Hodgkin lymphoma

Hodgkin lymphoma is an uncommon cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body.

The lymphatic system is part of your immune system. Clear fluid called lymph flows through the lymphatic vessels and contains infection-fighting white blood cells, known as lymphocytes.

In Hodgkin lymphoma, B-lymphocytes (a particular type of lymphocyte) start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system, such as the lymph nodes (glands). The affected lymphocytes lose their infection-fighting properties, making you more vulnerable to infection.

The most common symptom of Hodgkin lymphoma is a painless swelling in a lymph node, usually in the neck, armpit or groin.

Read more about the symptoms of Hodgkin lymphoma.

Who's affected?

Hodgkin lymphoma can develop at any age, but it mostly affects people between 20 and 40 years of age and those over 75. Slightly more men than women are affected.

Around 2,100 people are diagnosed with Hodgkin lymphoma in the UK each year.

Causes of Hodgkin lymphoma

The exact cause of Hodgkin lymphoma is unknown. However, your risk of developing the condition is increased if:

• you have a medical condition that weakens your immune system
• you take immunosuppressant medicine
• you've previously been exposed to a common virus called the Epstein-Barr virus, which causes glandular fever

You also have an increased risk of developing Hodgkin lymphoma if a first-degree relative (parent, sibling or child) has had the condition.

Read more about the causes of Hodgkin lymphoma.

How Hodgkin lymphoma is diagnosed

The only way to confirm a diagnosis of Hodgkin lymphoma is by carrying out a biopsy.

This is a minor surgical procedure where a sample of affected lymph node tissue is removed and studied in a laboratory.

Read more about diagnosing Hodgkin lymphoma.

Treatment and outlook

Hodgkin lymphoma is a relatively aggressive cancer and can quickly spread through the body. Despite this, it's also one of the most easily treated types of cancer.

Your recommended treatment plan will depend on your general health and age, because many of the treatments can put a tremendous strain on the body. How far the cancer has spread is also an important factor in determining the best treatment.

The main treatments used are chemotherapy, followed by radiotherapy or chemotherapy alone. Surgery isn't generally used as a treatment for the condition.

Overall, around 8 out of 10 people with Hodgkin lymphoma live at least 5 years and most of these will be cured. However, there's a risk of long-term problems after treatment, including infertility and an increased risk of developing another type of cancer in the future.

Read more about:

• treatment for Hodgkin lymphoma
• complications of Hodgkin lymphoma

 Symptoms Hodgkin lymphoma 

The most common symptom of Hodgkin lymphoma is a swelling in the neck, armpit or groin. The swelling is usually painless, although some people find that it aches.

The swelling is caused by an excess of affected lymphocytes (white blood cells) collecting in a lymph node (also called lymph glands). Lymph nodes are pea-sized lumps of tissue found throughout the body. They contain white blood cells that help to fight infection.

However, it's highly unlikely that you have Hodgkin lymphoma if you have swollen lymph nodes, as these glands often swell as a response to infection.

Read more about lumps and swellings.

Other symptoms

Some people with Hodgkin lymphoma also have other more general symptoms. These can include:

• night sweats
• unintentional weight loss
• a high temperature (fever)
• a persistent cough or feeling of breathlessness
• persistent itching of the skin all over the body

Other symptoms will depend on where in the body the enlarged lymph glands are. For example, if the abdomen (tummy) is affected, you may have abdominal pain or indigestion

A few people with lymphoma have abnormal cells in their bone marrow when they're diagnosed. This may lead to:

• persistent tiredness or fatigue
• an increased risk of infections
• excessive bleeding – such as nosebleeds, heavy periods and spots of blood under the skin

Sometimes, people with Hodgkin lymphoma have pain in their lymph glands when they drink alcohol.

When to get medical advice

See a GP if you have symptoms of Hodgkin lymphoma, particularly if you have persistently swollen glands with no other signs of infection.

While the symptoms are unlikely to be caused by Hodgkin lymphoma, it is best to get them checked out.

 Causes Hodgkin lymphoma 

Hodgkin lymphoma is caused by a change (mutation) in the DNA of a type of white blood cell called B lymphocytes. The exact reason why this happens isn't known.

The DNA gives the cells a basic set of instructions, such as when to grow and reproduce. The mutation in the DNA changes these instructions so the cells keep growing, causing them to multiply uncontrollably.

The abnormal lymphocytes usually begin to multiply in one or more lymph nodes in a particular area of the body, such as your neck or groin. Over time, it's possible for the abnormal lymphocytes to spread into other parts of your body, such as your:

• bone marrow
• spleen
• liver
• skin
• lungs

Who's most at risk?

While the cause of the initial mutation that triggers Hodgkin lymphoma is unknown, a number of factors can increase your risk of developing the condition. These include:

• age and gender – anyone can get Hodgkin lymphoma but it's more common in people aged 20 to 40 or over 75; it also affects slightly more men than women
• having a medical condition that weakens your immune system, such as HIV
• having medical treatment that weakens your immune system – for example, taking medicine to suppress your immune system after an organ transplant
• being previously exposed to the Epstein-Barr virus (EBV) – a common virus that causes glandular fever
• having previously had non-Hodgkin lymphoma, possibly because of treatment with chemotherapy or radiotherapy
• being very overweight (obese) – this may be more of a risk factor in women than men
• smoking

Hodgkin lymphoma isn't infectious and isn't thought to run in families. Although your risk is increased if a first-degree relative (parent, sibling or child) has had lymphoma, it's not clear if this is because of an inherited genetic fault or lifestyle factors.

 Diagnosis Hodgkin lymphoma 

If you see a GP because you're concerned about symptoms of Hodgkin lymphoma, they'll ask about your health and carry out a simple physical examination.

If necessary, the GP will refer you to hospital for further tests.

If you're referred to hospital, a biopsy will usually be carried out, as this is the only way to confirm a diagnosis of Hodgkin lymphoma.

Lymph node biopsy

A lymph node biopsy involves removing some or all of an affected lymph node, which is then studied in a laboratory.

A biopsy is a small operation that can often be carried out under local anaesthetic. Sometimes, the affected lymph node isn't easily accessible and a general anaesthetic may be required.

A pathologist (an expert in the study of diseased tissue) will then check the tissue sample for the presence of cancerous cells. If they find cancerous cells, they can also identify exactly which type of Hodgkin lymphoma you have, which is an important factor in planning your treatment.

Further testing

If a biopsy confirms a diagnosis of Hodgkin lymphoma, further testing will be needed to check how far the lymphoma has spread. This allows a doctor to diagnose the stage of your lymphoma.

Further tests may include:

• blood tests – samples of blood will be taken throughout your diagnosis and treatment to check your general health, the levels of red and white cells and platelets in your blood, and how well organs such as your liver and kidneys are working
• bone marrow sample – another biopsy may be carried out to see if the cancer has spread to your bone marrow; this involves using a long needle to remove a sample of bone marrow from your pelvis and can be done using a local anaesthetic
• chest X-ray – this can check whether the cancer has spread to your chest or lungs
• computerised tomography (CT) scan – this scan takes a series of X-rays that build up a 3D picture of the inside of the body to check the spread of the cancer
• magnetic resonance imaging (MRI) scan – this scan uses strong magnetic fields to build up a detailed picture of areas of your body, to check the spread of the cancer
• positron emission tomography (PET) scan – this scan measures the activity of cells in different parts of the body and can check the spread of the cancer and the impact of treatment; it's usually taken at the same time as a CT scan to show precisely how the tissues of different sites of the body are working

Stages of Hodgkin lymphoma

When testing is complete, it should be possible to determine the stage of your lymphoma. "Staging" means scoring the cancer by how far it's spread.

The main stages of Hodgkin lymphoma are:

• stage 1 – the cancer is limited to 1 group of lymph nodes, such as your neck or groin nodes either above or below your diaphragm (the sheet of muscle underneath the lungs)
• stage 2 – 2 or more lymph node groups are affected, either above or below the diaphragm
• stage 3 – the cancer has spread to lymph node groups above and below the diaphragm
• stage 4 – the cancer has spread through the lymphatic system and is now present in organs or bone marrow

Health professionals also add the letters "A" or "B" to your stage, to indicate whether or not you have certain symptoms.

"A" is put after your stage if you have no additional symptoms other than swollen lymph nodes. "B" is put after your stage if you have additional symptoms of weight loss, fever or night sweats.

 Treatment Hodgkin lymphoma 

Hodgkin lymphoma can usually be treated successfully with chemotherapy alone, or chemotherapy followed by radiotherapy.

Your treatment plan

Your specific treatment plan will depend on your general health and your age, as many of the treatments can put a tremendous strain on the body. How far the cancer has spread is also an important factor in determining the best treatment.

Discussions about your treatment plan will usually take place with several doctors and other health professionals who specialise in different aspects of treating lymphoma. This is known as a multidisciplinary team (MDT).

Your MDT may include a:

• specialist cancer nurse or "key worker" – who is the first point of contact between you and the members of the care team
• haematologist – a specialist in blood and bone marrow disorders
• clinical oncologist – a specialist in radiotherapy
• social worker
• transplant specialist
• psychologist
• counsellor

Your MDT will recommend the best treatment options for you. However, you should not be rushed into making a decision about your treatment plan. Before deciding, you may wish to talk to friends, family and your partner.

Treatment options

The main treatments for Hodgkin lymphoma are chemotherapy alone, or chemotherapy followed by radiotherapy. Occasionally, chemotherapy may be combined with steroid medicine. Some people also have biological medicines.

Surgery isn't generally used to treat the condition, except for the biopsy used to diagnose it.

Overall, treatment for Hodgkin lymphoma is highly effective and most people with the condition are eventually cured.

Chemotherapy

Chemotherapy is a type of cancer treatment where medicine is used to kill cancer cells. It can be given in a number of different ways, depending on the stage of your cancer.

If doctors think your cancer is curable, you'll normally receive chemotherapy through a drip directly into a vein (intravenous chemotherapy). If a cure is unlikely, you may only need to take chemotherapy tablets to help relieve your symptoms.

Chemotherapy is usually given over a period of a few months on an outpatient basis, which means you should not have to stay in hospital overnight. However, there may be times when your symptoms or the side effects of treatment become particularly troublesome and a longer hospital stay may be needed.

Chemotherapy can have several side effects, the most significant of which is potential damage to your bone marrow. This can interfere with the production of healthy blood cells and cause the following problems:

• fatigue
• breathlessness
• increased vulnerability to infection
• bleeding and bruising more easily

If you experience these problems, treatment may need to be delayed so you can produce more healthy blood cells. Growth factor medicines can also stimulate the production of blood cells.

Other possible side effects of chemotherapy include:

• nausea and vomiting
• diarrhoea
• loss of appetite
• mouth ulcers
• tiredness
• skin rashes
• hair loss
• infertility, which may be temporary or permanent (see complications of Hodgkin lymphoma for more information)

Most side effects should pass once your treatment has finished. Tell your care team if the side effects become particularly troublesome, as there are treatments that can help.

If regular chemotherapy is unsuccessful or Hodgkin lymphoma returns after treatment, you may have a course of chemotherapy at a higher dose.

However, this intensive chemotherapy destroys your bone marrow, leading to the problems mentioned above. You'll need a stem cell or bone marrow transplant to replace the damaged bone marrow.

Radiotherapy

Radiotherapy is most often used to treat early-stage Hodgkin lymphoma, where the cancer is only in 1 part of the body.

Treatment is normally given in short daily sessions, Monday to Friday, over several weeks. You should not have to stay in hospital between appointments.

Radiotherapy itself is painless, but it can have some significant side effects. These can vary and will be directly related to the part of your body being treated. For example, treatment to your throat can lead to a sore throat, while treatment to the head can lead to hair loss.

Other common side effects include:

• tiredness
• nausea and vomiting
• dry mouth
• loss of appetite

Most side effects are temporary, but there's a risk of long-term problems, including infertility and permanently darkened skin in the treatment area.

Read more about:

• side effects of radiotherapy
• complications of Hodgkin lymphoma

Steroid medicine

Steroid medicine is sometimes used in combination with chemotherapy as a more intensive treatment for advanced Hodgkin lymphoma, or if initial treatment has not worked.

The steroid medicine is given intravenously, usually at the same time as your chemotherapy.

Common side effects of steroid medicine include:

• increased appetite, which can lead to weight gain
• indigestion
• problems sleeping
• feeling agitated

The side effects of steroid medicine usually start to improve once treatment finishes.

Biological medicines (targeted therapies)

You might be offered a biological medicine if you're diagnosed with certain rare types of Hodgkin lymphoma, or if other treatments have not worked or are not suitable for you.

Biological medicines are also known as targeted therapies. They work by targeting cancer cells, or helping your immune system to attack cancer cells.

Biological medicines used for Hodgkin lymphoma include rituximab (used together with chemotherapy), brentuximab vedotin and pembrolizumab.

They're given through a drip into your vein (infusion).

Side effects depend on which medicine you have. Common side effects include:

• feeling or being sick
• skin rashes
• headaches
• tiredness
• muscle or joint pain
• shortness of breath

Side effects often improve as your body gets used to the medicine.

Follow-up

After your course of treatment ends, you'll need to have regular follow-up appointments to monitor your recovery and check for any signs of the cancer returning.

These appointments start off being every few weeks or months, but will become gradually less frequent over time.

Further information

For more information, see:

 Complications Hodgkin lymphoma 

Some people treated for Hodgkin lymphoma experience long-term problems, even if they've been cured.

Weakened immune system

Having a weakened immune system is a common complication of Hodgkin lymphoma and it can become more severe while you're being treated.

If you have a weak immune system, you're more vulnerable to infections and there's an increased risk of developing serious complications from infections.

Sometimes, you may be advised to take regular doses of antibiotics to prevent infections.

It's also important to report any symptoms of an infection to your GP or care team immediately, as prompt treatment may be needed to prevent serious complications.

Symptoms of infection include:

• a high temperature (fever)
• headache
• aching muscles
• diarrhoea
• tiredness

Vaccination

You should make sure that all of your vaccinations are up-to-date.

However, it's important to speak to your GP or care team about this, as it may not be safe for you to have "live" vaccines (vaccines containing a weakened form of the virus or organism being vaccinated against) until several months after your treatment finishes.

Examples of live vaccines include the:

• shingles vaccine
• BCG vaccine (against tuberculosis)
• MMR vaccine (against measles, mumps and rubella)

Infertility

Chemotherapy and radiotherapy for Hodgkin lymphoma can cause infertility. This is sometimes temporary, but it can be permanent.

Your care team will estimate the risk of infertility in your specific circumstances and let you know your options.

It may be possible for men to store samples of their sperm and for women to store their eggs before treatment, so they can be used to try for a baby afterwards.

Second cancers

People who have had Hodgkin lymphoma are more likely to get lymphoma, leukaemia or other cancers in the future. Chemotherapy and radiotherapy further increase this risk.

"Second cancers", such as breast cancer or lung cancer, usually develop more than 10 years after being treated for Hodgkin lymphoma. Rarely, other types of cancer, such as leukaemia or other lymphomas, develop after only a few years.

You can help to reduce your risk of a second cancer by adopting a healthy lifestyle through not smoking, maintaining a healthy weight with a balanced diet, and getting regular exercise.

You should report any symptoms that might suggest another cancer to your GP at an early stage and attend any cancer screening appointments you're invited to.

Other health problems

The risk of developing other health conditions in the future, such as cardiovascular disease and lung disease, is also higher in people who have had Hodgkin lymphoma.

You should report unexpected symptoms, such as increasing shortness of breath, to your GP for further advice.