Lymphoma - Hodgkin - ChildhoodLast Updated: October 26, 2011 This section has been reviewed and approved by the Cancer.Net Editorial Board, 09/11 Overview
Hodgkin lymphoma, also 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 lymph system change and grow uncontrollably, which may form a tumor. About the lymph 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 disease. 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 lymph system. Lymph nodes are found in clusters in the abdomen, groin, pelvis, underarms, and neck. 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 may spread along the lymphatic channels to other lymph nodes, the spleen, lungs, liver, bone marrow, or bone. It can spread elsewhere, but it is unusual. Types of Hodgkin lymphoma It is important to know the type of Hodgkin lymphoma, as this may affect the choice of treatment. 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, classical and nodular lymphocyte predominant. There are four subtypes of classical Hodgkin lymphoma: nodular sclerosing, mixed cellularity, lymphocyte rich, and lymphocyte depleted. Nodular sclerosis Hodgkin lymphoma (NSHL). 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 begin in the lymph nodes in the neck, chest, or abdomen and may spread to the lungs. Mixed cellularity Hodgkin lymphoma (MCHL). 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. Lymphocyte predominant Hodgkin lymphoma (LPHL). In this type, cells under the microscope resemble normal lymphocytes. It usually begins in the lymph nodes of the underarm, neck, groin, and sometimes the chest. Lymphocyte depleted Hodgkin lymphoma (LDHL). This is a very rare, aggressive type . It appears in the lymph nodes of the abdomen or pelvis, usually skipping the lymph nodes in the neck or underarms. LDHL is very uncommon in children. Age and Hodgkin lymphoma There are three different forms of Hodgkin lymphoma:
Hodgkin lymphoma is rare in children younger than five years old in the United States. It most often occurs in people between 15 and 40 years old and in people older than 55. In children younger than 5 years, Hodgkin lymphoma is more common in boys than in girls. This section covers Hodgkin lymphoma in children and adolescents. Learn more about adult Hodgkin lymphoma or non-Hodgkin lymphoma in children. Find out more about basic cancer terms used in this section. Looking for More of an Overview? If you would like additional introductory information, explore these related items on Cancer.Net:
Or, choose “Next” (below, right) to continue reading this detailed section. To select a specific topic within this section, use the icon panel located on the right side of your screen. Statistics
Hodgkin lymphoma accounts for about 4% of all cancers in children from birth to age 14 in the United States. It is the most common cancer in people ages 15 to 19. The five-year survival rate (the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases) of children with Hodgkin lymphoma is 95%. 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 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 2011. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people 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 trigger 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:
Symptoms and Signs
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.
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. Diagnosis
Doctors use many tests to diagnose cancer and find out if it has metastasized (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 metastasized. Your doctor may consider these factors when choosing a diagnostic test:
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. 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 your body using a small amount of radiation. For instance, a chest x-ray will show whether lymph nodes in the mediastinum (chest cavity) are enlarged. Mediastinal masses that take up one-third or more of the chest cavity are considered "bulky." They may cause coughing or breathing problems by narrowing the airway. Computed tomography (CT or CAT) 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 contrast medium (a special dye) is injected into a vein 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 the 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 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. Learn more about what to expect when having common tests, procedures, and scans. 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. Learn more about the first steps to take after a diagnosis of cancer. Staging
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and whether it is affecting the functions of other organs in 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 comes 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).
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. Treatment
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. Investigating 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 treats a child with cancer; 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, 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 lymphocyte predominant Hodgkin lymphoma (LPHL) 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. New studies of childhood Hodgkin lymphoma are trying to further reduce the amount of treatment to avoid long-term side effects. Descriptions of the most common treatment options for childhood Hodgkin lymphoma are listed below. 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 ABVD and another called MOPP. ABVD includes the drugs doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban, Velsar), and dacarbazine (DTIC-Dome). MOPP includes the drugs mechlorethamine (Mustargen), vincristine (Vincasar), prednisone (multiple brand names), and procarbazine (Matulane). These combinations are no longer the standard of care for children because other drugs with fewer long-term side effects are now available. Newer treatments for children use many of these drugs but replace mechlorethamine with cyclophosphamide (Cytoxan, Clafen, Neosar) and often replace procarbazine with etoposide (VePesid, Toposar) to reduce the risk of infertility (the inability to have children). More recently, treatment plans for later-stage disease have been designed to improve effectiveness by using more intensive combinations of drugs (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 for a child with Hodgkin lymphoma. For later-stage disease, current clinical trials often include radiation therapy (see below). For earlier-stage lymphoma, many research studies do not include radiation therapy for children who have an early or complete response to 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 a lymphoma that responds to treatment more slowly. For children with bulky or advanced disease, many doctors feel that a 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 recurs. 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. The long-term side effects of chemotherapy also depend on the type and total dose of each drug. Chemotherapy can affect heart and lung function and cause infertility in the future. 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. Pediatric clinical trials at most treatment centers use much smaller amounts of the drug that may affect the heart (such as doxorubicin [Adriamycin, Doxil]), lungs (such as bleomycin [Blenoxane]), and testicular or ovarian function (such as cyclophosphamide [Cytoxan, Clafen, Neosar] and procarbazine [Matulane]) than the amounts used for adults (particularly for advanced stage disease). Girls usually maintain ovarian function with the doses of alkylating agents (such as cyclophosphamide or procarbazine) used to treat Hodgkin lymphoma, but they are at risk for ovarian failure and early menopause if alkylating chemotherapy is combined with radiation to the abdomen or pelvis. Fertility preservation options are available for older adolescents and young adult women, but these procedures are being studied in younger girls. Learn more about late effects of childhood cancer. 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. Treatments for Hodgkin lymphoma in the past used high doses of radiation therapy to all of the lymph node areas. Children treated this way had problems with the growth of muscles and bones and had a higher risk of second cancers as they got older. Today, treatment with radiation therapy alone is rarely 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. This approach for children uses lower doses and reduces the amount of the body that receives radiation, compared with traditional regimens. The need for radiation therapy is determined by the stage of disease and how the disease responded to chemotherapy. Clinical trials are currently in progress to identify the patients who can be cured using treatment with chemotherapy alone (see Current Research). 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 chest are at increased risk of breast cancer. Since early heart disease, another significant, long-term risk of radiation therapy, affects boys as well, the current approach is to limit radiation therapy for both boys and girls, if possible. However, radiation therapy is a very effective treatment for Hodgkin lymphoma and plays a major role in curing the disease. The risk of long-term side effects is expected to be lower with newer radiation therapy techniques that give low doses only to lymph nodes involved by lymphoma. Learn more about radiation therapy. Recurrent Hodgkin lymphoma Once your treatment is complete and there is a remission (absence of cancer symptoms; also called “no evidence of disease” or NED), talk with your child’s doctor about the possibility of the cancer returning. Many survivors feel worried or anxious that the cancer will come back. Learn more about coping with this fear. 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. 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 may be used in a different combination or given at a different pace. Your 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. Ifosfamide (Cyfos, Ifex, Ifosfamidum) and vinorelbine (Navelbine) have recently been shown to be an effective treatment for recurrent disease in children and adolescents and are now the standard drugs recommended before stem cell transplantation/bone marrow transplantation (see below) in the Children’s Oncology Group studies. The combination of gemcitabine (Gemzar) with vinorelbine also has recently been shown to be quite effective in children and adolescents. If the disease has come back very soon after the first treatment or after the use of both chemotherapy and radiation therapy, more aggressive therapy, including a stem cell transplantation, may be recommended to increase the chances of keeping the disease in remission. 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 diseased bone marrow is replaced by highly specialized cells, called hematopoietic stem cells. 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 blood stem cells 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. ALLO transplants are not used as frequently for patients with recurrent Hodgkin lymphoma because of the greater risks of serious side effects. In an AUTO transplant, the patient’s own stem cells are used as the replacement. The stem cells are obtained from the patient when he or she is in remission from previous treatment. The stem cells are then frozen until the high-dose treatment for the transplant is completed. In an ALLO transplant, stem cells are obtained from a donor whose tissue matches the patient’s on a genetic level, called HLA-typing. Most often, a patient’s brother or sister serves as the donor, although unrelated donors can serve as the donor too. Millions of people worldwide have volunteered to donate stem cells for patients who do not have matched family members; your health care team will search a computer registry to look for a match. In addition, a donation of stem cells derived from umbilical cord blood is sometimes considered if family donors are not available. 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 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. This also destroys the patient’s bone marrow tissue and suppresses the patient’s immune system so that, in an ALLO transplant, the donor cells are not rejected by the body. After the high-dose treatment is given, blood stem cells are infused into the patient’s vein to replace the bone marrow and restore normal blood counts from donor cells. Sometimes, ALLO transplants can also be performed after giving lower doses of chemotherapy and/or radiation therapy that are still sufficient to suppress the immune system and allow growth of the donor cells. These transplants, sometimes termed “mini-transplants” or reduced-intensity transplants, have less immediate side effects, allowing the procedure to be used for frailer patients. For both ALLO and AUTO transplant types, the replacement cells engraft (begin to make new blood cells) and turn into healthy, blood-producing tissue within 10 days to three weeks. Because there are considerable risks with transplantation, the doctor will consider several factors, including the patient’s age and general health, before recommending this approach. Destroying the patient’s own marrow reduces the body’s natural defenses, temporarily leaving the patient at an increased risk of infection. Until the patient’s immune system is back to normal, patients may need antibiotics and blood transfusions, and they need to follow certain safety restrictions provided by the health care team to help avoid infections. In an ALLO transplant, another major risk is that the donor’s cells will recognize the patient’s body as foreign, causing graft-versus-host disease (GVHD). GVHD is a serious complication of allogeneic transplants and can be fatal. Other side effects may include liver problems, diarrhea, infections, and rashes. However, GVHD can also be a benefit because the donor cells can recognize the cancer cells as foreign and destroy these cells, a mechanism that is one of the major reasons why ALLO transplantation generally works so well over the long term. The risk of GVHD can be reduced with exact HLA-type matching and the use of preventive drugs. In an AUTO transplant, there is little risk of GVHD because the replacement stem cells are the patient’s own cells. However, there is a risk in an autologous transplant that some of the cells that are put back into the patient could still be cancerous. 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. 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. Find out more about common terms used during cancer treatment. About Clinical Trials
Doctors and scientists are always looking for better ways to treat children with Hodgkin lymphoma. To make scientific advances, doctors create research studies involving people, 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 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. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find clinical trials. For specific topics being studied for childhood Hodgkin lymphoma, learn more in the Current 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. 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 trials ends, and/or if the patient chooses to leave the clinical trial before it ends. Side Effects
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects occur. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health care team. Before treatment begins, talk with your child’s doctor about possible side effects of the specific treatments your child will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and your child’s overall health. Common side effects for each treatment option are described in detail within the Treatment section. Ask your child’s doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health care team. Also, be sure to communicate with your child’s doctor about side effects your child experiences during and after treatment. Care of a patient’s symptoms and side effects is an important part of a person’s overall treatment plan; this is called palliative or supportive care. It helps people with cancer at any stage of illness be as comfortable as possible. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Be sure to talk with your doctor 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 person with Hodgkin lymphoma. Learn more about caregiving. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. For many patients, a diagnosis of Hodgkin lymphoma is stressful and can bring difficult emotions. 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 medical care. A side effect that occurs months or years after treatment is called a late effect. Treatment of late effects is an important part of survivorship care. Learn more about late effects or long-term side effects by reading the After Treatment section or talking with your child’s doctor. After Treatment
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. 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), and 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. For most Hodgkin lymphoma survivors, the medical side effects of treatment do not significantly limit 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, many 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 start a family. Newer reproductive technologies may help some of these individuals; current treatment plans also attempt to reduce exposure to alkylating agents to limit such risks. Learn more about sexual and reproductive health after cancer. Based on the type of treatment the child received, the doctor will determine what examinations and tests are needed to check for long-term side effects and the possibility of secondary cancers. Your child’s doctor can recommend the necessary screening tests. Follow-up care should also address the 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 so that, as the 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 compile 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 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. Find out more about common terms used after cancer treatment is complete. Current Research
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 people 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. For example, the Children’s Oncology Group completed a study evaluating bortezomib (Velcade) in combination with gemcitabine and vinorelbine, and the results are being analyzed. Adding bortezomib to chemotherapy (in this study, gemcitabine and vinorelbine) may help to kill lymphoma cells better than chemotherapy alone. ALLO stem cell transplantation. As explained in the Treatment 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 allogenic 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. Learn more about common statistical terms used in cancer research. Looking for More about Current Research? If you would like additional information about the latest areas of research regarding childhood Hodgkin lymphoma, explore these related items:
Or, choose “Next” (below, right) to continue reading this detailed section. Frequently Asked Questions
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 in the Children’s Oncology Group do not use doxorubicin for more than four cycles (4 months) or radiation therapy that exceeds 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. The health care of adolescents and children 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 import to use a regimen that does not include procarbazine or mechlorethamine. 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 lifelong follow-up care. Learn more about keeping a personal medical record. Questions to Ask the Doctor
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.
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
