Hodgkin's Lymphoma: Diagnosis

lymph node biopsy
Image from lymph node biopsy

Often the one who makes the first diagnosis of Hodgkin's Lymphoma / Disease is the person affected. There are some symptoms for Hodgkin's but they are not specific. Often a lymph node swells, especially in the upper body area. Other times one feels they have a lack of energy. More serious symptoms can include weight loss, fever, and drenching night sweats. Some people have itching and others a lower back pain that is unexplained (lower back pain may be caused by growing lymph nodes pressing on nerves).

In occasional cases the involved nodes are painful after alcohol consumption. Finally, a good percentage of diagnoses are made when receiving normal examinations such as annual physicals or pregnancy check-ups. It often seems the diagnosis comes as a surprise and a shock.

Making the Diagnosis:

Hodgkin's is medically diagnosed by taking a tissue sample (biopsy) and searching for the presence of Reed-Sternberg cells, a cell specific to Hodgkin's lymphoma. A needle biopsy is sometimes used but a surgical biopsy, removal of a whole lymph node, is often preferred in getting enough tissue for a definite diagnosis. The biopsy tissue can also be tested using modern techniques to determine the exact type of cells involved.

Other tests your medical team may perform include the following:

  • A physical exam including examining the lymph nodes
  • Collecting a medical history and history of symptoms
  • A complete blood work-up including checks for abnormal blood cell count (numbers of white and red blood cells), blood chemistry, and abnormal erythrocyte sedimentation rate (ESR)
  • A chest x-ray to view lymph nodes and to see if other organs are involved
  • A computerized tomography (CT or CAT) scan or magnetic resonance imaging (MRI) scan of the chest, pelvis, and abdomen to determine the possible spread of the disease
  • A Positron Emission Tomography (PET) scan is a newer method to pinpoint hotspots of cellular activity
  • A gallium scan to check for radioactive intake of gallium in the lymph system indicating swelling and ultimately disease
  • A bone marrow aspiration and biopsy to determine if the bone marrow has been affected by Hodgkin's; in this procedure the hip is numbed and a needle is inserted into the bone; liquid bone marrow and a bone chip are extracted and examined under a microscope.
  • Certain medical centers may perform additional tests, including
  • Exploratory surgery (staging laparotomy) to determine the extent of the disease. In some cases the spleen is removed if it is the only organ affected. A tissue sample may also be taken of the liver.
  • A lymphangiogram, a procedure during which a radio-opaque liquid is injected into the lymph system through the feet; the fluid travels throughout the lymph system and remains visible by x-rays for up to six months
  • With modern diagnostic tools available, laparotomy and lymphangiogram are rarely used today.
  • Once a biopsy sample is taken, it is classified into one of five types of Hodgkin's shown below. This typing is called the histology of the disease.

Types of Hodgkin's Lymphoma:

Nodular sclerosis (NS)
The lymph nodes in the lower neck, chest and collarbone usually contain normal and reactive lymphocytes and Reed-Sternberg cells separated by bands of scar-like tissues. NS accounts for 60-70% of Hodgkin's cases. NS appears to account for the increase in Hodgkin's cases in recent years.
Lymphocyte predominance (LP)
The lymph nodes are composed largely of reactive lymphocytes and malignant L&H cells which have a "popcorn" appearance and very few Reed-Sternberg cells. LP accounts for 5% of Hodgkin's cases and affects more men than women.
Mixed cellularity (MC)
The lymph nodes usually contain Reed-Sternberg cells and inflammatory cells. MC accounts for 20-30% of Hodgkin's cases.
Lymphocyte depleted (LD)
There are two different variations of this classification: one with sheets of differing malignant cells; the other with few Reed-Sternberg cells and lymphocytes with scar-like tissue. Accounts for about 5% of Hodgkin's cases.
Nodular lymphocyte predominant (NLP)
Hodgkin's lymphoma - while the 4 types above are "Classical" types, NLP is in a category of its own. Typical Reed-Sternberg cells are rare to non-existent; instead variants called L & H cells (colloquially "popcorn cells") are seen.

Additional distinctive clinical features setting apart nodular lymphocyte predominance HL include:

  • an indolent though relapsing course with an excellent prognosis;
  • occasional cases relapsing as high-grade B-cell non-Hodgkin's lymphoma;
  • a peak incidence in males in their 30's and 40's, without the bimodal age pattern of classic HL;
  • a greater tendency to be restricted to cervical lymph nodes.

Stages of Hodgkin's Lymphoma:

The medical team will also stage the spread of the lymphoma. There are four stages which depend on how far the cancer has spread through the body:

Stage I
involves one lymph node region
Stage II
involves two or more lymph node regions on the same side of the diaphragm
Stage III
involves lymph nodes on both sides of the diaphragm
Stage IV
involves other organs besides the lymph system

The letter "E" is used after the stage to designate disease disease spread to other areas (bone marrow, lung, etc.)

Two other terms are used in staging:

Progressive
The disease progresses (grows) while the patient is in treatment (usually treatment reduces tumors).
Recurrent
Recurrent disease means that the cancer has come back after it has been treated. It may come back in the area where it first started or in another part of the body.

Staging is also dependent on whether the patient has had a group of symptoms including night sweats, fever, or weight loss. Patients who have had one or more of these are grade "B" while patients who have none grade "A". Itching and back pain are not symptoms which rate the "B" designation but can be common in many cases where "B" symptoms are evident. While statistics are for large groups of people, there still are requests for survival based on stage. Here are 5 year survival rates for Hodgkin's by stage although your individual case can differ (for example, treatments get better over time):

Prognosis

With the modern classification system have come sets of prognostic factors - if the following factors are present the outlook may be poorer and your medical team may change or intensify treatment:

  • A large mass in the mediastinum (middle of the chest)
  • Older age (>50)
  • A high erythrocyte sedimentation rate (a blood test)
  • Hodgkin's present in more than 4 regions of the body
  • A high white blood cell count or low red blood cell count
  • Do not despair if factors look poor just reading this type of information. The author of this website is a stage 4BE NS Hodgkin's (about as bad as it gets). 11+ years, Hodgkin's free. Modern treatments are great!
  • Please look at the treatment and resource sections for more information on Hodgkin's. Note - physician information is often technical. Take the information you find to discuss with your doctor and medical team. A glossary is available if terms are unfamiliar.

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