Hodgkin's Lymphoma: Types, Causes, Symptoms & Risk

Here are the two main types of Hodgkin's lymphoma:
Classical Hodgkin's Lymphoma (cHL)
Classical Hodgkin's lymphoma accounts for the majority of Hodgkin's lymphoma cases and is further subdivided into four subtypes:

1. Nodular Sclerosis Hodgkin's Lymphoma (NSHL): Nodular Sclerosis Hodgkin's
Lymphoma (NSHL) is the most common subtype of classical Hodgkin's lymphoma,
accounting for about 70-80% of cases. It primarily affects young adults and typically
involves the lymph nodes in the neck, chest, or mediastinum. Under microscopic
examination, NSHL is characterised by Reed-Sternberg cells surrounded by a fibrous
tissue framework.

2. Mixed Cellularity Hodgkin's Lymphoma (MCHL): Mixed Cellularity Hodgkin's Lymphoma (MCHL) comprises approximately 20% of classical Hodgkin's lymphoma cases. It is more commonly diagnosed in older adults and is linked with higher rates of Epstein-Barr virus (EBV) infection in regions where the virus is prevalent. This subtype manifests as a combination of different cell types, including Reed-Sternberg cells, lymphocytes, eosinophils, and histiocytes.

3. Lymphocyte-Rich Hodgkin's Lymphoma (LRHL): Lymphocyte-Rich Hodgkin's Lymphoma (LRHL) is a relatively rare form of classical Hodgkin's lymphoma, accounting for approximately 5% of cases. It primarily affects young adults and exhibits a high presence of reactive lymphocytes, which can pose challenges in distinguishing it from non-Hodgkin's lymphoma.

4. Lymphocyte-Depleted Hodgkin's Lymphoma (LDHL): Lymphocyte-Depleted Hodgkin's Lymphoma (LDHL) is the rarest subtype of classical Hodgkin's lymphoma and accounts for less than 1% of cases. It predominantly affects older adults and individuals with compromised immune systems. LDHL is characterised by a scarcity of reactive lymphocytes and an abundance of Reed-Sternberg cells.

Nodular Lymphocyte-Predominant Hodgkin's Lymphoma (NLPHL)
Nodular lymphocyte-predominant Hodgkin's lymphoma is a subtype that accounts for roughly
5% of all cases of Hodgkin's lymphoma. It differs significantly from classical Hodgkin's
lymphoma in terms of cell morphology, behaviour, and treatment approach.

NLPHL is characterised by the presence of "popcorn cells" or lymphocyte-predominant cells. These cells are large with multilobed nuclei resembling popcorn. Interestingly, they usually test positive for CD20, a specific marker found on B-cells. In contrast, classical Hodgkin's lymphoma Reed-Sternberg cells are typically CD20-negative.

NLPHL is known for its slower growth than classical Hodgkin's lymphoma, resulting in a
generally more favourable prognosis. Treatment for NLPHL typically involves localised therapies
like radiation or surgical resection, while chemotherapy may be employed for advanced or
aggressive cases.

Hodgkin's lymphoma's symptoms can vary depending on the stage and affected areas of the body. Hence, recognizing these signs and seeking medical attention is crucial. The most
common Hodgkin's lymphoma symptoms are:

1. Enlarged Lymph Nodes: Hodgkin's lymphoma is characterised by painless swelling in
the lymph nodes. This swelling typically occurs in the neck, armpits, or groin. The affected lymph nodes may feel firm and rubbery to touch and often have mobility.
2. Unexplained Fever: Many individuals with Hodgkin's lymphoma experience recurrent fevers that are not associated with any apparent infection. These fevers can be persistent and may occur during the day or night.
3. Night Sweats: Night Sweats are the excessive sweating that happens during sleep and is unrelated to external factors like room temperature. These episodes of sweating can be so intense that they may require changing bedclothes.
4. Unexplained Weight Loss: Hodgkin's lymphoma often presents itself through significant and unintentional weight loss. In medical terms, it refers to losing over 10% of body weight within six months without any dietary or physical activity changes.
5. Fatigue: Persistent fatigue and lack of energy are very prevalent in people suffering from Hodgkin's lymphoma. Patients often find themselves feeling tired despite receiving adequate rest.
6. Itchy Skin: Some individuals diagnosed with Hodgkin's lymphoma may experience a condition called generalised itching or pruritus. This uncomfortable sensation is not localised to the area of enlarged lymph nodes but can affect the entire body.
7. Loss of Appetite: Hodgkin's lymphoma can cause a decrease in hunger, resulting in a lessened desire to eat and subsequent weight loss.
8. Chest Symptoms: If the lymphoma affects the lymph nodes in the chest, it can lead to coughing, chest pain, and difficulty breathing. This occurs due to symptoms related to chest involvement.

Hodgkin's lymphoma occurs due to a combination of genetic, environmental, and immune
system factors. This condition arises from genetic mutations that cause uncontrolled growth and
proliferation of lymphocytes within the lymphatic system. Although the precise triggers for these
mutations remain unclear, certain risk factors are associated with an increased likelihood of
developing Hodgkin's lymphoma:

1. Epstein-Barr Virus (EBV) Infection: In some cases of Hodgkin's lymphoma, the
Epstein-Barr Virus (EBV) infection has been identified as a significant contributing factor.
EBV belongs to the herpesvirus family and is a common virus. It is linked to certain types
of lymphoma, especially in younger individuals.
2. Genetic Predisposition: Certain genetic factors can make some individuals more prone
to developing Hodgkin's lymphoma. For example, individuals with a family history of the disease may face a slightly elevated risk.
3. Age and Gender: Hodgkin's lymphoma primarily affects two distinct age groups: young
adults aged 15 to 40 and older adults over 55 years old. Additionally, it is worth noting that men have a slightly higher likelihood of developing Hodgkin's lymphoma than women.
4. Weak Immune System: People with weakened immune systems, such as those living
with HIV/AIDS, organ transplant recipients, or individuals taking immunosuppressive
drugs, face a much greater risk of developing Hodgkin's lymphoma. The compromised
immune system may struggle to regulate abnormal cell growth, thus, enabling the proliferation of cancerous cells.
5. Previous Cancer Treatment: Some studies suggest that undergoing radiation therapy
or chemotherapy can slightly increase the long-term risk of developing Hodgkin's lymphoma. However, it is essential to note that the overall risk remains relatively low.
6. Environmental and Lifestyle Factors: Research is underway to explore environmental
and lifestyle factors that may contribute to the development of Hodgkin's lymphoma. However, no definitive causative agents have been identified yet.

Here are some risk factors for Hodgkin's lymphoma:

1. Age: Hodgkin's lymphoma affects two age groups: young adults aged 15 to 40 and older
adults over the age of 55. This disease is less common among children and individuals
aged 41 to 54.
2. Gender: Men have a slightly greater risk of developing Hodgkin's lymphoma compared to women. The underlying reason behind this gender disparity is uncertain.
3. Family History: A person's risk of developing Hodgkin's lymphoma may increase if they have a family history of the disease. Additionally, individuals who have a first-degree relative (such as a parent, sibling, or child) with Hodgkin's lymphoma are more likely to develop the condition themselves.
4. Epstein-Barr Virus (EBV) Infection: Epstein-Barr Virus (EBV) Infection is linked to an
increased risk of developing Hodgkin's lymphoma. EBV is a widespread virus that infects most people at some point in their lives. It often causes no Hodgkin's lymphoma symptoms or only mild illness. However, in some instances, EBV can contribute to the development of certain cancers, including some types of Hodgkin's lymphoma.
5. Weak Immune System: Individuals with weakened immunity are at a higher risk of
developing Hodgkin's lymphoma. For example, people with HIV/AIDS or individuals who have received organ transplants and are taking immunosuppressive medication. This also includes individuals who were born with certain immune deficiencies.
6. Previous Cancer Treatment: Radiation therapy and certain types of chemotherapy can
slightly increase the long-term risk of developing Hodgkin's lymphoma. However, it is
essential to note that the overall risk remains relatively low.
7. Socioeconomic Factors: Some studies indicate that individuals with higher socioeconomic status may have a slightly elevated risk of developing Hodgkin's lymphoma. Nevertheless, the exact reasons behind this association remain a mystery.
8. Geography: The incidence of Hodgkin's lymphoma varies based on geography. Plus,
certain regions of the world exhibit higher rates than others. Developed countries and areas with higher socioeconomic status tend to have a greater prevalence of this disease.

Since the exact cause of Hodgkin's lymphoma is not fully understood, providing definitive
preventive strategies is challenging. However, certain lifestyle choices and behaviours can help
lower the risk of Hodgkin's lymphoma. Here are some strategies that can help you in reducing
the risk of Hodgkin's lymphoma:

1. Stay Physically Active: Staying physically active is paramount for maintaining good health and lessening the risk of cancers. Additionally, engaging in regular, moderate-intensity exercise can have significant benefits. Try to get a minimum of 150 minutes of moderate exercise or 75 minutes of vigorous exercise every week.
2. Eat a Balanced Diet: It is paramount to consume a balanced diet to maintain good health. This entails incorporating a variety of fruits, vegetables, whole grains, and lean proteins into your meals. Additionally, it is advisable to limit the intake of processed and red meats and sugary foods. You must also avoid excessive consumption of alcohol.
3. Avoid Smoking and Tobacco Use: Smoking and tobacco use, including cigarettes, cigars, and smokeless tobacco, have long been recognized as significant factors contributing to various types of cancer, particularly lung cancer. By avoiding these harmful substances altogether, one can significantly decrease their chances of developing cancer.
4. Limit Alcohol Consumption: Research has linked excessive alcohol intake to an increased likelihood of developing various types of cancers, including lymphomas. Hence, if one chooses to consume alcohol, moderation is key. For adults, moderate drinking means consuming up to one drink per day for women and up to two drinks per day for men.
5. Protect Against Viral Infections: Certain viruses, like Epstein-Barr virus (EBV), have been linked to an increased likelihood of Hodgkin's lymphoma. We advise you to practise proper hygiene, receive appropriate vaccinations, and avoid close contact with infected individuals. By adopting these measures, individuals can minimise their chances of contracting viral infections that might contribute to Hodgkin's lymphoma.
6. Maintain a Healthy Weight: Carrying extra weight or being obese can heighten the likelihood of various cancers, including lymphoma. Hence, strive for a healthy weight by adopting a well-balanced diet and engaging in regular physical activity.
7. Regular Health Check-ups: Regular health check-ups are crucial as they help in recognizing any Hodgkin's lymphoma symptoms. Prompt medical intervention can significantly improve outcomes and overall well-being by detecting these problems early on.

The diagnosis of Hodgkin's lymphoma requires a thorough medical evaluation. That's because
accurate identification and diagnosis of Hodgkin's lymphoma is crucial in developing an
appropriate treatment plan and ensuring the best possible outcomes. The diagnostic process
generally comprises the following steps:

1. Medical History and Physical Examination: The very first step in the diagnosis of Hodgkin's lymphoma involves thoroughly reviewing the patient's medical history and conducting a detailed physical examination. The doctor enquires about the experienced Hodgkin's lymphoma symptoms, their duration, or any pertinent medical conditions or familial history.
2. Blood Tests: Blood tests are conducted to evaluate the patient's overall health and eradicate any other causes of the Hodgkin's lymphoma symptoms. These examinations may encompass a complete blood count (CBC) test to assess any inconsistencies in blood cell counts.
3. Imaging Studies: Imaging studies play a crucial role in evaluating the disease's extent
and determining the stage of Hodgkin's lymphoma. Commonly used imaging techniques
include:

1. X-rays: X-rays are utilised to identify abnormalities in the chest, notably enlarged lymph nodes. It can be beneficial in detecting any irregularities within the chest.
2. Computed Tomography (CT) Scan: This is a medical procedure that provides detailed cross-sectional images of the body. It is commonly used to evaluate organs such as lymph nodes, spleen, and liver.
3. Positron Emission Tomography (PET) Scan: This diagnostic tool helps in the detection of cancerous tissue by identifying areas of increased metabolic activity.

4. Biopsy: A biopsy involves removing a sample of the affected lymph node or tissue for microscopic examination. The most commonly used type of biopsy is excisional, where the entire lymph node is surgically removed. However, a needle biopsy could also be performed to obtain a smaller tissue sample.
5. Pathological Examination: In this process, the biopsy sample is sent to a pathologist. This expert examines the tissue under a microscope, searching for the presence of distinct Reed-Sternberg cells. These unusually large and abnormal cells serve as a key indicator of Hodgkin's lymphoma. Additionally, the pathologist identifies the specific subtype of Hodgkin's lymphoma and assesses other characteristics of the tumour.
6. Bone Marrow Biopsy: A bone marrow biopsy is performed to determine the presence
of Hodgkin's lymphoma cells in the bone marrow. This procedure helps assess if the
disease has spread beyond the lymphatic system.

Hodgkin’s lymphoma has different stages to determine the disease’s spread and devise the appropriate treatment plan. Hodgkin’s lymphoma uses the Ann Arbor staging system and has four main stages (I to IV) based on lymph nodes and organ involvement. Here is a detailed explanation of each stage:

1. Stage I: In the first stage, Hodgkin’s lymphoma is confined to either a single lymph node region or a solo organ outside the lymph nodes. Usually, this affected region or organ is on one side of the diaphragm. Stage I can be further divided into two sub-stages:

1. Stage IA: The disease is limited to a single lymph node region.
2. Stage IB: The disease involves a single organ or an area of contiguous (adjacent) organs.

2. Stage II: In stage II of Hodgkin’s lymphoma, there is involvement of two or more lymph node regions on the same side of the diaphragm. Alternatively, it may involve one lymph node region and a nearby organ. Like stage I, stage II can be further divided into two sub-stages:

1. Stage IIA: The disease affects two or more lymph node regions on the same side of the diaphragm.
2. Stage IIB: This stage signifies that the disease affects a lymph node region, an adjacent organ, or a series of neighbouring organs. 

3. Stage III: In stage III of Hodgkin’s lymphoma, the disease affects lymph node regions on both sides of the diaphragm. Additionally, it may involve the spleen, an abdominal organ, or other nearby organs. 

4. Stage IV: Stage IV indicates the most advanced phase of Hodgkin’s lymphoma, where the disease has extended beyond the lymphatic system to affect one or multiple organs like the liver, bone marrow, lungs, or distant areas.

In addition to the main stages, here are some letters that are used to offer more comprehensive details regarding the presence or absence of specific Hodgkin’s disease symptoms:

A: If the patient does not have significant symptoms, the stage is indicated by the letter "A" (e.g., IIA).

B: If patients have significant symptoms like unexplained fever, night sweats, or unintentional weight loss, the stage is indicated by adding the letter "B" (e.g., IIB). 

For instance, a patient diagnosed with Hodgkin’s lymphoma, who is experiencing significant symptoms and shows the involvement of two lymph node regions on the same side of the diaphragm, may be classified as stage IIBX. In this staging, "X" indicates the presence of "B"symptoms.

The main treatment options for Hodgkin's lymphoma are chemotherapy, radiation therapy,
targeted therapy, immunotherapy, and stem cell transplantation. The primary objective of
Hodgkin's lymphoma treatment is to achieve remission - the complete disappearance of all
Hodgkin's disease symptoms - while also enhancing the patient's quality of life. Here are the
various treatment modalities for Hodgkin's lymphoma:

1. Chemotherapy: This is the administration of drugs to eradicate or impede the growth of
cancer cells. It serves as a primary approach in treating most instances of Hodgkin's
lymphoma, particularly during advanced stages (III and IV). There are various
chemotherapy regimens based on the subtype and stage of Hodgkin's lymphoma.
Chemotherapy can be administered either alone or in conjunction with other therapeutic
methods.

2. Radiation Therapy: Radiation therapy utilises high-energy X-rays or other forms of
radiation to target and eliminate cancer cells. It is commonly employed during the early
stages (I and II) of Hodgkin's lymphoma or in conjunction with chemotherapy for more
advanced cases. Radiation therapy proves most effective when addressing localised
disease or when residual masses persist after chemotherapy.
3. Targeted Therapy: Targeted therapy aims to attack cancer cells while preserving the
healthy ones. One such example of targeted therapy employed in Hodgkin's lymphoma
is brentuximab vedotin, which selectively targets a protein named CD30 present on the
surface of Hodgkin's lymphoma cells. Brentuximab vedotin can be used alone or
combined with chemotherapy in certain cases.
4. Immunotherapy: Immunotherapy is a type of treatment that strengthens the body's
immune system to detect and attack cancer cells. In Hodgkin's lymphoma treatment,
checkpoint inhibitors like pembrolizumab or nivolumab are used. These medications
block certain proteins that restrict the immune response, enabling the immune system to
identify and eliminate cancer cells more effectively.
5. Stem Cell Transplantation: Stem cell transplantation is also known as bone marrow
transplant. It is used when the disease has relapsed or proved resistant to treatment.
This procedure involves administering high-dose chemotherapy to eliminate cancer
cells. However, it also damages healthy bone marrow cells. Healthy stem cells are put
into the patient's body to counter this effect.
6. Clinical Trials: Clinical trials are conducted to evaluate new or experimental treatments
for Hodgkin's lymphoma. By participating in a clinical trial, patients can gain access to
cutting-edge therapies and improve their treatment outcomes. However, it is essential for
patients to discuss clinical trial options with their healthcare team.
7. Regular Follow-Up Visits: After completing the initial treatment, patients diagnosed
with Hodgkin's lymphoma will need to attend regular follow-up visits. These visits are
essential for monitoring their condition and evaluating the response to Hodgkin's lymphoma treatment. Typically, follow-up appointments may involve physical examinations, blood tests, imaging studies, and occasionally bone marrow biopsies. The frequency of these visits may vary depending on the stage of the disease and the potential risk of recurrence.

The recovery and aftercare process for individuals with Hodgkin's lymphoma is a critical phase
of their cancer journey. Once treatment is completed, patients enter a phase called survivorship,
where the focus shifts to monitoring their health, managing potential treatment side effects, and
supporting overall well-being. Here's an in-depth overview of the road to recovery and aftercare
for Hodgkin's lymphoma patients.

1. Follow-up Visits: After completing the initial treatment, patients will need to attend regular follow-up visits with their healthcare team. These visits are crucial for monitoring their condition, evaluating treatment progress, and identifying any potential recurrence. The frequency of these follow-up visits may vary depending on the disease stage and
the individual's risk of recurrence.

2. Imaging and Laboratory Tests: During follow-up visits, patients may have to undergo imaging tests such as CT scans, PET scans, or X-rays to check for signs of disease recurrence or new cancer growth. Blood tests may also be performed to monitor blood cell counts and other health indicators.

3. Managing Long-term Side Effects: Survivors of Hodgkin's lymphoma may face an array of lasting treatment repercussions. These encompass heart and lung problems, fertility challenges, secondary cancers, and hormonal imbalances. To ensure survivors enjoy the best possible quality of life, healthcare providers diligently monitor and address these side effects.

4. Emotional and Psychological Support: Dealing with cancer can have a profound impact on both patients and their loved ones, taking a toll on their emotional and psychological well-being. After surviving cancer, individuals experience various emotions as they navigate life post-treatment. However, during this phase, seeking counselling services, engaging in support groups, or utilising mental health resources can offer invaluable emotional support.

5. Healthy Lifestyle Choices: A healthy lifestyle can greatly benefit one's recovery and overall well-being. Hence, it is vital for patients to adopt various healthy habits, including maintaining a balanced diet, engaging in regular physical activity, refraining from smoking and excessive alcohol consumption, and managing stress. These choices contribute to improved health outcomes and promote overall wellness.

6. Survivorship Care Plans: Survivorship care plans consist of documents that outline the
patient's treatment history, potential long-term side effects, and recommendations for ongoing care. These plans help survivors navigate their post-treatment journey and serve as a roadmap.

7. Addressing Fertility Concerns: Hodgkin's lymphoma treatment can sometimes impact the fertility of young patients. Hence, it is crucial to discuss the available options if you're worried about your ability to conceive.

8. Transitioning to Primary Care: After completing active cancer treatment, survivors shift towards receiving more care from their primary care physician. However, they still maintain regular communication with their oncologist or haematologist during the post-treatment phase.

9. Participation in Clinical Trials: Hodgkin's lymphoma survivors may have the opportunity to participate in clinical trials that assess novel treatments and long-term management strategies. Engaging in these trials provides access to cutting-edge therapies and contributes to the progression of cancer research.

10. Celebrating Milestones: Survivorship presents numerous opportunities for celebrating milestones. These include commemorating treatment completion anniversaries, reaching specific recovery goals, and accomplishing personal achievements. Such celebrations serve as morale boosters and provide a sense of accomplishment and hope.

1. Is Hodgkin's lymphoma contagious?
No, Hodgkin's lymphoma is not contagious. It is a type of cancer that results from genetic mutations in lymphocytes and is not caused by an infectious agent.

2. Can Hodgkin's lymphoma be hereditary?
While most cases of Hodgkin's lymphoma are not hereditary, a small percentage of individuals may have a genetic predisposition to the disease. However, the majority of cases are not linked to a family history of the condition.

3. Are there any specific dietary restrictions for Hodgkin's lymphoma patients during treatment?
There are no specific dietary restrictions for Hodgkin's lymphoma patients during treatment. However, maintaining a balanced diet and staying hydrated are essential for overall well-being.

4. Can Hodgkin's lymphoma recur after successful treatment?
Yes, Hodgkin's lymphoma can recur even after successful treatment. Regular follow-up
visits with the healthcare team are essential to monitor for any signs of recurrence.

5. Are there alternative therapies for Hodgkin's lymphoma?
While some people explore complementary or alternative therapies, there is no scientific
evidence to support their effectiveness as a primary treatment for Hodgkin's lymphoma.
It's essential to discuss any alternative therapies with the healthcare team.

6. Does having Hodgkin's lymphoma increase the risk of other cancers?
Yes, Hodgkin's lymphoma survivors may have a slightly higher risk of developing certain
secondary cancers, such as breast cancer, lung cancer, or non-Hodgkin's lymphoma.
Regular monitoring and screenings can help detect these cancers early.

7. Can Hodgkin's lymphoma affect fertility in men and women?
Yes, treatments for Hodgkin's lymphoma, such as chemotherapy and radiation therapy,
can sometimes impact fertility in both men and women. Discussing fertility preservation
options before treatment is essential for those concerned about future fertility.

8. Can exercise help during Hodgkin's lymphoma treatment?
Moderate exercise during Hodgkin's lymphoma treatment can help improve overall well-
being, reduce fatigue, and manage stress. However, patients should consult their healthcare team before starting any exercise regimen.

9. Is it safe to get vaccinated against infections during Hodgkin's lymphoma treatment?
Vaccination recommendations may vary based on the stage of treatment and the type of
treatment being received. It is essential to consult with the healthcare team before getting vaccinated.

10. Can Hodgkin's lymphoma be misdiagnosed as other diseases?
Yes, due to the similarity of some Hodgkin's disease symptoms with other conditions, Hodgkin's lymphoma can be misdiagnosed. A definitive diagnosis relies on a biopsy and pathological examination by a specialist.