Searching for a cure
Hodgkin’s lymphoma, or Hodgkin’s disease, as it is also called, is one of the many kinds of cancer of the lymphatic system that can affect children and adults. In Hodgkin’s disease, a certain kind of cell — called the Reed-Sternberg cell — begins to reproduce uncontrollably. It is the overabundance of this specific kind of cell that distinguishes Hodgkin’s lymphomas from non-Hodgkin’s lymphomas.
The lymph system is the network of vessels that conducts a colorless fluid called lymph throughout your body. As part of the immune system, lymph is an important infection-fighting agent. In certain areas of your body its vessels widen into lymph nodes. This is where the lymphatic system makes and stores infection-fighting cells. If you’ve had an infection or disease like mononucleosis you’ve probably felt the lymph nodes in your groin, under your arm, or neck enlarged by infection.
Because there is lymph tissue throughout the body, Hodgkin’s disease can start almost anywhere — and spread almost anywhere, too.
- It is rare in children under age 5.
- In children under age 10 it is more common in boys than in girls.
- It usually affects people between 15-35 years old, and over 50.
- When Hodgkin’s disease is detected early and treated properly, as many as 90 percent of the cases can be cured. This is a big change from the prognosis — or outlook — 25 years ago. Before the development of new anti-cancer drugs, the disease was almost always fatal.
- With more advanced forms of Hodgkin’s, 50 to 80 percent are considered cured (no disease present 10 years after chemotherapy).
In the case of a young child, the parent is the most likely person to find an early sign of Hodgkin’s lymphoma: an enlarged, or swollen lymph node in the armpit, groin or neck that feels hard and rubbery, and does not reduce in size for more than three weeks. Because the swelling is usually painless, its presence is often discovered by accident. Older children, teens and adults might find the enlarged node while bathing or showering. Other signs and symptoms include:
- Fever that doesn’t go away
- Continual fatigue, lasting for weeks and not linked to activity
- Night sweats
- Weight loss and loss of appetite
- Severe itching at any place on the body
- Numbness or loss of strength in arms and legs (unusual)
- Loss of bowel or bladder control (unusual)
When Hodgkin’s disease is suspected — due to any of the above symptoms, and especially, the presence of an enlarged, rubbery lymph node — a doctor may want to perform other tests. The doctor will look for cancer cells, particularly Reed-Sternberg cells. Other tests that may be done include:
- Medical history and physical examination, with special attention to the lymph nodes.
- Blood (blood cell count, sedimentation rate, etc.) and urine sample.
- Lymph node biopsy, which is a sampling of the lymph nodes to examine under a microscope
- X-rays of the chest, to see lymph nodes and check for unusual masses.
- CT or CAT scan (computerized tomography), to look for any unusual masses.
- MRI (magnetic resonance image) using magnetic waves to make a picture of any tumors.
- Gallium scan or PET scan. These may be useful markers in following Hodgkin’s disease response to treatment.
- Bone marrow biopsy. To check for cancer in the bone marrow, your doctor will numb the hip, insert a thin needle and withdraw liquid bone marrow. A bone sliver will be taken, too. Both it and the marrow will be examined under the microscope for cancer cells.
To determine the spread of the disease and to plan the best treatment, a physician will “stage” the disease. This is a way of expressing the extent to which the cancer cells have spread to surrounding tissues, or to other parts of the body.
Staging depends on two categories of information:
1. The results of the biopsy and other diagnostic tests, such as blood, x-rays, CT and MRI scans. These constitute clinical staging. If abdominal surgery is performed, it is called pathological staging. A Roman numeral I through IV is assigned here, or the term “recurrent.” Recurrent means the cancer has come back after treatment.
2. Symptoms the child is experiencing. Children with no symptoms are in the A category. Children with symptoms like weight loss, fever or night sweats are in the B category.
The following stages are used for childhood Hodgkin’s disease:
Involvement of a single lymph node region or localized involvement of a single extralymphatic organ or site.
Involvement of two or more lymph node regions on the same side of the diaphragm or localized contiguous involvement of a single extralymphatic organ or site and its regional lymph nodes with involvement of one or more lymph node regions on the same side of the diaphragm.
Involvement of lymph node regions on both sides of the diaphragm, which may also be accompanied by localized contiguous involvement of an extralymphatic organ or site, by involvement of the spleen, or both.
Disseminated involvement of one or more extralymphatic organs or tissues, such as bone marrow, with or without associated lymph node involvement, or isolated extralymphatic organ involvement with distant nodal involvement It is imperative that children be treated at medical centers that have both high-level expertise and extensive experience in treating Hodgkin’s disease. Among the features it should have are:
- Multidisciplinary medical teams (pediatric oncologist, radiation oncologist, surgeon, etc.). This team approach ensures many lines of expertise converge in the treatment of your child.
- A long history treating Hodgkin’s patients, and large patient load. This ensures depth and breadth of understanding the disease and its response to various treatments.
- Access to the latest research findings and the clinical expertise to apply them. This ensures a treatment regimen most likely to maximize cure while minimizing negative side-effects.
There are treatments for all patients with childhood Hodgkin’s disease. The most common treatments are radiation therapy and/or chemotherapy. But treatment regimens vary among patients depending on the stage of cancer and the child’s age — specifically, on whether he or she has reached full growth. In certain patients, bone marrow transplants are being studied as another treatment option.
Treatment for childhood Hodgkin’s disease depends on:
- the type and stage of the disease
- how the stage was determined
- child’s age
- child’s gender
- child’s symptoms
- child’s general health
Treatment for Hodgkin’s disease is always evolving. In an effort to find the most effective and least toxic therapy, clinical trials may compare two similar therapies. When no trial is underway, the best results of the previous trial are often considered the standard. Why clinical trials are chosen is a personal as well as a medical decision. But one of the major reasons is that despite steadily and dramatically improving cure rates of childhood Hodgkin’s disease, some cases do not respond well to standard treatment therapies. Clinical trials hold the promise for a better way to treat cancer.
Treatment by staging
- Stage I and II: Those with low stage disease will receive chemotherapy with or without radiation therapy depending on the site of disease, gender, amount and size of disease, and presence or absence of “B” symptoms.
- Stage III and IV: Those with more advanced disease will generally receive more extensive chemotherapy, particularly those with “B” symptoms. Radiation therapy will also be used to treat areas of bulk disease and may also include “total nodal irradiation.”
Recurrent childhood Hodgkin’s disease
Treatment depends on the location at which the cancer recurs, and the type of treatment previously given. If radiation was previously given, the child may receive chemotherapy when the cancer comes back. If chemotherapy was previously given, the child may receive the same or different drugs.
Clinical trials are testing new combinations of drugs. In children who benefit from chemotherapy, autologous bone marrow transplant may be considered. Clinical trials of chemotherapy and bone marrow transplant are ongoing.