayo" /><ref name="nci" />This mass of tissue growth is called the tumor. The reason that these B cells are malignant is unknown, but recent evidence implies that it begins from an infection or inflammation. Genes from a virus called Epstein-Barr have been found in half of all HL cases.<ref name="nci" /> &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;
 
Once the lymphoma begins in the lymph nodes, typically the neck, axilla or groin, it can travel to all other lymph nodes in the body then spread outside of the lymph nodes into any part of the body.<ref name="mayo" />&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp;&nbsp; <ref>Lymph system.  http://search.creativecommons.org/?q=lymph%20system.  Accessed on February 27, 2011.</ref>
 
<br><br>
 
== Systemic Involvement  ==
 
Hodgkin’s lymphoma primarily affects the lymph nodes in the neck, axillas, and groin but can also affect and grow to the spleen, liver, tonsils, thymus and bone marrow, which are all part of the lymphatic system.&nbsp; The spleen, composed of blood and lymphoid tissue, is where the final destruction of red blood cells, filtration and storage of blood takes place as well as production of lymphocytes. The liver is a vascular, glandular organ that secretes bile to aid in digestion and changes substances in blood that passes through it. The tonsils are masses of lymphoid tissue near on either side of the throat. The thymus gland is composed of lymph tissue and functions in cell-mediated immunity by developing T cells. This gland is highly active in the younger population, then disappears with age. Bone marrow is the inner part of the bone where blood cells are made. B cells, which are white blood cells that help to aid in fighting infection. These B cells are the particular cells in Hodgkin’s lymphoma that become abnormal and begin the multiply to form a tumor.<ref name="dict">National Institutes of Health.  Medical Dictionary.  http://www.nlm.nih.gov/medlineplus/mplusdictionary.html.  Updated July 11, 2010.  Accessed on February 27, 2011.</ref>
 
Other organs and systems can be involved by way of metastasis. Hodgkin’s lymphoma can metastasize to all tissues of the body due to the lymphoreticular cells inhabiting all types of tissue except the central nervous system. “Hematological spread may also occur, possibly by means of direct infiltration of blood vessels.”<ref name="path" /><br>
 
== Medical Management (current best evidence) ==
 
Management of Hodgkin’s lymphoma is done by chemotherapy or a combination of chemotherapy and radiation. The different medications used in chemotherapy are listed above under the Medications section. However, treatment does depend on several different factors:<br>
 
*&nbsp;The type of Hodgkin's lymphoma (most people have classic Hodgkin's)<ref name="nlm" />
*&nbsp;The stage at which the cancer is at as well as number of lymph nodes involved<ref name="mayo" />
*&nbsp;The size of the tumor
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o “A staging evaluation is necessary to determine the treatment plan”<ref name="nlm" /><br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Stage I: one lymph node region involved<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Stage II: two lymph node regions on the same side of the diaphragm involved<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Stage III: lymph node regions are involved on both sides of the diaphragm<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; • Stage IV: cancer is found outside the lymph nodes (i.e. bone)<ref name="nlm" /><br>
 
*&nbsp;The patient's age and co-morbidities
*&nbsp;“Other factors, including weight loss, night sweats, and fever”<ref name="nlm" />
*&nbsp;Age of patient<ref name="nci" />
*&nbsp;Whether the patient is pregnant or not<ref name="mayo" />
 
Treatment is different for patients in a certain stage and age<ref name="nlm" />:<br>
 
*&nbsp;Stages I and II: treated with local radiation therapy, chemotherapy, or both.
*&nbsp;Stage III: “treated with chemotherapy alone or a combination of radiation therapy and chemotherapy.”
*&nbsp;Stage IV: usually treated with chemotherapy alone
 
<br>
 
'''Surgery''': There are several different types of surgery that may be performed to decrease or rid of any tumor. These are:<br>
 
*Partial resection or debulking: used when only part of the tumor can be removed.
*Complete resection: the whole tumor is removed.
*Mohs surgery: each layer of the tumor is removed until it is completely gone
*Lymph node dissection
*Implantation of radioactive beads (brachytherapy)<ref name="journal">Billek-Sawhney B, Wells CL.  Oncology considerations for the patient in acute care.  Acute Care Perspectives.  2009; 18: (4): 3-24.</ref><br><br>
 
'''Chemotherapy''': Chemotherapy is a mix of specific drugs that are introduced through the bloodstream to kill tumor cells. Most of the drugs are given intravenously, but some can also be given orally. Chemotherapy is given in cycles with a rest period. The amount of time spent in each cycle is determined by the type of drug used and stage of cancer.<ref name="seer" />
 
<br>'''Radiation Therapy'''
 
<br>Radiation therapy uses high energy x-rays to kill cancer cells and decrease pain. The duration of radiation therapy depends on what stage the cancer is in. Radiation is confined to a certain area, killing the cells in only that area. It is usually combined with chemotherapy and rarely used by itself.<ref name="nci" /> Most children who receive radiation are given a low-dose.<ref name="mayo" />
 
[[Image:Radiation therapy.jpg|right|200x200px]]<br>Side Effects of radiation therapy:<br>
 
*&nbsp;Increased risk of heart disease<ref name="mayo" />
*&nbsp;Stroke<ref name="mayo" />
*&nbsp;Thyroid problems<ref name="mayo" />
*&nbsp;Infertility<ref name="mayo" />
*&nbsp;Other forms of cancer<ref name="mayo" />
*&nbsp;Red, dry tender skin<ref name="nci" />
*&nbsp;Fatigue<ref name="nci" />
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <ref>Biomedical Communications.  http://www.biocom.arizona.edu/showproject.cfm?project=52.  Accessed on March 24, 2011.</ref><br>
 
'''Biotherapy''' or tumor immunotherapy uses a pharmacological approach to genetically engineer antibodies that specifically attack antigens on cancer cells.<ref name="journal" /><br>
 
<br>
 
'''Bone marrow or stem cell transplantation''' may be used if the cancer returns or if the patient is not responding to treatment. Bone marrow or stem cells are taken from the patient, frozen and stored. The patient then receives high dose chemotherapy to destroy all the cancerous cells. Then the frozen marrow or stem cells are injected into the body through the patient’s veins.<ref name="mayo" />
 
<br>Additional treatments may be used due to symptoms:<br>
 
*&nbsp;Blood transfusion to fight low platelet counts<ref name="nlm" />
*&nbsp;Antibiotics to fight infection<ref name="nlm" /><br>
 
<br>
 
== Physical Therapy Management (current best evidence)  ==
 
Physical therapy for patients with Hodgkin’s lymphoma focuses on cardiovascular and pulmonary health, strength, and flexibility in order to improve quality of life and reduce symptoms produced from the cancer and treatments. Most physical therapy sessions focus on activities of daily living, but also focus on the ability to reduce fatigue. The ability to improve cardiovascular and pulmonary health along with strength and flexibility will allow patients the ability to help their tolerance to chemotherapy and radiation while maintaining or improving their ability to do everyday activities.<ref name="CTCA">Cancer Treatment Centers of America.  Hodgkins Disease Treatments - Complementary and Alternative Medicines.  http://www.cancercenter.com/hodgkins-disease/complementary-alternative-hodgkins-disease-treatment.cfm.  Updated October 3, 2007.  Accessed on February 27, 2011.</ref> In a literature review by Courneya and Friedenreich, 24 empirical studies that were published between 1980 and 1997 showed that physical exercises and activity has a positive effect on quality of life in patients with cancer. Physical activity is able to increase functional health as well as psychological and emotional welfare.<ref name="article">Courneya KS, Friedenreich CM.  Physical exercise and quality of life following cancer diagnosis: a literature review.  Ann Behav Med. 1999; 21: (2): 171-179.</ref>
 
== Alternative/Holistic Management (current best evidence)  ==
 
“There are no alternative medicine treatments that can cure Hodgkin's lymphoma, but some alternative and complementary therapies can reduce symptoms or relieve side effects from treatment.” Following some of these therapies will help the patient reduce stress and anxiety to help improve their quality of life.<ref name="mayo" /> Some therapies are: <br>
 
*&nbsp;Relaxation techniques such as meditation and yoga<ref name="mayo" />
*&nbsp;Acupuncture will help treat nausea from the chemotherapy<ref name="mayo" />  
*&nbsp;Massage will help decrease stress, anxiety, depression and pain.<ref name="mayo" />
*&nbsp;Aromatherapy will help diminish anxiety, pain, queasiness and depression.<ref name="mayo" />
*&nbsp;Nutrition Therapy<ref name="CTCA" />
*&nbsp;Pain Management<ref name="CTCA" />
*&nbsp;Naturopathic Medicine<ref name="CTCA" />
*&nbsp;Mind Body Medicine<ref name="CTCA" /><br>
*&nbsp;Spiritual Support<ref name="CTCA" />
*&nbsp;Image Enhancement<ref name="CTCA" />
 
<br>
 
<u>Nutrition Therapy</u>: Eating right and staying active is another way to help your body feel better and relieve some stress. Patients should try to maintain the correct amount of calories to maintain a good weight, eat enough protein to increase strength and create more energy.<ref name="nci" /> Vitamins and minerals may also be used to supplement when a patient is not getting enough in their meals.<ref name="CTCA" />
 
<u><br>Pain Management</u>: Pain management is finding a way of reducing pain or the perception of pain through use of pharmacological agents and non-pharmacological agents. Non-pharmacological agents consist of “behavioral techniques, emotional counseling and support, physical therapy, radiation, neurological and neurosurgical interventions, and traditional nursing and psychosocial interventions.”<ref name="CTCA" />
 
<br><u>Naturopathic Medicine</u>: A central goal of naturopathic medicine is to use the healing power of nature to maintain and restore health. Naturopathic medicine focuses on clinical nutrition, botanical medicine, physical medicine, Chinese medicine, psychological medicine and homeopathic medicine. “Naturopathic practice also includes the use of any medical substances that contain elements that are components of bodily tissues, or can be employed by the body, for the maintenance of life and the repair of tissues. This also encompasses methods of diagnostic testing and imaging, including X-ray and ultrasound.”<ref name="CTCA" />
 
<br><u>Mind Body Medicine</u>: Mind body medicine is based on psychoneuroimmunology which influences your mind over your body.
 
<br><u>Spiritual Support</u>
 
<br><u>Image Enhancement</u>: image enhancement through beauticians, cosmetologists and salon personnel can help improve a patient’s well-being and self-confidence.<br>
 
<br>
 
To read more about these therapies offered go to [http://www.cancercenter.com/hodgkins-disease/complementary-alternative-hodgkins-disease-treatment.cfm Cancer Treatment Centers of America]
 
== Differential Diagnosis  ==
 
Differential Diagnoses include<ref>Alarcon PA.  Pediatric Hodgkin Disease: Differential Diagnoses &amp; Workup.  http://emedicine.medscape.com/article/987101-diagnosis.  Updated December 2, 2008.  Accessed on February 27, 2011.</ref><ref>MDGuidelines.  Hodgkin’s Disease.  http://www.mdguidelines.com/hodgkins-disease/differential-diagnosis. Accessed on February 27, 2011.</ref>:
 
*Actue lymphoblastic leukemia
*lymphadenopathy
*brucellosis
*lymphoproliferative disorders
*catscratch disease
*mononucleosis and Epstein-Barr virus infection
*cytomegalovirus infection
*non-Hodgkin lymphoma
*histoplasmosis
*toxoplasmosis
*lymph node disorder
*tuberculosis
*lymphadenitis
*fibrosing mediastinitis
*atypical mycobasteria
*AIDS
*human immunodeficiency virus
*systemic lupus erythmatosus


== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==


add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
*[[Hodgkin's Lymphoma Case Study|Hodgkin's Lymphoma Case Study]]
 
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907869/?tool=pmcentrez Hodgkin's lymphoma masquerading as vertebral osteomyelitis in a man with diabetes: a case report]
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907869/?tool=pmcentrez Hodgkin's lymphoma masquerading as vertebral osteomyelitis in a man with diabetes: a case report]<br>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822792/?tool=pmcentrez Hodgkin's lymphoma presenting with heart failure: a case report]
 
*[http://www.ncbi.nlm.nih.gov/pmc?term=hodgkin%27s%20lymphoma%20case%20report A case of nodular sclerosis Hodgkin’s lymphoma repeatedly relapsing in the context of composite plasma cell-hyaline vascular Castleman’s disease: successful response to rituximab and radiotherapy]
<br>
 
[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822792/?tool=pmcentrez Hodgkin's lymphoma presenting with heart failure: a case report]<br>
 
<br>
 
[http://www.ncbi.nlm.nih.gov/pmc?term=hodgkin%27s%20lymphoma%20case%20report A case of nodular sclerosis Hodgkin’s lymphoma repeatedly relapsing in the context of composite plasma cell-hyaline vascular Castleman’s disease: successful response to rituximab and radiotherapy]<br>
 
== Resources <br>  ==
 
[http://www.cancer.gov/cancertopics/wyntk/hodgkin What you need to know about<sup>TM</sup> Hodgkin Lymphoma]<br>


[http://www.lymphoma.org/site/pp.asp?c=chKOI6PEImE&b=1574105 Lymphoma Research Foundation]: resources for facts, information and support groups
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1vY7UytnXUWxw5qAxf-ix7jiGCAAXR2mAklWeLMpG0s8LGf9fN|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].
<br>
<references />  
<references />  


[[Category:Oncology]]
[[Category:Medical]]
[[Category:Bellarmine_Student_Project]]
[[Category:Bellarmine_Student_Project]]
[[Category:Conditions]]

Latest revision as of 01:18, 2 December 2023

Original Editors - Ann Bedwell from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Ann Bedwell, Kim Jackson, Lucinda hampton, Admin, Elaine Lonnemann, WikiSysop, Vidya Acharya, Kirenga Bamurange Liliane, Aminat Abolade, Kapil Narale, Aya Alhindi, 127.0.0.1, Tony Lowe, Wendy Walker, Evan Thomas and Venugopal Pawar

Introduction[edit | edit source]

Reed-Sternberg cell.jpg

Hodgkin lymphoma or Hodgkin disease (HD) is a type of lymphoma and accounts for 1% of all cancers.

  • Hodgkin disease spreads contiguously and predictably along lymphatic pathways and is curable in 90% of cases, depending on its stage and sub-type[1].
  • This type of cancer is malignant and may travel to other parts of the body. As it progresses, it may compromise the body’s ability to fight infection since it is attacking the immune system.[2]

The disease is characterised by the presence of Reed-Sternberg cells (a cell that is part of the tissue macrophage system and have twin nuclei and nucleoli that give them the appearance of owl eyes,considered to be a type of B cell)[3]. These cells however only occupy a very small proportion (<5%) of the overall cell population of the affected lymph node. Contiguous spread is another feature. EBV infection is present in 40-80% depending on subtype[1]

Subtypes[edit | edit source]

There are five recognised histological subtypes, subdivided into two groups:

Classical group Positive for CD15/CD30 and negative for CD20/CD45/EMA:

  • nodular sclerosing: ≈70%
  • mixed cellularity: ≈25%
  • lymphocyte-rich: 5%
  • lymphocyte depleted: <5%

Non-classical group:

Positive for CD 19, 20, 22, 79a/EMA and negative for CD15/CD30:

  • nodular lymphocyte predominant (nodular paragranuloma)[1]

[4]

Pediatric Hodgkin lymphoma[edit | edit source]

Hodgkin Lymphoma (HL) is uncommon in children below 4 years old, and among older children and adolescents, there are two distinct forms: childhood HL (affecting 10 to 14-year-olds, predominantly males, associated with larger family size and lower socioeconomic status) and adolescent/young adult HL (15 to 35 years old, with an equal gender incidence, linked to higher socioeconomic status, early birth order, and fewer siblings). Early contact with other children and infection with common childhood viruses are associated with a lower risk of adolescent/young-adult HL. Epstein Barr virus (EBV) infection plays a role, with higher proportions in patients under 10 years, showing male predominance as in pediatric HL. Recent primary EBV infection is a risk factor for childhood HL, while delayed EBV infection, especially with infectious mononucleosis, is associated with young-adult HL. The role of a yet-to-be-identified infectious agent is considered in EBV-negative young-adult cases. [5] Similar to adult Hodgkin Lymphoma (HL), painless lymphadenopathy is the predominant initial sign in pediatric cases. Around 80% of young children exhibit cervical lymphadenopathy, with a minority having mediastinal disease at presentation compared to adolescents and young adults. This discrepancy is attributed, in part, to the prevalence of mixed cellularity histology in young children. Overall, pediatric patients are more inclined to present with stage I/II disease and less likely to present with stage IV disease compared to adults. [5]

Epidemiology[edit | edit source]

It is estimated that HL accounts for approximately 10% of cases of newly diagnosed lymphoma in the United States (8260 of 80,500 cases), and the remainder are non‐Hodgkin lymphoma (NHL).

  • Of 21,210 estimated deaths yearly because of lymphoma, about 1070 (or 5%) are from HL (accounting for about 0.5% of newly diagnosed cases of cancer in the United States and about 0.2% of all cancer deaths).
  • Males are expected to comprise about 56% of patients newly diagnosed with HL in 2017
  • The median age of diagnosis is 39 years; HL is most frequently seen in the group ages 20 to 34 years, which makes up almost one‐third of new diagnoses.

The incidence rates[edit | edit source]

  • Do not seem to vary between white and black Americans (3.1 new cases per 100,000 males)
  • Are about one‐half as much in Asians/Pacific Islanders (1.6 new cases per 100,000 males) and American Indians/Alaskan Natives.
  • Are lower in Hispanic Americans (2.6 new cases per 100,000 males) compared with white and black populations.
  • HL have stayed flat since the mid‐1970s, but mortality rates have steadily declined from 1.3 cases per 100,000 in 1975 to 0.3 cases per 100,000 in 2014.

Across all stages of diagnosis, the relative 5‐year survival of patients with HL has improved from 70% to 85% during the same period[6]

Etiology[edit | edit source]

Lymphatic sytem.png

The etiology of HL is not well understood.

  • The risk of developing EBV‐positive HL is significantly increased after an episode of infectious mononucleosis, also known as Epstein-Barr Virus, with an estimated median incubation time of 4.1 year. However, the absolute risk of developing HL after infectious mononucleosis remains small at approximately 1 in 1000.
  • Immunosuppression in a variety of medical conditions increases the risk of HL.
  • The incidence of HL is significantly higher in the human immunodeficiency virus (HIV)‐infected population than in the general population (standardized rate ratio, 14.7 in a US study).
  • The advent of highly active antiretroviral therapy (HAART) has indirectly led to the increase in rates of HL in HIV‐infected patients.Most cases are EBV‐positive and can occur in patients who have normal CD4 counts with a more aggressive histological phenotype; however, survival in HIV‐associated HL has improved significantly in the post‐HAART period.
  • The incidence of HL also increases after solid organ transplantation and in patients with a history of autoimmune conditions, such as rheumatoid arthritis, systemic lupus erythematosus, and sarcoidosis[6]

Characteristics/Clinical Presentation[edit | edit source]

Signs[edit | edit source]

  • Painless, unilateral, enlargement of nymph node usually in the neck, underarm or groin[7]
    • The lymph nodes should be examined based on the size, mobility, consistency and tenderness. A lymph node that is “over 1 centimeter in diameter and firm or rubbery consistency or tender are considered suspicious
    • Lymph nodes that are soft and tender to touch are usually indicative of infection.
    • Any changes in the shape, size, consistency, or mobility are red flags and should be reported to a physician immediately.

Symptoms[edit | edit source]

  • Fatigue [7]
  • Fever and chills that come and go
    • Typically peaks in the late afternoon
  • Itching all over the body that cannot be explained
    • Itching occurs mostly at night
  • Loss of appetite
  • Soaking night sweats
  • Painless swelling of the lymph nodes in the neck, armpits, or groin (swollen glands)
  • Weight loss that cannot be explained

Other symptoms that may occur with this disease:[edit | edit source]

  • Coughing, chest pains, or breathing problems if there are swollen lymph nodes in the chest [8]
  • Excessive sweating [8]
  • Pain or feeling of fullness below the ribs due to swollen spleen or liver [8]
  • Pain in lymph nodes after drinking alcohol [8]
  • Skin blushing or flushing [8]
  • Malaise [7]
  • Anorexia [7]
  • Symptoms may occur due to the obstruction or compression of structures by the enlarged lymph nodes. This may cause edema in the neck, face or right arm due to blockage of the superior vena cava or renal failure from blockage of the urethra [7].
  • Obstruction of bile ducts results in liver damage or jaundice, which will present as a yellowish color to the skin
  • “Mediastinal lymph node enlargement with involvement of lung parenchyma and invasion of the pulmonary pleura progressing to the parietal pleura may result in pulmonary symptoms, including nonproductive cough, dyspnea, chest pain and cyanosis. [7]
  • Nerve root pain and paraplegia could occur if the cancer spreads to the bones
  • Invasion pericardium caused by enlarged “penetrating lymph nodes adjacent to the heart” [3]
  • Hepatosplenomegaly [3]

Many of these signs and symptoms may be due to other health problems.

Treatment[edit | edit source]

Chemotherapy and radiation therapy are the main treatments for HL.

  • Depending on the case, one or both of these treatments might be used.
  • Certain patients might be treated with immunotherapy or with a stem cell transplant, especially if other treatments haven’t worked. Except for biopsy and staging, surgery is rarely used to treat HL.[9]

Even in advanced‐stage disease, HL is highly curable with combination chemotherapy, radiation, or combined‐modality treatment.

  • Although the same doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapeutic regimen has been the mainstay of therapy over the last 30 years, risk‐adapted approaches have helped de‐escalate therapy in low‐risk patients while intensifying treatment for higher risk patients.
  • Even patients who are not cured with initial therapy can often be salvaged with alternate chemotherapy combinations, the novel antibody‐drug conjugate brentuximab, or high‐dose autologous or allogeneic hematopoietic stem cell transplantation.
  • The programmed death‐1 inhibitors nivolumab and pembrolizumab have both demonstrated high response rates and durable remissions in patients with relapsed/refractory HL.
  • Alternate donor sources and reduced‐intensity conditioning have made allogeneic hematopoietic stem cell transplantation a viable option for more patients.
  • Future research will look to integrate novel strategies into earlier lines of therapy to improve the HL cure rate and minimize long‐term treatment toxicities[6]

Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

Hodgkin’s lymphoma presents like many other disorders, so it is hard to differentiate and diagnose. The following tests and procedures are taken to positively diagnose Hodgkin’s lymphoma:

  • “Physical exam: Your doctor checks for swollen lymph nodes in your neck, underarms, and groin. Your doctor also checks for a swollen spleen or liver.”[10]
  • Biopsy of lymph tissue that looks be involved and bone marrow. Once the sample is taken, it is checked for Reed-Sternberg cells that indicate Hodgkin’s lymphoma.[2]
  • Blood Chemistry Tests: check protein levels, liver function tests, kidney function tests and uric acid levels[8]
  • CT Scans: chest, abdomen and pelvis[8]
  • X-Rays: show swollen lymph nodes[2]
  • PET Scan: glucose is injected in the patient’s veins and be will more concentrated around cancerous cells[2]
  • MRI[2]

Once tests reveal that a patient has Hodgkin’s lymphoma, additional tests will be done to see if the cancer has spread therefore finding out what stage the cancer is in.[8] Once the cancer stage has been found, future treatments can be planned and initiated.

Physical Therapy Management[edit | edit source]

Physical therapy for patients with Hodgkin’s lymphoma focuses on cardiovascular and pulmonary health, strength, and flexibility in order to improve quality of life and reduce symptoms produced from cancer and treatments.

  • Most physical therapy sessions focus on activities of daily living, but also focus on the ability to reduce fatigue.
  • The ability to improve cardiovascular and pulmonary health along with strength and flexibility will allow patients the ability to help their tolerance to chemotherapy and radiation while maintaining or improving their ability to do everyday activities[11].
  • In a literature review by Courneya and Friedenreich, 24 empirical studies that were published between 1980 and 1997 showed that physical exercises and activity has a positive effect on quality of life in patients with cancer.
  • Physical activity is able to increase functional health as well as psychological and emotional welfare.[12]
  • Research suggests that treadmill exercises (aerobic exercises) provide cardioprotective effects on the Doxorubicin-induced cardiotoxicity[13]. 


For an indepth look at studies and physiotherapy/exercise regimes see below

Title, Author and Year
 Study Design
 Summary and Results
Nelson JP. Perceived health, self-esteem, health habits, and perceived benefits and barriers to exercise in women who have and who have not experienced stage I breast cancer. 1991.

 Cross-sectional
 Patients self reported exercises they did posttreatment. Healthy behaviors showed a positive relationship with self-esteem.
Young-McCaughan S, Sexton DL. A retrospective investigation of the relationship between aerobic exercise and quality of life in women with breast cancer. 1991.
 Retrospective
 Patients self reported exercise during or after treatment. Patients who exercised reported a higher QOL.
Baldwin MK, Courneya KS. Exercise and self-esteem in breast cancer survivors: An application of the exercise and self-esteem model. 1997.
 Cross-Sectional
 Patients self reported mild, moderate or strenuous exercise during or after treatment. Strenuous physical activity related positively with self-esteem and physical competence.
Bremer BA, Moore CT, Bourbon BM, Hess DR, Bremer KL. Perceptions of control, physical exercise, and psychological adjustment to breast cancer in South African women. 1997.

 Cross-sectional
 Patient’s self reported posttreatment exercises. No difference was found between patients that exercised and those that did not.
Courneya KS, Friedenreich CM. Relationship between exercise pattern across the cancer experience and current quality of life in colorectal cancer survivors. 1997.

 Retrospective
 Patients self reported mild, moderate and strenuous exercise prediagnosis, during treatment and after treatment. “Survivors who permanently relapsed from pretreatment to posttreatment reported lowest QOL.”
Courneya KS, Friedenreich CM. Relationship between exercise during cancer treatment and current quality of life in survivors of breast cancer. 1997.

 Retrospective
 Self reported mild, moderate and strenuous exerciseprediagnosis, during treatment and after treatment. Patients who maintained an exercise program from pre- to post-treatment reported the highest QOL.
BuettnerLL. Personality changes and physiological changes of a personalized fitness enrichment program for cancer patients. 1980.

 Quasi-experimental
 Exercise sessions with cardiovascular, strength and flexibility during post-treatment. Experimental group showed an increase in strength, functional capacity and personality.
Winningham ML. Effects of a bicycle ergometry program on functional capacity and feelings of control in women with breast cancer. 1983.

 Quasi-experimental
 Patients exercised on a cycle ergometer during chemotherapy. Experimental group increased their functional capacity.
Cunningham BA, Morris G, Cheney CL et al. Effects of resistance exercise on skeletal muscle in marrow transplant recipients receiving total parenteral nutrition. 1986.
 Experimental
 Exercise following bone marrow transplant. Experimental group maintained creatine exertion level.
MacVicar MG, Winningham ML. Promoting the functional capacity of cancer patients. 1986.
 Quasi-experimental
 Exercise on cycle ergometer during chemotherapy. Experimental group increased functional capacity, where controls decreased.
Winnginham ML, MacVicar MG. The effect of aerobic exercise on patient reports of nausea. 1988.
 Experimental
 Exercise on a cycle ergometer during chemotherapy. Experimental group had a larger decrease in nausea.
Decker WA, Turner-McGlade K, Fehir KM. Psychosocial aspects and the physiological effects of a cardiopulmonary exercise program in patients undergoing bone marrow transplantation for acute leukemia. 1989.
 Quasi-experimental
 Home-based exercise program before and after bone marrow transplant. Patients exhibited a decreased aerobic capacity and weight loss.
MacVicar MG, Winningham ML, Neckel JL. Effects of aerobic interval training on cancer patients’ functional capacity. 1989.
 Experimental
 Exercise on a cycle ergometer during chemotherapy. Experimental group increased their functional capacity.
Winningham ML, MacVicar MG, Bondoc M, Anderson JL, Minton JP. Effect of aerobic exercise on body weight and composition in patients with breast cancer on adjuvant chemotherapy. 1989.
 Experimental
 Exercise on a cycle ergometer during chemotherapy. Experimental group decreased their percent body fat and increased their lean body mass.
Pfalzer LA. The responses of bone marrow transplant patients to graded exercise testing prior to transplant and after transplant with and without exercise training. 1990.
 Quasi-experimental
 Patient’s exercised on cycle ergometer after bone marrow transplant. Patient’s showed an increase in VO2, decreased depression and fatigue.
Peters C. Ausdauersport als rehabilitationsmassnahme in der krebs-nachsorge. 1992.
 Quasi-experimental
 Patient’s exercised on a cycle ergometer. Patient’s showed an increase in natural killer cell activity.
Seifert E, Ewert S, Werle J. Exercise and sports therapy for patients with head and neck tumors. 1992.
 Quasi-experimental
 Group exercise showed favor in the experimental group but there wasn’t a significant difference with the control group.
Sharkey AM, Carey AB, Heise CT, Barber G. Cardiac rehabilitation after cancer therapy in children and adults. 1993.
 Quasi-experimental
 Exercises showed an increase in peak oxygen uptake and ventilator anaerobic threshold.
Mock V, Burke MB, Sheehan P, et al. A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy. 1994.
 Experimental
 Walking program showed an increase in physical functioning and fewer symptoms than the control group.
Nieman DC, Cook VD, Henson DA, et al. Moderate exercise training and natural killer cell cytotoxic activity in breast cancer patients. 1995.
 Experimental
 Walking and weight training program during post-treatment showed an increase in the 6 minute walk test and a decrease in heart rate.
Dimeo F, Bertz H, Finke J, et al. An aerobic exercise program for patients with haemotological malignancies after bone marrow transplantation. 1996.
 Quasi-experimental
 Treadmill walking post-bone marrow transplant showed an increase in physical performance.
Dimeo F, Tilmann MHM, Bertz H, et al. Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. 1997.
 Quasi-experimental
 Treadmill walking showed an increase in maximum performance and hemoglobin levels while decreasing fatigue.
Dimeo F, Fetscher S, Lange W, Mertelsmann R, Keul J. Effects of aerobic exercise on the physical performance and incidence of treatment-related complications after high-dose chemotherapy. 1997.
 Experimental
 Biking by use of a bed ergometer showed an increase in functional capacity and a decrease in pain and length of hospital stay.
Mock V, Dow KH, Meares CJ, et al. Effects of exercise on fatigue, physical functioning and emotional distress during radiation therapy for breast cancer. 1997.
 Experimental
 Home walking program during radiation increased patient’s functional capacity and decreased fatigue.

Treatment and prognosis[edit | edit source]

Prognosis depends on stage as well as several other factors such as age, serological markers (ESR), presence of B symptoms, and histological tumour subtype:

  • Nodular lymphocyte-predominant: best prognosis
  • Lymphocyte depleted: worse prognosis

Treatment is dependant on the stage of the disease:

  • Stage IIa and below: localised radiotherapy
  • Stage IIb and above: chemotherapy +/- radiotherapy to sites of large tumour bulk[1]

Case Reports/ Case Studies[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Radiopedia Hodgkin Disease .
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Mayo Clinic Staff. Hodkgin’s lymphoma (Hodgkin’s Disease). Updated November 5, 2010.
  3. ↑ 3.0 3.1 3.2 Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd edition. St. Louis, Missouri: Saunders Elsevier, 2009.
  4. ↑ UCTV. Conversations with History: The Story of Hodgkin’s Disease. http://www.youtube.com/watch?v=jBzMp-pnfcA. Accessed on February 27, 2011.
  5. ↑ 5.0 5.1 Hodgson DC, Hudson MM, Constine LS. Pediatric hodgkin lymphoma: maximizing efficacy and minimizing toxicity. Semin Radiat Oncol. 2007;17(3):230–42.
  6. ↑ 6.0 6.1 6.2 Shanbhag S, Ambinder RF. Hodgkin lymphoma: a review and update on recent progress. CA: a cancer journal for clinicians. 2018 Mar;68(2):116-32.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Zieve D, Chen Y. Hodgkin’s Lymphoma. Updated March 3, 2010.
  9. ↑ ACS Hodgkins Disease Available from:https://www.cancer.org/cancer/hodgkin-lymphoma/treating.html (last accessed 1.8.2020)
  10. ↑ National Cancer Institute. Hodgkin lymphoma.
  11. ↑ Cancer Treatment Centers of America. Hodgkins Disease Treatments - Complementary and Alternative Medicines. Updated October 3, 2007.
  12. ↑ Courneya KS, Friedenreich CM. Physical exercise and quality of life following cancer diagnosis: a literature review. Ann Behav Med. 1999; 21: (2): 171-179.
  13. ↑ Yang HL, Hsieh PL, Hung CH, Cheng HC, Chou WC, Chu PM, Chang YC, Tsai KL. Early Moderate Intensity Aerobic Exercise Intervention Prevents Doxorubicin-Caused Cardiac Dysfunction Through Inhibition of Cardiac Fibrosis and Inflammation. Cancers. 2020 May;12(5):1102.
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