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Lymphoma - Hodgkin - Childhood - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Childhood Hodgkin Lymphoma. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Hodgkin lymphoma, previously called Hodgkin’s disease, is one type of lymphoma. Lymphoma is a cancer of the lymphatic or lymph node system. Lymphoma begins when cells in the lymphatic system change and grow uncontrollably, which may form a tumor.

About the lymphatic system

The lymphatic system is made up of thin tubes that branch out to all parts of the body. Its job is to fight infection and other diseases. The lymphatic system carries lymph, a colorless fluid containing lymphocytes (white blood cells). Lymphocytes fight germs in the body. B-lymphocytes (also called B cells) make antibodies to fight bacteria, and T-lymphocytes (also called T cells) kill viruses and foreign cells and trigger the B cells to make antibodies.

Groups of bean-shaped organs called lymph nodes are located throughout the body at different areas in the lymphatic system. Lymph nodes are found in clusters in the neck, chest, underarms, abdomen, pelvis and groin. Other parts of the lymphatic system include the spleen, which makes lymphocytes and filters blood; the thymus, an organ under the breastbone; and the tonsils, which are located in the throat.

Hodgkin lymphoma most commonly affects lymph nodes in the neck or the area between the lungs and behind the breastbone (called the mediastinum). It can also begin in groups of lymph nodes under the arms, in the groin, or in the abdomen or pelvis.

If Hodgkin lymphoma spreads, it typically spreads along the lymphatic channels to other lymph nodes and the spleen, or outside of the lymphatic system, most commonly to the lungs, liver, bone marrow, or bone.

Types of Hodgkin lymphoma

It’s important to know the type of Hodgkin lymphoma, as this may affect the patient’s treatment plan. Doctors determine the type of Hodgkin lymphoma based on how the cells in a tissue sample look under a microscope and whether the cells contain abnormal patterns of certain proteins. There are two main types of Hodgkin lymphoma: nodular lymphocyte predominant and classical.

Nodular lymphocyte predominant Hodgkin lymphoma. This is more common among male and younger patients. The disease is usually found in the neck, underarm, or groin.

Classical Hodgkin lymphoma. There are four subtypes of classical Hodgkin lymphoma: nodular sclerosing, mixed cellularity, lymphocyte rich, and lymphocyte depleted.

  1. Nodular sclerosis Hodgkin lymphoma. This is the most common type of Hodgkin lymphoma in adolescents and young adults in the United States and in other developed countries. Tumors are often very bulky; they most often begin in the lymph nodes in the neck, chest, or abdomen and may spread to the lungs.
  2. Mixed cellularity Hodgkin lymphoma. This type is more common in children age 10 years or younger and shows the strongest link to the Epstein-Barr virus (the virus that causes mononucleosis). It usually begins in the lymph nodes in the abdomen or in the spleen.
  3. Lymphocyte rich Hodgkin lymphoma. This type is rare and may be hard to distinguish from nodular lymphocyte predominant Hodgkin lymphoma. It usually begins in the lymph nodes of the neck, underarm, and groin, and sometimes involves the spleen and nodes in the chest.
  4. Lymphocyte depleted Hodgkin lymphoma. This is a very rare, aggressive type that is uncommon in children. This type is usually more widespread, involving lymph nodes as well as the bones and bone marrow.

Age and Hodgkin lymphoma

There are three different forms of Hodgkin lymphoma:

  • A childhood form (in children 14 years or younger)
  • A young adult form (in people 15 to 34 years old)
  • An older adult form (in people 55 to 74 years old)

The childhood form of Hodgkin lymphoma is less common in the United States and is especially rare in children younger than five years. Hodgkin lymphoma is most commonly diagnosed in the young adult form and older adult form. In children younger than 5 years, Hodgkin lymphoma is more common in boys than in girls. Among adolescents, the rates of Hodgkin lymphoma are roughly equal among boys and girls.

This section covers Hodgkin lymphoma in children and adolescents. Learn more about adult Hodgkin lymphoma or non-Hodgkin lymphoma in children.

Looking for More of an Overview?

If you would like additional introductory information, explore this related item. Please note that this link takes you to another section on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a one-page fact sheet (available in PDF) that offers an easy-to-print introduction this type of cancer.

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Lymphoma - Hodgkin - Childhood - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find information about how many children learn they have this type of lymphoma each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

Hodgkin lymphoma accounts for about 4% of all cancers diagnosed in children under age 15 in the United States and 15% of all cancers diagnosed in adolescents between the ages of 15 and 19. It is the eighth most common type of cancer diagnosed in children and the most common cancer diagnosed in adolescents. This year an estimated 380 children and 800 adolescents in the United States will be diagnosed with Hodgkin lymphoma.

The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. The five-year survival rate of children with Hodgkin lymphoma is approximately 97%.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with childhood Hodgkin lymphoma. Because the survival statistics are measured in five-year intervals, they may not represent recent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts and Figures 2014.

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Lymphoma - Hodgkin - Childhood - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find out more about what factors increase the chance of this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some children with several risk factors never develop cancer, while others with no known risk factors do.

The cause of Hodgkin lymphoma is unknown, although infection with the Epstein-Barr virus may play a role in the development of the cancer in approximately 30% of children and teens. People with immune system problems also have a higher risk of developing Hodgkin lymphoma. This group includes:

  • Children born with the hereditary condition of ataxia telangiectasia, which causes immune system problems
  • Children with human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS)
  • Children who are taking drugs that suppress the immune system following an organ transplant

To continue reading this guide, use the menu on the side of your screen to select another section.  

Lymphoma - Hodgkin - Childhood - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

Children with Hodgkin lymphoma may experience the following symptoms or signs. Sometimes, children with Hodgkin lymphoma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your child’s doctor.

  • Painless swelling of lymph nodes in the neck, underarm, or groin that doesn’t go away in a few weeks
  • Coughing or problems breathing, which may mean that the lymph nodes in the chest are swollen and pressing on the windpipe
  • Unexplained fever (without other signs of infection) that doesn’t go away
  • Unexplained weight loss
  • Night sweats (usually drenching)
  • Itching
  • Fatigue

Your child’s doctor will ask you questions about the symptoms your child is experiencing to help find out the cause of the problem, called a diagnosis. This may include how long your child has been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your child’s health care team about symptoms your child experiences, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it has spread. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. Imaging tests may be used to find out whether the cancer has spread. This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your child’s doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

The following tests may be used to diagnose Hodgkin lymphoma:

Physical examination/blood tests. Children tend to have larger lymph nodes than adults. Usually, a child has enlarged lymph nodes for several weeks or months before a doctor suspects Hodgkin lymphoma, which is uncommon in children. The doctor first looks for signs of a more common infection that may cause the lymph nodes to swell and may prescribe antibiotics.

If swelling in the lymph nodes does not go down after a course of antibiotics, the swelling may be caused by something other than an infection. In these instances, the doctor does a physical examination of all the lymph node areas, the liver, and the spleen, which may be enlarged in children with Hodgkin lymphoma.

Blood tests may also be done to check blood counts and evaluate how the liver and kidneys are working. There is no specific blood test for Hodgkin lymphoma, but changes in blood counts (such as unexplained anemia or a low number of red blood cells) are sometimes more common in children with Hodgkin lymphoma.

Biopsy. If the lymph nodes don’t feel normal when the doctor examines them and don’t respond to antibiotics, the doctor will check tissue from the abnormal lymph node for cancer cells. Hodgkin lymphoma makes a distinctive kind of abnormal cell, called a Reed-Sternberg cell, that is easily identified under the microscope. The only way to diagnose Hodgkin lymphoma is to look at the tissue from an abnormal lymph node under the microscope, which is done by a pathologist, which is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. The process of removing the tissue is called a biopsy.

To perform a standard biopsy for Hodgkin lymphoma, a surgeon cuts through the skin and removes an entire lymph node or a piece of a mass of lymph nodes. In children, a lymph node biopsy is usually performed with general anesthesia or conscious sedation, in which the child is awake but the pain and discomfort are lessened with medication.  

Sometimes, a doctor may first try to obtain tissue from the lymph node by doing a fine needle aspiration biopsy. In this test, a thin needle is used to remove small amounts of fluid and tissue from the lymph node. This type of biopsy may not provide enough tissue to diagnose the disease, so it is recommended only when a standard, surgical biopsy may be too difficult or dangerous.

If a biopsy confirms the diagnosis of Hodgkin lymphoma, several tests and scans can help the doctor learn more about the disease, show how far the disease has spread (a process called staging), and indicate how well treatment is working. These scans and tests may include:

X-ray. An x-ray is a way to create a picture of the structures inside of the body using a small amount of radiation. For instance, a chest x-ray will show whether lymph nodes in the mediastinum are enlarged. A mediastinal tumor that takes up one-third or more of the chest cavity is considered "bulky." It may cause coughing or breathing problems by narrowing the airway.

Computed tomography (CT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein or given orally (by mouth) to provide better detail. The CT scan shows if lymph nodes in the chest or abdomen are enlarged, which may be a sign of cancer. Also, this test will show if other organs—such as the lungs, liver, or spleen—are involved.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

PET scans are often used to add to the information gathered from a CT scan and physical examination. This test can also be used to evaluate how well treatment is working. Before treatment, areas of active Hodgkin lymphoma appear bright on the scan in most people. During and after treatment, these bright areas usually go away as the cancer cells are dying. This test can reassure families and doctors—without doing a biopsy—that scar tissue still present on a CT scan after treatment does not contain active cancer cells.

Bone marrow biopsy. Hodgkin lymphoma rarely spreads to the bone marrow in children with localized Hodgkin lymphoma located only in the lymphatic system. A bone marrow biopsy is recommended for children with signs of more widespread disease involving lymph glands above and below the diaphragm. It is also recommended for children with other signs of Hodgkin lymphoma that has spread outside the lymph node system to the lungs, liver, or bones, who are more likely to have lymphoma in the bone marrow.

For a bone marrow biopsy, the child’s skin is numbed with a local anesthetic, or—more commonly—conscious sedation is given while a needle is inserted into the bone in the hip until it reaches the spongy part of the bone at the center, the bone marrow. A small amount of marrow is removed and examined under a microscope.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium (a special dye) may be injected into a patient’s vein or given orally (by mouth) to create a clearer picture. This test may be used instead of or in addition to a CT scan at diagnosis or during follow-up care to check for lymphoma in the abdomen, bones, or lymph nodes in the chest. 

After these diagnostic tests are done, your child’s doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section helps explain the different stages for this type of cancer. Use the menu on the side of your screen to select Stages, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Stages and Groups

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. In addition, you will find information on the grouping of the disease. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

After the diagnostic tests (described in the Diagnosis section) are completed, the doctor will assign a stage, which is needed to plan treatment. The four stages of Hodgkin lymphoma (I to IV; one to four) are described below.

In addition, each person’s disease is put into one of two categories, A or B, based on whether the person has symptoms of unexplained fever, drenching night sweats, or weight loss in the six months before diagnosis. A means the patient does not have these symptoms, while B means that the patient has at least one of these symptoms.

Stage I: Cancer is in only one area of the lymph nodes or in one area or organ outside of the lymph nodes.

Stage II: Cancer is in two or more lymph node areas on the same side of the diaphragm, or cancer is in one lymph node area and in one area or organ next to the lymph nodes.

Stage III: Cancer is in lymph node areas above and below the diaphragm. The cancer may have spread to an area or organ near these lymph nodes and, possibly, to the spleen.

Stage IV: Cancer has spread outside of the lymph node system to the lungs, liver, bones, bone marrow, or other organs.

Recurrent: Recurrent cancer is cancer that has come back after treatment. If there is a recurrence, the cancer may need to be staged again (re-staging) using the system above.

Risk grouping

A treatment regimen (schedule) may be selected based on the disease’s classification as low, intermediate, or high risk. This classification is based on several factors, including the cancer’s stage, whether the tumor is bulky, and whether the patient is experiencing specific symptoms (defined as A or B; see above).

  • Children with low risk Hodgkin lymphoma usually have stage IA or stage IIA disease without bulky tumors.
  • In high risk Hodgkin lymphoma, the cancer is in a later stage or is causing B symptoms like fever, drenching night sweats or weight loss. This could include stages IIIB and IVB.
  • Other patients are usually considered intermediate risk.

Source: The Ann Arbor staging system, as outlined by and used with permission from the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010), published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a treatment plan.  The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will learn about the different ways doctors use to treat children with this type of cancer. To see other pages, use the menu on the side of your screen.

In general, cancer in children is uncommon, so it can be hard for doctors to plan treatments unless they know what has been most effective in other children. That’s why more than 60% of children with cancer are treated as part of a clinical trial. Clinical trials are research studies that compare the standard treatments (the best proven treatments available) with newer treatments that may be more effective. Studying new treatments involves careful monitoring using scientific methods, and all participants are followed closely to track their health and progress.

To take advantage of these newer treatments, all children with cancer should be treated at a specialized cancer center. Doctors at these centers have extensive experience in treating children with cancer and have access to the latest research. A doctor who specializes in treating children with cancer is called a pediatric oncologist. In many cases, a team of doctors works with a child and the family to provide care; this is called a multidisciplinary team.

Pediatric cancer centers often have extra support services for children and their families, such as child life specialists, nutritionists, physical and occupational therapists, social workers, and counselors. Special activities and programs to help your child and family cope may also be available. An increasing number of pediatric cancer centers also have services for teenagers and young adults. Sometimes, adult cancer centers also offer special services and clinical trials for teens and young adults with cancer.

Treatment overview

Treatment of Hodgkin lymphoma consists of chemotherapy and/or radiation therapy. Surgery is not commonly used as a treatment, although it may sometimes be used for localized nodular lymphocyte predominant Hodgkin lymphoma when the doctor believes it can be completely removed by surgery.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, its risk grouping, possible side effects, and the patient’s preferences and overall health. The amount and type of treatment used to treat Hodgkin lymphoma also depends on how many lymph node areas are involved and how large the lymph nodes have grown. Children with more widespread (advanced) or "bulky" disease may have more cycles of chemotherapy and radiation therapy than children with early-stage disease. Ongoing studies of childhood Hodgkin lymphoma are trying to further reduce the amount of treatment to avoid long-term side effects. Some treatments can affect reproductive function (the ability to have a child). It is important to talk with your child’s doctor about ways to preserve fertility before treatment begins. 

Descriptions of the most common treatment options for childhood Hodgkin lymphoma are listed below. Take time to learn about your child’s treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your child’s doctor and what your child can expect while receiving the treatment. Learn more about making treatment decisions.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy for childhood Hodgkin lymphoma is given by a pediatric oncologist. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

For children and adolescents, chemotherapy is almost always used. In the past, treatments for Hodgkin lymphoma were one of two combinations of chemotherapy, one called MOPP and another called ABVD. MOPP includes the drugs mechlorethamine (Mustargen), vincristine (Vincasar), prednisone (multiple brand names), and procarbazine (Matulane). ABVD includes the drugs doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban), and dacarbazine (DTIC-Dome). The MOPP combination is no longer the standard of care for children, but ABVD may be used for some patients.  Many of the individual drugs in MOPP may be used in combination with other drugs that have fewer long-term side effects.

Newer treatment combinations for children may replace mechlorethamine with cyclophosphamide (Neosar) and often replace procarbazine with etoposide (VePesid, Toposar) to reduce the risk of infertility (the inability to conceive a child or maintain a pregnancy). More recently, treatment plans for later-stage disease have been designed to improve effectiveness by using more intensive combinations of drugs, called dose-dense, over shorter periods of time (therapies with combinations of drugs called ABVE-PC, Stanford V, and BEACOPP).

Doctors may recommend treatment with chemotherapy alone or a combination of chemotherapy and radiation therapy (see below) for a child with Hodgkin lymphoma. For later-stage disease, current clinical trials often include radiation therapy. For earlier-stage lymphoma, many research studies do not include radiation therapy for children whose disease is treated successfully with chemotherapy. Current chemotherapy regimens evaluate the lymphoma’s response to treatment early in the treatment schedule. A child with lymphoma that responds more quickly to treatment may need less treatment than children with lymphoma that responds to treatment more slowly.

For children with bulky or advanced disease, many doctors feel that combination treatment gives the best chance for cure because there are two ways to attack the cancer cells. In combination treatment, doctors reduce the total amount of chemotherapy and radiation therapy, which should reduce long-term side effects. The most important consideration is to use enough treatment to cure the disease with the first treatment plan. This is because the intensity of therapy is high if the disease comes back.

Because chemotherapy attacks rapidly dividing cells, including those in normal tissues such as the hair, lining of the mouth, intestines, and bone marrow, children receiving chemotherapy may lose their hair, develop mouth sores, or have nausea and vomiting. In addition, chemotherapy may lower the body’s resistance to infection, lead to increased bruising and bleeding, and cause fatigue. These side effects usually can be controlled during treatment and go away after chemotherapy is completed. The severity of the side effects depends on the type and amount of the drug being given and the length of time the child receives the drug. Learn more about long-term side effects of chemotherapy in After Treatment.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your child’s doctor is often the best way to learn about the medications prescribed for him or her, their purpose, and their potential side effects or interactions with other medications. Learn more about your child’s prescriptions by using searchable drug databases.

Radiation therapy

Radiation therapy is the use of x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

In the past, treatments for Hodgkin lymphoma used high doses of radiation therapy to all of the lymph node areas. Children treated this way had problems with muscle and bone growth and had a higher risk of second cancers as they got older. Today, treatment with radiation therapy alone is never used for children. Much more commonly, doctors combine chemotherapy (see above) with low-dose radiation therapy given to areas where the lymph nodes contain cancer cells. This approach reduces the amount of radiation therapy to the body compared with previous regimens.

The need for radiation therapy is determined by the stage of disease and how well the disease responds to chemotherapy. Clinical trials are currently in progress to identify patients whose disease can be treated successfully using chemotherapy alone (see Latest Research). However, radiation therapy is a very effective treatment for Hodgkin lymphoma and plays a major role in curing the disease.

In general, short-term side effects from radiation therapy include tiredness, sore throat, dry mouth, mild skin reactions, upset stomach, and loose bowel movements. Long-term side effects of radiation therapy may include growth problems of bones and soft tissues; dental, thyroid, heart, and lung problems; and second cancers. In particular, girls treated for Hodgkin lymphoma with radiation to the mediastinum (chest area) are at increased risk of breast cancer. Learn more about radiation therapy.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a child at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. Your child may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your child’s doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your child’s health care team about the possible side effects of your child’s specific treatment plan and supportive care options. And during and after treatment, be sure to tell your child’s doctor or another health care team member if your child is experiencing a problem so it can be addressed as quickly as possible. Learn more about palliative care.   

Recurrent Hodgkin lymphoma

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors and families feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your child’s doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence

If the cancer does return after the original treatment, it is called recurrent cancer. The disease can come back in the same area in which it began or in a new area of the body.

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage and grouping has changed. After testing is done, you and your child’s doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as chemotherapy and radiation therapy) but they may be used in a different combination or given at a different pace. Your child’s doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

Treatment for recurrent Hodgkin lymphoma depends on where the disease recurs, the type of treatment the child has had previously, and the time since the first treatment was completed. For example, if chemotherapy was given initially, then the child may be given another round of chemotherapy using different drugs. If the disease has come back very soon after the first treatment or after the use of chemotherapy and radiation therapy, more aggressive therapy, including bone marrow/stem cell transplantation (see below), may be recommended to increase the chances of keeping the disease in remission. A combination like Ifosfamide (Cyfos, Ifex, Ifosfamidum) and vinorelbine (Navelbine) is typically used to shrink sites of recurrent disease before stem cell transplantation/bone marrow transplantation. Another combination that has been shown to have activity in recurrent Hodgkin lymphoma is gemcitabine (Gemzar) and vinorelbine. These are examples of possible drug combinations but other treatment plans are also effective in treating this disease. Such combination names include ICE, MIED, DHAP, ESHPA, APE, and DECAL. It is important to talk with your child’s doctor about which treatment plan is best.  

When cancer recurs, patients and their families often experience emotions such as disbelief or fear. Families are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

Stem cell transplantation/bone marrow transplant

Often when high doses of chemotherapy or radiation therapy are used to treat recurrent Hodgkin lymphoma, the bone marrow becomes damaged and can’t produce healthy blood cells. To replace those lost cells, a stem cell transplant may be recommended.

A stem cell transplant is a medical procedure in which bone marrow that contains cancer is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and the patient’s age and general health.

There are two types of stem cell transplantation, depending on the source of the blood stem cells: allogeneic (ALLO) and autologous (AUTO). An AUTO transplant is most commonly used for Hodgkin lymphoma. An ALLO transplant is not used as frequently for patients with recurrent Hodgkin lymphoma because of the greater risks of serious side effects.

In both types, the goal of transplantation is to destroy cancer cells in the marrow, blood, and other parts of the body and have replacement blood stem cells to create healthy bone marrow. In most stem cell transplants, the patient is treated with high doses of chemotherapy and/or radiation therapy to destroy as many cancer cells as possible.

Learn more about bone marrow and stem cell transplantation.

If treatment fails

Although treatment is successful for the majority of children with Hodgkin lymphoma, sometimes it is not. If a child’s cancer cannot be cured or controlled, this is called advanced or terminal cancer. This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your child’s doctor and health care team to express your family’s feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families.

Parents or guardians are encouraged to think about where the child would be most comfortable: at home, in a home-like setting elsewhere, in the hospital, or in a hospice environment. Hospice care is a type of palliative care for people who are expected to live less than six months. It is designed to provide the best possible quality of life for people who are near the end of life. Nursing care and special equipment can make staying at home a workable alternative for many families. Some children may be happier if they can arrange to attend school part-time or keep up other activities and social connections. The child’s health care team can help parents or guardians decide on an appropriate level of activity. Making sure a child is physically comfortable and free from pain is extremely important as part of end-of-life care. Learn more about caring for a terminally ill child and advanced cancer care planning.

The death of a child is an enormous tragedy, and families may need support to help them cope with the loss. Pediatric cancer centers often have professional staff and support groups to help with the process of grieving. Learn more on grieving the loss of a child.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat children with Hodgkin lymphoma. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Children who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your child’s doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating Hodgkin lymphoma. Even if they do not benefit directly from the clinical trial, their participation may benefit future children with Hodgkin lymphoma.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare in general, and placebos are never used in clinical trials for treating children with cancer. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, parents and children must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

For specific topics being studied for childhood Hodgkin lymphoma, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about Hodgkin lymphoma, ways to prevent it, how to best treat it, and how to provide the best care to children diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your child’s doctor about the diagnostic and treatment options best for your child.

New drugs. To reduce side effects and improve the effectiveness of treatment, it is important for researchers to find new drugs, as well as new combinations of current drugs.

ALLO stem cell transplantation. As explained in the Treatment Options section, stem cell transplantation is sometimes used to treat Hodgkin lymphoma. Doctors are researching increasing the use of stem cell transplantation, including using donor blood stem cells to replace the patient’s bone marrow (called allogeneic or ALLO transplantation).

Personalized treatments. Overall, the major goal of Hodgkin lymphoma research is to improve treatment effectiveness while reducing long-term side effects. Early response of the disease to a specific treatment is being studied as a method to tailor therapy to the individual. Shorter, more intensive regimens may improve effectiveness. It is important that researchers learn which patients need radiation therapy and which patients may be cured without the long-term side effects of radiation exposure.

Targeted therapy. Targeted therapy is a treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. Recent studies are evaluating antibodies—such as brentuximab vedotin (SGN-35)—directed against proteins on the Hodgkin lymphoma cells. Learn more about targeted treatments.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current Hodgkin lymphoma treatments in order to improve patients’ comfort and quality of life.

Looking for More about Latest Research?

If you would like additional information about the latest areas of research regarding childhood Hodgkin lymphoma, explore these related items that take you outside of this guide:

  • To find clinical trials specific to your diagnosis, talk with your child’s doctor or search online clinical trial databases now.

  • Visit ASCO’s CancerProgress.Net website to learn more about the historical pace of research for childhood cancer, including lymphoma. Please note this link takes you to a separate ASCO website. 

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your child’s health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for Hodgkin lymphoma are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your child’s overall health.

Before treatment begins, talk with your child’s doctor about possible side effects of each type of treatment your child will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving your child may need during treatment and recovery, as family members and friends often play an important role in the care of a child with Hodgkin lymphoma. Learn more about caregiving.

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. Learn more about the importance of addressing such needs, including concerns about managing the cost of your child's cancer care

During and after treatment, be sure to tell the health care team about the side effects your child experiences, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your child’s doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will read about your child’s medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After treatment for Hodgkin lymphoma ends, talk with your child’s doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your child’s recovery for the coming months and years. All children treated for cancer, including Hodgkin lymphoma, should have life-long, follow-up care.

People with Hodgkin lymphoma are most often adolescents or young adults. While the treatment period is limited and the outcome is often excellent, there are several possible long-term side effects. The long-term side effects of chemotherapy also depend on the type and total dose of each drug. These include:

  • heart problems (after doxorubicin or radiation therapy),
  • lung problems (after bleomycin or radiation therapy),
  • thyroid problems (after radiation therapy),
  • secondary cancers (after radiation therapy or chemotherapy),
  • reproductive effects (after procarbazine, mechlorethamine, or pelvic radiation).

In addition, children who had a splenectomy (surgical removal of the spleen) have an ongoing chance of serious infection. Rarely, children with Hodgkin lymphoma develop a second cancer, acute myeloid leukemia, because of chemotherapy’s effects on bone marrow function. Fortunately, the risk of long-term side effects is much lower with newer treatment plans that limit the doses of drugs that cause serious health problems.

For most Hodgkin lymphoma survivors, the medical side effects of treatment do not significantly affect life span. However, Hodgkin lymphoma survivors report significant concerns regarding their health status compared with other survivors of childhood cancer. This may result from the social and emotional effects of treatment during adolescence, when the adolescent may feel different from healthy peers. In addition, some Hodgkin lymphoma survivors experience long-term fatigue that may require lifestyle changes, such as taking a reduced course load at college or choosing employment that is consistent with the individual’s energy level. Learn more about specific coping strategies for this age group.

Infertility may also affect the young adult who is hoping to someday become pregnant or father a child. Newer reproductive technologies may help some of these individuals; current treatment plans also attempt to reduce exposure to alkylating agents to limit such risks (see Frequently Asked Questions Regarding Hodgkin Lymphoma). Learn more about sexual and reproductive health after cancer.

Based on the type of treatment your child received, the doctor will determine what examinations and screening tests are needed to check for long-term side effects and the possibility of secondary cancers. Follow-up care should also address your child’s quality of life, including any developmental or emotional concerns. Learn more about childhood cancer survivorship.

The child’s family is encouraged to organize and keep a record of the child’s medical information. That way, as your child enters adulthood, he or she has a clear, written history of the diagnosis, the treatment given, and the doctor’s recommendations about the schedule for follow-up care. The doctor’s office can help you create this. This information will be valuable to doctors who care for your child during his or her lifetime. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment your child received and develop a survivorship care plan once treatment is completed.

Children and teens who have had cancer can also enhance the quality of their future by following established guidelines for good health into and through adulthood, including not smoking, maintaining a healthy weight, eating a balanced diet, and participating in regular physical activity. Talk with the doctor about developing a plan that is best for your child’s needs.  Learn more about the next steps to take in survivorship.

Ongoing follow-up care by health care professionals experienced in long-term side effects is important. Preventive health care, including breast cancer screening (after mediastinal radiation therapy), not smoking (after bleomycin or radiation therapy due to enhanced lung cancer risk), and reducing the risk for heart disease through exercise, diet, and medication are important steps for Hodgkin lymphoma survivors. Such preventative measures may foster better, long-term outcomes and offer the person some control of his or her own health.

The next section offers a list of frequently asked questions regarding Hodgkin lymphoma in children and teens. Use the menu on the side of your screen to select Frequently Asked Questions, or you can select another section, to continue reading this guide. 

Lymphoma - Hodgkin - Childhood - Frequently Asked Questions

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find answers to commonly asked questions. Be sure to ask your child’s health care team any questions that you might have. To see other pages, use the menu on the side of your screen.

Is my child/adolescent being treated with a treatment plan (regimen) designed for this age group rather than for adults?

Pediatric treatment regimens are designed to reduce the long-term side effects of treatment. Specifically, current regimens for children do not use doxorubicin for more than four cycles (4 months) or radiation therapy doses higher than 25.5 Gy unless the disease has recurred. Gy is a measurement of how much radiation the child receives. In most instances, less radiation is used. Ideally, the health care of adolescents and children with Hodgkin lymphoma should be managed by a pediatric oncologist to make sure that the treatment given will reduce the chance of long-term side effects as much as possible.

What are the immediate and long-term side effects of the treatment planned? Are there other regimens that might be as effective with different risks?

Unfortunately, all regimens have potential side effects. For some patients or families, one set of risks is more tolerable than others. Many new clinical trials give the drugs at a faster rate, since this may be more effective. There could be more side effects early on, but the child may need less therapy in total, which reduces the long-term effects. Be sure to talk with your child’s doctor to understand the balance between early side effects and long-term effects. For example, high-dose radiation therapy (without chemotherapy) is often easier and faster than chemotherapy, but the long-term side effects for young people are significant. That’s why this approach is not recommended for most children or adolescents.

Under what circumstances should sperm banking be considered?

 Boys who will receive alkylating agents should try to bank sperm before treatment begins, since these drugs can cause sterility. Alkylating agents most commonly used in Hodgkin lymphoma are cyclophosphamide, mechlorethamine, procarbazine, and ifosfamide. Your child’s doctor can advise you whether the planned dose is likely to cause significant risk.  For boys who are too young to bank sperm, it is preferred to use a regimen that does not include procarbazine or mechlorethamine when possible. Learn more about sexual and reproductive health.

If a girl receives pelvic radiation therapy, can fertility be preserved?

The ovaries can be moved out of the radiation field to try to preserve fertility. Fertility preservation options are available for older adolescents and young adult women. Researchers are also studying fertility preservation through freezing ovarian tissue or ovum prior to treatment in younger girls. Learn more about sexual and reproductive health.

What is recommended for the long-term care of my child?

At the end of treatment, it is important to talk with your child’s doctor about which screening tests should be performed in the months, years, and decades that will follow. As the child matures, this information should be passed to them, so they will understand any health risks. The details about the drugs and radiation treatment given should be written down with a recommendation for life-long follow-up care. Learn more about keeping a personal medical record.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your child’s diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your child’s health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your child’s next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your child’s care.

  • What type of lymphoma has been diagnosed?
  • What subtype of Hodgkin lymphoma does my child have?
  • What is the stage of the disease? What is the risk grouping?
  • Can you explain my child’s pathology report (laboratory test results) to me?
  • What are my child’s treatment options?
  • What clinical trials are open to my child?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the cancer, help my child feel better, or both?
  • Who will be part of my child’s health care team, and what does each member do?
  • Who will be coordinating my child’s overall treatment and follow-up care?
  • What are the possible side effects of this treatment plan, both in the short term and the long term?
  • Could this treatment affect my child’s ability to have a child (fertility) in the future? If so, what fertility preservation options are available?
  • How will this treatment affect my child’s daily life? Will he or she be able to attend school or perform his or her usual activities?
  • If I’m worried about managing the costs related to my child’s cancer care, who can help me with these concerns?
  • What follow-up tests will my child need, and how often will he or she need them?
  • What support services are available to my child? To my family?
  • Whom should I call for questions or problems?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.  

Lymphoma - Hodgkin - Childhood - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2013

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Childhood Hodgkin Lymphoma. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

This is the end of Cancer.Net’s Guide to Childhood Hodgkin Lymphoma. Use the menu on the side of your screen to select another section, to continue reading this guide.