Hodgkin Lymphoma Treatment

Childhood Hodgkin lymphoma is a cancer that develops in the lymph system.

The lymph system is part of the immune system. It helps protect the body from infection and disease.

The lymph system is made up of the following:

• Lymph: Colorless, watery fluid that travels through the lymph vessels and transports T and B lymphocytes. Lymphocytes are a type of white blood cell.
• Lymph vessels: A network of thin tubes that collect lymph from different parts of the body and return it to the bloodstream.
• Lymph nodes: Small, bean-shaped structures that filter lymph and store white blood cells that help fight infection and disease. Lymph nodes are found along a network of lymph vessels throughout the body. Groups of lymph nodes are found in the neck, underarm, mediastinum (the area between the lungs), abdomen, pelvis, and groin. Hodgkin lymphoma most commonly forms in the lymph nodes above the diaphragm.
• Spleen: An organ that makes lymphocytes, stores red blood cells and lymphocytes, filters the blood, and destroys old blood cells. The spleen is on the left side of the abdomen near the stomach.
• Thymus: An organ in which T lymphocytes mature and multiply. The thymus is in the chest behind the breastbone.
• Bone marrow: The soft, spongy tissue in the center of certain bones, such as the hip bone and breastbone. White blood cells, red blood cells, and platelets are made in the bone marrow.
• Tonsils: Two small masses of lymph tissue at the back of the throat. There is one tonsil on each side of the throat.

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The lymph system is part of the body's immune system and is made up of tissues and organs that help protect the body from infection and disease. These include the tonsils, thymus, spleen, bone marrow, lymph vessels, and lymph nodes. Lymph (clear, watery fluid) and lymphocytes (white blood cells) travel through the lymph vessels and into the lymph nodes where the lymphocytes destroy harmful substances. The lymph enters the bloodstream through a large vein near the heart.

Bits of lymph tissue are also found in other parts of the body such as the lining of the gastrointestinal tract, bronchus, and skin.

There are two general types of lymphoma: Hodgkin lymphoma and non-Hodgkin lymphoma. This summary is about the treatment of childhood Hodgkin lymphoma.

Hodgkin lymphoma occurs most often in adolescents 15 to 19 years of age. The treatment for children and adolescents is different than treatment for adults.

Other PDQ summaries with information related to lymphoma include the following:

• Childhood Non-Hodgkin Lymphoma Treatment
• Hodgkin Lymphoma Treatment

The two main types of childhood Hodgkin lymphoma are classic and nodular lymphocyte-predominant.

• Classic Hodgkin lymphoma is the most common type of Hodgkin lymphoma. It occurs most often in adolescents. When a sample of lymph node tissue is looked at under a microscope, Hodgkin lymphoma cancer cells, called Reed-Sternberg cells, may be seen.
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  Reed-Sternberg cell. Reed-Sternberg cells are large, abnormal lymphocytes (a type of white blood cell) that may contain more than one nucleus. These cells are found in people with Hodgkin lymphoma. Reed-Sternberg cells are also called Hodgkin and Reed-Sternberg cells.
  

  Classic Hodgkin lymphoma is divided into four subtypes, based on how the cancer cells look under a microscope:

  • Nodular-sclerosing Hodgkin lymphoma occurs most often in older children and adolescents. It is common to have a chest mass at diagnosis.
  • Mixed cellularity Hodgkin lymphoma most often occurs in children younger than 10 years of age. It is linked to a history of Epstein-Barr virus (EBV) infection and often occurs in the lymph nodes of the neck.
  • Lymphocyte-rich Hodgkin lymphoma is rare in children. When a sample of lymph node tissue is looked at under a microscope, there are Reed-Sternberg cells and many normal lymphocytes and other blood cells.
  • Lymphocyte-depleted Hodgkin lymphoma is rare in children and occurs most often in adults or adults with HIV. When a sample of lymph node tissue is looked at under a microscope, there are many large, oddly shaped cancer cells and few normal lymphocytes and other blood cells.
• Nodular lymphocyte-predominant Hodgkin lymphoma is less common than classic Hodgkin lymphoma. It most often occurs in children younger than 10 years of age. Nodular lymphocyte-predominant Hodgkin lymphoma often occurs as a swollen lymph node in the neck, underarm, or groin. Most individuals do not have any other signs or symptoms of cancer at diagnosis. When a sample of lymph node tissue is looked at under a microscope, the cancer cells are shaped like popcorn.

Epstein-Barr virus infection and a family history of Hodgkin lymphoma can increase the risk of childhood Hodgkin lymphoma.

Anything that increases a person's chance of getting a disease is called a risk factor. Not every person with one or more of these risk factors will develop childhood Hodgkin lymphoma, and it can develop in some children who don't have any known risk factors. Talk with your child's doctor if you think your child may be at risk.

Risk factors for childhood Hodgkin lymphoma include the following:

• being infected with the Epstein-Barr virus (EBV)
• being infected with HIV
• having certain diseases of the immune system, such as autoimmune lymphoproliferative syndrome
• having a weakened immune system after an organ transplant or from medicine given after a transplant to stop the organ from being rejected by the body
• having a parent, brother, or sister with a personal history of Hodgkin lymphoma

Inherited changes in genes may increase the risk of childhood Hodgkin lymphoma.

Being exposed to common infections in early childhood may decrease the risk of Hodgkin lymphoma in children.

Signs of childhood Hodgkin lymphoma include swollen lymph nodes, fever, drenching night sweats, and weight loss.

The signs and symptoms of Hodgkin lymphoma depend on where the cancer forms in the body and the size of the cancer. It's important to check with your child's doctor if your child has any symptoms below:

• painless, swollen lymph nodes near the collarbone or in the neck, chest, underarm, or groin
• fever for no known reason
• weight loss for no known reason
• drenching night sweats
• feeling very tired
• anorexia
• itchy skin
• coughing
• trouble breathing, especially when lying down
• pain in the lymph nodes after drinking alcohol

Fever for no known reason, weight loss for no known reason, or drenching night sweats are called B symptoms. B symptoms are an important part of staging Hodgkin lymphoma and understanding the patient's chance of recovery.

These symptoms may be caused by conditions other than childhood Hodgkin lymphoma. The only way to know is to see your child's doctor. The doctor will ask you when the symptoms started and how often your child has been having them as a first step in making a diagnosis.

Tests that examine the lymph system and other parts of the body are used to diagnose and stage childhood Hodgkin lymphoma.

If your child has symptoms that suggest Hodgkin lymphoma, their doctor will need to find out if these are due to cancer or to another condition. They will ask about your child's personal and family health history and do a physical exam. The doctor may recommend diagnostic tests to find out if your child has Hodgkin lymphoma. The results of these tests will also help you and your child's doctor plan treatment.

The following tests and procedures may be used:

• Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
  • The number of red blood cells, white blood cells, and platelets.
  • The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.
  • The portion of the blood sample made up of red blood cells.
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    Complete blood count (CBC). Blood is collected by inserting a needle into a vein and allowing the blood to flow into a tube. The blood sample is sent to the laboratory and the red blood cells, white blood cells, and platelets are counted. The CBC is used to test for, diagnose, and monitor many different conditions.
    

• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood, including albumin, by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• C-reactive protein test: A test in which a blood sample is checked to measure the amount of c-reactive protein in the blood. C-reactive protein is made by the liver and sent to the bloodstream in response to inflammation. A higher-than-normal amount of c-reactive protein in the blood may be a sign of disease.
• Sedimentation rate: A procedure in which a sample of blood is drawn and checked for the rate at which the red blood cells settle to the bottom of the test tube. The sedimentation rate is a measure of how much inflammation is in the body. A higher-than-normal sedimentation rate may be a sign of lymphoma. Also called erythrocyte sedimentation rate, sed rate, or ESR.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the neck, chest, abdomen, or pelvis, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. To learn more, see Computed Tomography (CT) Scans and Cancer.
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  Computed tomography (CT) scan. The child lies on a table that slides through the CT scanner, which takes a series of detailed x-ray pictures of areas inside the body.
  

• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
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  Positron emission tomography (PET) scan. The child lies on a table that slides through the PET scanner. The head rest and white strap help the child lie still. A small amount of radioactive glucose (sugar) is injected into the child's vein, and a scanner makes a picture of where the glucose is being used in the body. Cancer cells show up brighter in the picture because they take up more glucose than normal cells do.
  

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the lymph nodes. This procedure is also called nuclear magnetic resonance imaging (NMRI).
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  Magnetic resonance imaging (MRI) scan. The child lies on a table that slides into the MRI machine, which takes a series of detailed pictures of areas inside the body. The positioning of the child on the table depends on the part of the body being imaged.
  

• PET-CT scan: A procedure that combines the pictures from a positron emission tomography (PET) scan and a computed tomography (CT) scan. The PET and CT scans are done at the same time with the same machine. The combined scans give more detailed pictures of areas inside the body than either scan gives by itself.
• PET-MRI scan: A procedure that combines the pictures from a positron emission tomography (PET) scan and a magnetic resonance imaging (MRI) scan. A PET scan uses a radioactive tracer to highlight abnormal areas in the body. An MRI uses radio waves and a powerful magnet to take detailed pictures of tissues in the body. For a PET-MRI, the scans are done at the same time with the same machine. The combined scans give more detailed pictures of areas inside the body than either scan gives by itself. The overall amount of radiation a person is exposed to is also reduced. A PET-MRI may be used to help diagnose disease, such as cancer, plan treatment, or find out how well treatment is working.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Bone marrow aspiration and biopsy: The removal of bone marrow and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow and bone under a microscope to look for abnormal cells. Bone marrow aspiration and biopsy is done for patients with advanced disease and/or B symptoms.
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  Bone marrow aspiration and biopsy. After a small area of skin is numbed, a bone marrow needle is inserted into the child’s hip bone. Samples of blood, bone, and bone marrow are removed for examination under a microscope.
  

• Lymph node biopsy: The removal of all or part of one or more lymph nodes. The lymph node may be removed during an image-guided CT scan or a thoracoscopy, mediastinoscopy, or laparoscopy. One of the following types of biopsies may be done:
  • Excisional biopsy: The removal of an entire lymph node.
  • Incisional biopsy: The removal of part of a lymph node.
  • Core biopsy: The removal of tissue from a lymph node using a wide needle.

  A pathologist views the lymph node tissue under a microscope to check for cancer cells called Reed-Sternberg cells. Reed-Sternberg cells are common in classic Hodgkin lymphoma.

  The following test may be done on tissue that was removed:

  • Immunophenotyping: A laboratory test that uses antibodies to identify cancer cells based on the types of antigens or markers on the surface of the cells. This test is used to help diagnose specific types of lymphoma.

You may want to get a second opinion.

You may want to get a second opinion to confirm your child's diagnosis and treatment plan. If you seek a second opinion, you will need to get important medical test results from the first doctor to share with the second doctor. The second doctor will review the pathology report, slides, and scans before giving a recommendation. They may agree with the first doctor, suggest changes or another approach, or provide more information about your child's cancer.

To learn more about choosing a doctor and getting a second opinion, see Finding Cancer Care. You can contact NCI's Cancer Information Service via chat, email, or phone (both in English and Spanish) for help finding a doctor or hospital that can provide a second opinion. For questions you might want to ask at your appointments, see Questions to Ask Your Doctor.

Certain factors affect prognosis (chance of recovery) and treatment options.

If your child has been diagnosed with Hodgkin lymphoma, you may have questions about how serious the cancer is and your child's chances of survival. The likely outcome or course of a disease is called prognosis. The prognosis and treatment options depend on the following:

• the stage of the cancer (the size of the cancer and whether the cancer has spread below the diaphragm or to more than one group of lymph nodes)
• the size of the tumor
• whether there are B symptoms (fever for no known reason, weight loss for no known reason, or drenching night sweats) at diagnosis
• the type of Hodgkin lymphoma
• having more than the usual number of white blood cells or anemia at the time of diagnosis
• whether there is fluid around the heart or lungs at diagnosis
• the sedimentation rate or the albumin level in the blood
• how well the cancer responds to initial treatment with chemotherapy
• the child's sex
• whether the cancer is newly diagnosed or has recurred (come back)

The treatment options also depend on:

• whether there is a low, medium, or high risk the cancer will come back after treatment
• the child's age
• the risk of long-term side effects

Most children and adolescents with newly diagnosed Hodgkin lymphoma can be cured.

Your child's cancer care team is in the best position to talk with you about your child's prognosis.

After childhood Hodgkin lymphoma has been diagnosed, tests are done to find out if cancer cells have spread within the lymph system or to other parts of the body.

The process used to find out if cancer has spread is called staging. The information gathered from the staging process determines the stage of the disease. The results of the tests and procedures done to diagnose and stage Hodgkin lymphoma are used to help make decisions about treatment.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

The following stages are used for childhood Hodgkin lymphoma:

Stage I

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Stage I childhood Hodgkin lymphoma. Cancer is found in one or more lymph nodes in a group of lymph nodes or, in rare cases, cancer is found in the Waldeyer’s ring, thymus, or spleen. In stage IE (not shown), cancer has spread to one area outside the lymph system.

Stage I is divided into stage I and stage IE.

• Stage I: Cancer is found in one of the following places in the lymph system:
  • One or more lymph nodes in one lymph node group.
  • Waldeyer's ring.
  • Thymus.
  • Spleen.
• Stage IE: Cancer is found outside the lymph system in one organ or area.

In addition to the stage number, the letters A, B, E, or S may be noted.

The letters A, B, E, or S may be used to further describe the stage of childhood Hodgkin lymphoma.

• A: The patient does not have B symptoms (fever, weight loss, or drenching night sweats).
• B: The patient has B symptoms.
• E: Cancer is found in an organ or tissue that is not part of the lymph system but which may be next to an area of the lymph system affected by the cancer.
• S: Cancer is found in the spleen.

Childhood Hodgkin lymphoma is treated according to risk groups.

Untreated childhood Hodgkin lymphoma is divided into risk groups based on the stage, size of the tumor, and whether the patient has B symptoms (fever, weight loss, or drenching night sweats). The risk group describes the likelihood that Hodgkin lymphoma will not respond to treatment or recur (come back) after treatment. It is used to plan initial treatment.

• Low-risk childhood Hodgkin lymphoma.
• Intermediate-risk childhood Hodgkin lymphoma.
• High-risk childhood Hodgkin lymphoma.

Low-risk Hodgkin lymphoma requires fewer cycles of treatment, fewer anticancer drugs, and lower doses of anticancer drugs than high-risk lymphoma.

Sometimes childhood Hodgkin lymphoma does not respond to treatment or comes back after treatment.

Primary refractory Hodgkin lymphoma is cancer that does not respond to initial treatment.

Recurrent Hodgkin lymphoma is cancer that has recurred (come back) after it has been treated. The lymphoma may come back in the lymph system or in other parts of the body, such as the lungs, liver, bones, or bone marrow.

There are different types of treatment for children with Hodgkin lymphoma.

There are different types of treatment for children with Hodgkin lymphoma. You and your child's care team will work together to decide treatment. Many factors will be considered, such as your child's overall health, and whether the tumor is newly diagnosed or has come back.

Children with Hodgkin lymphoma should have their treatment planned by a team of health care providers who are experts in treating childhood cancer.

A pediatric oncologist, a doctor who specializes in treating children with cancer, will oversee treatment of childhood Hodgkin lymphoma. The pediatric oncologist works with other pediatric health care providers who are experts in treating children with Hodgkin lymphoma and who specialize in certain areas of medicine. These may include the following specialists and others:

• pediatrician
• medical oncologist/hematologist
• radiation oncologist
• pathologist
• pediatric nurse specialist
• psychologist
• social worker
• child-life specialist
• fertility specialist

The treatment of Hodgkin lymphoma in adolescents and young adults may be different than the treatment for children. Some adolescents and young adults are treated with an adult treatment regimen.

The following types of treatment may be used:

Clinical trials

A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. Because cancer in children is rare, taking part in a clinical trial should be considered.

Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. Some clinical trials are open only to patients who have not started treatment. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

To learn more, see Clinical Trials Information for Patients and Caregivers.

Treatment for childhood Hodgkin lymphoma causes side effects and late effects.

To learn more about side effects that begin during treatment for cancer, visit Side Effects.

Side effects from cancer treatment that begin after treatment and continue for months or years are called late effects. Because late effects affect health and development, regular follow-up exams are important.

Late effects of cancer treatment may include the following:

• physical problems that affect the following:
  • development of sex and reproductive organs
  • fertility (ability to have children)
  • bone and muscle growth and development
  • thyroid, heart, or lung function
  • teeth, gums, and salivary gland function
  • spleen function (increased risk of infection)
• changes in mood, feelings, thinking, learning, or memory
• second cancers (new types of cancer), such as breast, thyroid, skin, lung, stomach, or colorectal

For female survivors of Hodgkin lymphoma, there is an increased risk of breast cancer. This risk depends on the amount of radiation the breast received during treatment and the chemotherapy regimen used. The risk of breast cancer is decreased if radiation to the ovaries was also given.

It is suggested that female survivors who received radiation therapy to the breast have a mammogram and MRI once a year starting 8 years after treatment or at age 25 years, whichever is later. It is also suggested that female survivors do a breast self-exam every month beginning at puberty and have a breast exam done by a health professional every year beginning at puberty until age 25 years. The breast exams done by a health professional will increase to every 6 months at age 25 years.

For male survivors who received radiation therapy to the chest, there may be a higher risk of cardiovascular disease. Limiting radiation therapy to the chest is suggested if possible.

Some late effects may be treated or controlled. It is important to talk with your child's doctors about the possible late effects caused by some treatments. To learn more, see Late Effects of Treatment for Childhood Cancer.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI’s clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

Follow-up tests may be needed.

As your child goes through treatment, they will have follow-up tests or check-ups. Some tests that were done to diagnose or stage the cancer may be repeated to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your child's condition has changed or if the cancer has recurred (come back).

For patients who receive chemotherapy alone, a PET scan may be done 3 weeks or more after treatment ends. For patients who receive radiation therapy last, a PET scan should not be done until 8 to 12 weeks after treatment ends.

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This PDQ cancer information summary has current information about the treatment of childhood Hodgkin lymphoma. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

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A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI's website. For more information, call the Cancer Information Service (CIS), NCI's contact center, at 1-800-4-CANCER (1-800-422-6237).

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PDQ® Pediatric Treatment Editorial Board. PDQ Childhood Hodgkin Lymphoma Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/lymphoma/patient/child-hodgkin-treatment-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389224]

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