Asked by Katie, Texas
How does Hodgkin lymphoma affect the organs in the lymphatic system?
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
Hodgkin lymphoma, or HL, was formerly called Hodgkin's disease. It is a cancer of the lymphatic system, which is a part of the immune system that consists of a series of ducts or tubes that parallel the arteries and veins throughout the body. These lymph ducts drain a milky white fluid that contains byproducts of immune activity away from areas of inflammation and infection.
There are filters at certain points throughout the lymphatic system called lymph nodes, which usually exist in grape-like clusters. The lymph nodes normally filter the cellular waste products and debris from infections that travel through the lymph ducts. Immune cells in the lymph nodes neutralize and degrade this debris.
Lymph nodes also harbor white blood cells known as lymphocytes, which are important in fighting bacterial, viral and other infectious agents.
HL arises within a lymph node and spreads through lymph ducts to other lymph nodes in the immediate area. The cancer eventually moves down lymphatic ducts to other areas of the body to other lymph nodes. A lymphoma starting in a neck node will first spread to other nodes on the same side of the neck. The disease might then move down lymphatic ducts to nodes in the armpit on the same side of the neck.
Late in the disease, as the tumor burden increases, HL can spread through the bloodstream. This leads to broader dissemination to organs and bone marrow. A few types of Hodgkin lymphoma can extend directly from an involved lymph node into an organ that is touching it.
HL is most often diagnosed when patients are in their 20s and 30s. There is a second peak in incidence in patients in their 50s.
Most HL patients' main first symptom is enlarged lymph nodes. The lymph nodes are painless and have a rubbery consistency. The lymph nodes of the neck are the most common site of diagnosis, the armpit is the second most common area for initial diagnosis, and the groin is third. A small number are initially diagnosed when a large mass is found in the mediastinum in the middle of the chest. The mass is usually a surprise finding when a chest X-ray is done for reasons unrelated to the cancer.
Rarely, a mass in the mediastinum is diagnosed because it produces chest pain, cough or shortness of breath. Even more rarely, the disease starts in the abdomen and gets very large, causing abdominal discomfort and pain, especially while the patient is lying down. The bulk of the tumor pressing on the liver or kidney can cause problems.
Pathologists have classified HL into five types, which are associated with site of origin and spread. Most patients with nodular lymphocyte-predominant Hodgkin lymphoma present with localized disease in the upper neck. Patients with the lymphocyte depletion subtype usually present with involvement of abdominal lymph nodes. The majority of patients with nodular sclerosis histology have the disease in the chest. Patients with mixed cellularity or lymphocyte deplete subtypes of HL often have HL involving the liver. And the lymphocyte deplete subtype is the kind that most often extends from nodes to adjacent organs.
Some patients with Hodgkin lymphoma develop symptoms before swollen or enlarged lymph nodes are discovered. These symptoms are called "B symptoms" and are nonspecific and more consistent with infection instead of a malignant disease. They include fever (of more than 100.4° F), night sweats and weight loss. Fatigue and itching may also be seen, but they are not considered "B symptoms." Some patients also have burning in involved lymph nodes after alcohol ingestion.
When localized to one area of the body, HL is treated with radiation therapy or radiation therapy with chemotherapy. When the disease has spread such that one radiation beam cannot safely encompass all of it, the disease is treated with chemotherapy. Patients often go into complete remission, and a high proportion of patients are cured. Even patients with widely disseminated stage 3 or 4 disease can often be cured. Those who relapse, meaning their tumor returns, are usually candidates for secondary chemotherapy treatments.
Patients with HL do have some immune suppression because of the disease and have a higher risk of getting certain infections. Patients who are successfully treated for HL continue to have this immune suppression and long term have a higher risk of leukemia and some other cancers because of their therapy.
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