What Is Hodgkin Disease?

What Is Hodgkin Disease?

Hodgkin disease is a type of lymphoma. There are 2 kinds of lymphoma:

Hodgkin disease (named after Dr. Thomas Hodgkin, who first recognized it in 1832)
Non-Hodgkin lymphoma
Hodgkin disease starts in lymphatic tissue. Lymphatic tissue includes the lymph nodes and other organs that are part of the body’s immune and blood-forming systems.

Lymph nodes are small, bean-shaped organs found in many places throughout the body. The lymph nodes make and store lymphocytes, which are special white blood cells that fight infection. There are 2 types of lymphocytes:

B lymphocytes (B cells)
T lymphocytes (T cells).
Lymph vessels, narrow tubes something like blood vessels, connect the lymph nodes. These vessels carry a clear fluid called lymph that contains the white blood cells. Other parts of the lymphatic system include the spleen, the bone marrow, and the thymus gland.

Because lymphatic tissue is found in many parts of the body, Hodgkin disease can start almost anywhere. Most often it starts in lymph nodes in the upper part of the body. This disease causes the lymphatic tissue to become enlarged and press on nearby structures. But lymph nodes can become swollen for many reasons. More often it happens when the body is fighting an infection.

Cancer can spread through the lymphatic vessels. Rarely, and late in the disease, it gets into the blood vessels and can then spread to almost any other place in the body.

The cancer cells in Hodgkin disease are unique. They are called Reed-Sternberg cells (or Hodgkin cells). They are an abnormal type of B lymphocyte that are much larger than normal lymphocytes.
B lymphocyte


T lymphocyte



There are 2 main types of Hodgkin disease and several sub-types as well. The types differ in the way the cancer cells look under a microscope. The types are important because each grows and spreads in a different way. Often they are treated differently. You can ask your doctor about the exact type of Hodgkin disease you (or your child) has.

Hodgkin disease occurs in both children and adults.Hodgkin disease is similar in both children and adults.

How Many People Get Hodgkin Disease?

The American Cancer Society estimates that in 2006 there will be about 7,800 new cases of Hodgkin disease in this country. About 1,490 people will die of the disease. Because of better treatment, death rates have fallen by more than 60% since the early 1970s.

Both children and adults can get Hodgkin disease but it is most common in two age groups: early adulthood (ages 15 to 40) and late adulthood (after age 55). About 10% to 15% of cases are found in children 16 years old and younger.

What Causes Hodgkin Disease?

We do not yet know exactly what causes Hodgkin disease, but we do know that certain risk factors are linked to the disease. Scientists have found a few risk factors that may make a person more likely to get Hodgkin disease.

There is a higher risk of Hodgkin disease among people who have had "mono" (infectious mononucleosis), caused by the Epstein-Barr virus. The risk appears to be as much as 4 times higher in people who have had this disease.
Some people who have reduced immune system function, for example, those with AIDS and organ transplant patients are also at a higher risk of Hodgkin disease.
In some families there are a higher number of people with Hodgkin disease than would be expected. But this is not common, and it accounts for around 5% of cases.
There does not appears to be any link between Hodgkin disease and lifestyle factors such as smoking, diet, exercise, use of alcohol, or type of job.
Can Hodgkin Disease Be Prevented?

Since we do not know what causes Hodgkin disease, it is not possible at this time to prevent the disease.

How Is Hodgkin Disease Found?

There are no tests to find Hodgkin disease early, and some people with the disease have no symptoms at all. Most people with Hodgkin disease see their doctor because they have felt a lump that hasn’t gone away or they just don’t feel well and go in for a checkup. They may have a swollen lymph node in the neck, under the arm, or in the groin area. Sometimes it will go away only to come back. Eventually, it doesn’t go away, and although it doesn’t hurt, it will get larger and cause the person to go to the doctor.

But in most people, especially children, enlarged lymph nodes are caused by an infection or other illness and not cancer. If you (or your child) have lymph nodes over an inch in size and no recent infection, it is best to have them checked by the doctor.

Other symptoms of Hodgkin disease can include:

fever
drenching night sweats
weight loss
Itching
tiredness
decreased appetite
coughing or shortness of breath
The fever can come and go over periods of several days or weeks. If you or your child has any of these symptoms, talk to your doctor right away. And remember, there are often reasons for these symptoms other than cancer.

What tests will be done to Diagnose Hodgkins Disease?
If there is any reason to think that you have Hodgkin disease, the doctor will want to do certain tests. The first step would be to ask questions about your health now and in the past and to do a thorough physical exam to see whether there is an infection. During the exam, the doctor will pay special attention to the lymph nodes. Since it is so common for people, especially children, to have swollen lymph nodes, the doctor will look for infection first. If the doctor thinks that Hodgkin disease might be causing the symptoms, he or she will want to do a biopsy.

A biopsy involves removing a tissue sample and looking at it under a microscope. There are several different kinds of biopsies, and the doctor wi ll choose the one best suited for you or your child. The goal is to get enough tissue to be sure of the diagnosis.

Some biopsies involve cutting through the skin to remove an entire node or a small part of a la rge tumor. If the node is near the surface of the skin, the skin can simply be numbed and the sample taken. But if the node is deeper inside the body, the patient may need to be asleep first.

In a less common type of biopsy, the doctor uses a thin needle to remove a small amount of fluid and tiny bits of tissue from the tumor.

A doctor with special training in blood and lymph tissue disease looks at all biopsy samples under a microscope. Sometimes the first biopsy does not provide a definite answer and more biopsies are needed.

Staging

Staging is the process of finding out how far the cancer has spread. This is very important because the treatment and the outlook for recovery depend on the stage of the cancer.

If a biopsy has confirmed that Hodgkin disease is present, the next step is clinical staging . This consists of taking a medical history, doing a physical exam, and then doing imaging studies.

Imaging studies such as CT scans (computed tomography), MRI (magnetic resonance imaging), and PET (positron emission tomography) are different ways used to create pictures of the inside of the body. They can help show the size and shape of lumps or tumors that might be cancerous.
Blood Tests: Hodgkin disease cells do not appear in the blood, but a complete blood count can sometimes reveal signs of the disease.
A shortage of red blood cells (anemia) can be a sign of more advanced Hodgkin disease.
A high white blood cell count is another sign, although it can also be caused by infections.
Blood tests of liver function might also point to Hodgkin disease in that organ.
Tests of the bone marrow (a bone marrow biopsy) may be done to tell if Hodgkin disease is in the marrow.
To do the test, a long thin needle is used to remove small bits of bone marrow.
Or a piece of bone might be removed with a thicker needle.
The samples are usually taken at the same time from the back of the hip bone after numbing the area. But even with the numbing, many people feel some pain. but the whole process takes only a few minutes.
For most people, the results of the clinical staging are all that are needed to plan their treatment. Others, though, may need another step called pathological staging .

In this process, the doctor performs an operation called a laparotomy, checking inside the abdomen to see if any of the organs contain cancer.
Small pieces of tissue are removed and looked at under a microscope to see if Hodgkin disease is present.
The spleen is also usually removed at this time. But this surgery is not needed as much anymore because the imaging tests mentioned above are so good.
The stages of Hodgkin disease are usually labeled using Roman numerals I through IV (1-4). In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer. An "E" is added to the stage if the disease affects an organ outside the lymph system.

Stages are further divided into "A" or "B."

"A" means that certain symptoms are not present
"B" means that they are. These symptoms include weight loss, a high fever, or drenching night sweats.
Resistant disease is the term used when the disease does not go away or gets worse while a person is being treated.
Recurrent disease means that the Hodgkin disease has come back after it had been treated with good results.
Survival Rates of Hodgkin Disease

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. Many of these patients live longer than 5 years. Since these figures go back 5 years, results for people diagnosed recently can be even better because treatments are always improving.

5-year relative survival rate

I 90% to 95%
II 90% to 95%
III 80% to 85%
IV About 60% to 70%

These numbers are based on a large number of adults treated well before 1990. While statistics provide an overall picture, keep in mind that every person’s situation is unique and the numbers can’t predict exactly what will happen in your case.


Other Factors

Certain factors, if present, regardless of stage, tend to make the outlook (prognosis) poorer and often influence the doctor to make the treatment more intense. These are:

B stage versus A stage
a high white blood cell count (above 15,000)
a low red blood cell count (hemoglobin level below 10.5)
a low blood lymphocyte count (below 600)
being male
age over 45
low blood albumin level
How Is Hodgkin Disease Treated?

In recent years, much progress has been made in treating Hodgkin disease. Most people can be cured with chemotherapy and radiation therapy. Treatment is based on the stage and type of the disease, but a person’s age, overall health and other factors may be taken into account as well.

After Hodgkin disease is staged, the doctor will discuss treatment choices with you. It is important to take time and think about all the choices. Some factors to take into account include you (or your child's) overall health and the type and stage of the disease. Be sure that you understand all the risks and side effects before making a decision.
For nearly all people with Hodgkin disease, complete cure is the main goal. The two main methods of treating Hodgkin disease are chemotherapy and radiation therapy. Sometimes both treatments are used. High dose chemotherapy with blood-forming stem cell transplants, discussed later, is used for certain people. For the most part, surgery is usually not part of the treatment of Hodgkin disease.

Chemotherapy

Chemotherapy refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth (as pills). Once the drugs enter the bloodstream, they spread throughout the body. Several drugs are given at the same time to treat Hodgkin disease.

Although the drugs kill cancer cells, they also damage normal cells, which can lead to side effects. The exact side effects depend on the type and dose of drugs used and the length of time they are taken, but they can include:

hair loss
mouth sores
greater chance of infection
easy bruising or bleeding
fatigue
loss of appetite
nausea
vomiting.
These side effects are temporary and go away after treatment is finished.

If you or your child has side effects, your cancer care team can suggest steps to ease their impact. For example, other drugs can be given along with the chemotherapy to prevent or reduce nausea and vomiting.

In addition, some of these drugs can have side effects that occur long after treatment has ended. These can affect a person's heart, lungs, growth, and ability to have children. There is also an increased risk of developing a second type of cancer. It's important to discuss these possible side effects with the doctor before treatment begins. If the patient is old enough and is going to receive drugs that cause sterility, sperm banking should be discussed before treatment is started.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays to destroy cancer cells. When radiation therapy is given for Hodgkin disease, it usually involves a focused beam of radiation, given from a machine outside the body. This is known as external beam radiation. Radiation therapy is often given after 3 or 4 courses of chemotherapy.

Radiation therapy can produce some serious side effects including damage to nearby healthy tissue. Other problems can include skin changes similar to sunburn, tiredness, upset stomach, and diarrhea. There can be long-term side effects as well, such as an increased chance of getting another cancer later in life. To reduce the risk of side effects, doctors are careful to give the exact dose needed and to aim the beam so that it hits only the cancer.

As more patients have been able to live longer, doctors have seen more long-term problems from radiation. For this reason, they are slowly moving away from using radiation, or at least limiting the dose.

Blood or Bone Marrow Stem Cell Transplant

Sometimes Hodgkin disease does not respond completely to standard treatment or the disease comes back later. In these cases, the next step might be very high doses of chemotherapy followed by blood-forming stem cell transplant.

In one approach, blood-forming stem cells from the patient’s own blood (or, less often, bone marrow) are removed, frozen, and stored. Then very high doses of chemotherapy (with or without radiation therapy) are given in order to kill the cancer. These high doses will destroy bone marrow, too. When that happens, the body won’t be able to make new blood cells. Therefore, after the treatment, the stored stem cells are thawed and given back to the patient through a vein. The cells enter the bloodstream and return to the bone, replacing the marrow and making new red and white blood cells.

The short-term side effects from stem cell transplants are about the same as those from other forms of chemotherapy, although they may be more severe because of the higher doses used.

Resistant Hodgkin Disease

Treatment for Hodgkin disease should get rid of all traces of the cancer. If tests show that some disease remains, many experts think that more of the same treatment will not cure the disease. Sometimes, radiation to a single area of disease that remains after chemotherapy might work. Or using chemotherapy after radiation has failed might be an option. But if both have failed, you might want to consider a stem cell transplant.

Recurrent Hodgkin Disease

The treatment for Hodgkin disease that comes back depends on where the disease shows up and on the treatment that was used before. If the first treatment were just radiation therapy, then chemotherapy would usually be given. If chemotherapy were used first, and the cancer came back only in the lymph nodes, then radiation therapy, with or without more chemotherapy, could be given to the lymph nodes.

Although chemotherapy with different drugs can be used for people with recurrent disease, radiation usually cannot be given again in the same area. For example, if someone had Hodgkin disease in the chest that had been treated with radiation, more radiation could not be used if the disease came back. This holds true no matter how much time has gone by.

If the Hodgkin disease has returned within a few months of the first treatment, high-dose chemotherapy with stem cell transplantation might be an option. On the other hand, if the disease has returned after a long time, then giving different chemotherapy drugs might provide a cure. These are decisions that need to be made by you and your doctor.

Hodgkin Disease in Pregnancy: If a pregnant woman has Hodgkin disease, there are several options. In about half of cases, a woman can wait until the baby is born and then begin treatment. This is the approach that is safest for the baby.

If treatment needs to begin right away, one (or several) chemotherapy drugs may be given, depending upon the situation. Radiation is often not given, because of concerns about the long-term effects to the unborn baby. However, there have been a few studies of radiation as a treatment for pregnant women with Hodgkin disease. These studies suggest that as long as very careful precautions are taken to aim the radiation precisely and limit the doses used, pregnant women with Hodgkin disease affecting lymph nodes in the neck, underarm area, or inside the chest may be able to have this treatment with little or no risk of birth defects or childhood cancer.

Asbestos and The Lungs

Asbestos and The Lungs - What Happens When Asbestos Is In The Air We Breathe?
Asbestos fibers enter the body in the air we breathe. Most of the asbestos fibers we breathe - like other dust particles - are stopped long before they enter the small airways of the lungs. For example, when we enter a dusty room or sprinkle powder, we sometimes choke. We literally cough up the mucus that contains most of the irritating substances. However, because asbestos fibers are so small and thin, many of them pass all the way down to the small airways and alveoli (or air sacs.)
Once the fibers are inside the lungs, the body's defense mechanisms try to break them down and remove them. Despite these attempts, many fibers remain in the body and are potential disease-causing agents. Each fiber is a foreign body, rather like a splinter in a finger. Inflammations develop as the body tries to neutralize, break down or move the sharp, irritating fibers. These processes lead to the development of the various kinds of asbestos-caused diseases.
The body's defenses often coat these fibers with a layer of protein and they are then called "asbestos bodies." If a piece of lung tissue is stained with an iron stain these asbestos bodies become readily visible under a microscope. Finding enough of these asbestos bodies in lung tissue proves prior occupational exposure to asbestos, but it does not in itself prove that the person has an asbestos disease. (Also, not finding asbestos bodies does not prove that there was no prior exposure to asbestos.)
Click on A, B and C to see three microscopic slides of asbestos fibers lodged in the lungs.
Although all of the different kinds of asbestos fibers can be inhaled and become lodged in the lungs, some fibers (amphiboles, like amosite and crocidolite) seem to accumulate to a greater extent than others (such as chrysotile.) This might be because some chrysotile fibers, being long and curly, get stuck higher up in the lungs rather than transported all the way into the small airways. Or it might be because chrysotile fibers, being fragile and unstable, break up in the body within a few months and are transported away from the lungs into the pleura or lymph system.
Once fibers are inside the body, they can move around. How this happens is not fully understood. It might be because they are thin and sharp. The fibers can move from the lungs into the pleura and into the lymph nodes, and this means that they can move into other parts of the body.
Finally, asbestos can be swallowed (ingested) as well as inhaled. For example, when mucus and sputum that contain a lot of fibers are swallowed, some of those fibers can stick in the intestinal tract and from there they can move into the lining of the abdomen (peritoneum.)
However, when we are healthy, breathing is easy - so easy we don't even think about it.