Treatment for Hodgkin Lymphoma

Hodgkin lymphoma arises when a lymphocyte (most often a type of immune cell called a B cell) changes and becomes malignant, or cancerous — able to grow and spread uncontrollably. The malignant cell begins producing identical copies of itself, or clones, in the lymph nodes.

Over time, these cells can spread to neighboring groups of lymph nodes and, if not treated, may spread to other parts of the body. In Hodgkin lymphoma, the tumors usually spread from one lymph node group to another via the lymphatic vessels. Hodgkin lymphoma most commonly develops in the lymph nodes in the neck and chest.

Physicians distinguish Hodgkin lymphoma from other types of lymphoma in part by examining tissue samples under a microscope. Biopsied tissue from patients with Hodgkin lymphoma includes a certain number of cells called Reed-Sternberg cells (named after the two physicians who first described them). These distinctive cells are bigger than normal cells and have large, pale nuclei (the part of the cell where chromosomes — genetic material — are located).

Types of Hodgkin Lymphoma

There are two main types of Hodgkin lymphoma:

Classical Hodgkin lymphoma

Approximately 95 percent of cases fall into this category, which is further divided into three subtypes:

• Nodular Sclerosis Hodgkin Lymphoma — In this form of the disease, which accounts for 70 to 80 percent of cases, the lymph nodes usually contain scar tissue (sclerosis), normal and reactive lymphocytes, and Reed-Sternberg cells.
• Mixed Cellularity Hodgkin Lymphoma — In this form of the disease, which accounts for 20 percent of cases, the lymph nodes contain Reed-Sternberg cells and inflammatory cells, but do not have sclerosis.
• Lymphocyte Depletion Hodgkin Lymphoma — There are two types of this form of the disease, one with layers of malignant cells, the other with few Reed-Sternberg cells and lymphocytes. In recent years, the incidence of this form of lymphoma has declined for unclear reasons. It is very unusual to have this kind of Hodgkin lymphoma.

Nodular Lymphocyte-Predominant Hodgkin Lymphoma

In this type of Hodgkin lymphoma, the lymph nodes contain mainly enlarged “reactive” lymphocytes and malignant B cells called popcorn cells or lacunar cells. This form of the disease affects more men than women, and accounts for 5 percent of all cases of Hodgkin lymphoma. It is usually in a very early stage when diagnosed.

Classical and nodular lymphocyte-predominant Hodgkin lymphoma are distinct genetically and clinically.

Treatment for Hodgkin Lymphoma at Memorial Sloan-Kettering

The majority of patients with Hodgkin lymphoma can have very good outcomes with current therapy. Memorial Sloan-Kettering personalizes treatment for Hodgkin lymphoma based on specific characteristics of your disease.

Our goal is not only to provide effective treatment, but also to limit its short- and long-term side effects.

Treatment for Early-Stage Disease

Classical Hodgkin lymphoma is usually treated with chemotherapy. Sometimes radiation therapy is used, either alone or in combination with chemotherapy.

Some patients with nodular lymphocyte-predominant Hodgkin lymphoma receive involved-field radiation therapy. This technique delivers radiation only to the area of the body where lymphoma has been detected.

For both early-stage classical Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma, physicians at Memorial Sloan-Kettering are working to reduce the side effects of treatment and improve patients' quality of life. Whenever possible, our radiation oncologists limit both the size of the area exposed to radiation and the dose of radiation. Our medical oncologists tailor chemotherapy to avoid late complications and give fewer cycles of chemotherapy when it is appropriate to do so.

Treatment for Advanced-Stage Disease

For advanced-stage Hodgkin lymphoma, the standard of care is a combination of chemotherapy drugs. One common regimen is called ABVD, a combination of doxorubicin (also called Adriamycin), bleomycin, vinblastine, and dacarbazine. Another is BEACOPP, which is sometimes given to patients with high-risk features. It is an intensive regimen of seven drugs: bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine (Oncovin-), prednisone, and procarbazine.

For patients with large tumor masses, radiation therapy is sometimes combined with ABVD. Radiation therapy is also used in some cases of early-stage Hodkgin lymphoma. If either of these approaches might be appropriate for you, your doctor will discuss this with you in detail.

Treatment for Recurrent Disease

In some cases, Hodgkin lymphoma can return after initial treatment. When this occurs, Memorial Sloan-Kettering physicians choose from among a variety of different approaches, depending on what treatments you have already received.

For patients whose relapse follows chemotherapy or a combination of different treatments, your doctor may suggest a second-line treatment that includes a different combination of chemotherapy drugs.

The most commonly used second-line treatment at Memorial Sloan-Kettering is called ICE. Developed by our medical oncologists, ICE combines three chemotherapeutic agents (ifosfamide, carboplatin, and etoposide). This treatment has been shown to improve the rate at which the tumor responds to treatment, reduce toxicity, and enable physicians to harvest more stem cells for transplantation.

Second-line treatment may also include, or be followed by, high-dose chemotherapy with stem cell transplantation. A study published in 2010 showed a five-year cure rate of 67 percent for patients who had an autologous transplant for relapsed Hodgkin lymphoma at Memorial Sloan-Kettering.¹ This compares to national average cure rates of 45 to 50 percent as reported by the Bone Marrow Transplant Registry.²

Follow-Up Care

After the completion of your treatment, you will see your physicians for frequent follow-up exams. They will watch for any side effects of treatment and for signs of the recurrence of disease. During these check-ups, you may undergo tests including a physical exam, blood tests, bone marrow aspirates, biopsies, and x-rays or other imaging. If you experience any new symptoms, you should contact your physicians, even between visits. The sooner these symptoms are evaluated and treated, the better the outcome is likely to be.

The length of follow-up care and the frequency of visits depend on the nature of your disease, its stage, and the treatments you received. After a few years of follow-up, some patients can be followed by their internists and see their oncologist on an as-needed basis.

^{1Moskowitz AJ, Kewalramani T, Maragulia JC, Vanak JM, Zelenetz AD, Moskowitz CH. Pre-transplant functional imaging predicts outcome following autologous stem cell transplant for relapsed and refractory Hodgkin lymphoma. Blood. 2010 Dec 2;116(23):4934-7. [PubMed Abstract]}

^{2Schmitz N, Pfistner B, Sextro M, et al. Aggressive conventional chemotherapy compared with high-dose chemotherapy with autologous haemopoietic stem-cell transplantation for relapsed chemosensitive Hodgkin's disease: a randomised trial. Lancet. 2002 Jun 15;359:2065-71. [PubMed Abstract]}