A number of different examinations and tests are usually required to diagnose Hodgkin's lymphoma, as well as to assess how far the disease has spread and how well your body systems are working. Depending on your situation, the physician may use some or all of these tests to determine the best way to treat your disease.
The information from a patient’s history, physical examinations, x-rays, scans, laboratory tests and biopsy is analyzed to allow the doctor to determine the extent of disease and recommend the treatment (or treatments) that have the best chance of either producing a remission or cure.
SIGNS AND SYMPTOMS OF HODGKIN’S LYMPHOMA
A sign or symptom is anything out of the ordinary that the patient experiences, that could be caused by a disease. Symptoms are not specific to lymphomas and are, in fact, similar to those of many other illnesses.
People often first go to the doctor because they think they have a cold, the flu, or some other respiratory infection that does not go away.
The most common sign of Hodgkin's lymphoma is usually a swelling of lymph nodes, that may or may not be painful, and most often occurs in the neck. Some people may also experience swelling of lymph nodes in other parts of the body. Other symptoms of Hodgkin's lymphoma may include unexplained fever, weight loss, or sweating (usually at night), or a lack of energy. Coughing, shortness of breath, or chest discomfort may be signs of Hodgkin's lymphoma in the chest. There is usually no pain involved, especially when Hodgkin's lymphoma is in the early stages of development. About 5% of patients may experience pain at the tumor site after drinking alcoholic beverages. While this symptom is rare, it is characteristic for Hodgkin's lymphoma. The cause of this symptom is unknown.
Most people who have non-specific complaints such as these will not have Hodgkin's lymphoma. However, it is important that anyone who has persistent symptoms be seen by a doctor to make sure that Hodgkin's lymphoma is not present. Serious illnesses do not simply come and go, they persist.
What the doctor looks for during a physical examination
If you have symptoms suggesting Hodgkin's lymphoma, a complete physical examination will be performed. During this examination, the doctor will look for swollen lymph nodes under the chin, in the neck and tonsil area, under the arms, and in the groin. The doctor will also examine other parts of the body to see whether there is swelling or fluid in your chest or abdomen that could be caused by swollen lymph nodes. You will be asked about pain and examined for any weakness or paralysis that could be caused by an enlarged lymph node against nerves or the spinal cord. Your abdomen will be examined to see whether any internal organs are enlarged, especially the spleen and liver. If the doctor suspects Hodgkin's lymphoma after reviewing your symptoms and performing a physical examination, he or she may order other tests to help confirm the diagnosis. These tests should include a biopsy, and may also include blood tests, x-rays and other imaging tests, scans, or a bone marrow evaluation.
BIOPSIES AND HOW THEY ARE PERFORMED
A biopsy is a procedure in which a piece of tissue from an area of suspected cancer is removed from the body for examination under a microscope. Hodgkin's lymphoma is diagnosed by looking for the characteristics of this disease in the lymph nodes or other tissues. The information provided by this tissue sample is crucial to diagnosing and treating Hodgkin's lymphoma.
There are several types of biopsies. One is called a core, or needle biopsy, in which a needle is inserted into a lymph node suspected of being cancerous and a small tissue sample is removed. This type of biopsy can be done under local anesthesia and stitches are usually not required.
Core biopsies are usually inadequate to diagnose properly and classify Hodgkin's lymphoma. It is usually much more accurate and informative to have an open biopsy (also called a surgical biopsy), in which an entire abnormal lymph node is removed. This procedure can usually be done under local anesthesia, but a general (whole body) anesthetic may sometimes be needed and a few stitches are often required. When the only signs of lymphoma are in the abdomen or the pelvis, a core needle biopsy, laparoscopy(inserting a tube) or even abdominal surgery may be necessary to obtain a sample of the tumor for examination.
After a tissue sample has been removed, it is examined by a pathologist (a doctor who studies tissues and cells to identify diseases). Pathologists look at the tissue under a microscope and then provide the oncologist with a detailed report. Information obtained from a biopsy indicates the type of Hodgkin's lymphoma. If the pathologist's interpretation of the biopsy is uncertain, it should be reviewed by another pathologist who is an expert in lymphoma (hematopathologist). Specialized molecular tests can also help distinguish Hodgkin's lymphoma from non-Hodgkin's lymphoma or even from reactive (non-cancerous) lymph nodes.
IMAGING TESTS AND HOW THEY HELP EVALUATE THE CANCER
Physicians often will order imaging tests that provide pictures of the inside of the body. Most of these tests are painless, and no anesthetic is required. Several types of imaging procedures may be needed, and the necessary tests will be chosen to help best evaluate your cancer, including:
X-RAYS: X-rays use radiation to take pictures of areas inside the body. The amount of radiation used in most diagnostic tests are so small that it poses little risk to the patient.
CT OR CAT (COMPUTERIZED AXIAL TOMOGRAPHY) SCAN:
A CAT scan takes x-rays from different angles around the body. The pictures that are obtained are then combined using a computer to give a detailed image. People with Hodgkin’s lymphoma often have CAT scans of the neck, chest, abdomen, and pelvis. These tests are useful in determining the extent of nodal involvement and whether internal organs are affected by Hodgkin’s lymphoma.
MRI (MAGNETIC RESONANCE IMAGING): An MRI is similar to a CAT scan but uses magnets and radio frequency waves instead of x-rays. An MRI can provide important information about tissues and organs, particularly the nervous system, that is not available from other imaging techniques. An MRI may be ordered when the physician wants to get clear images of the brain and spinal cord to see whether the cancer has spread to these areas.
GALLIUM (RADIOISOTOPE) SCAN: Radioactive gallium is a chemical that collects in some tumors. Gallium scans are sometimes used when a patient is diagnosed with Hodgkin’s lymphoma. This scan is performed by injecting a small amount of radioactive gallium into the body. The small amount of chemical used is not harmful. The body is then scanned from several angles to see whether the gallium has collected in a tumor. If the tumor attracts this chemical, the scan can be repeated after treatment is completed to help determine if the tumor has completely disappeared or become inactive.
PET(POSITRON EMISSION TOMOGRAPHY) SCAN: PET scans are now often replacing gallium scans in many cancer centers, because the technique is more convenient and more sensitive, particularly in the abdomen. This test evaluates Hodgkin's lymphoma activity in different parts of the body. To perform the test, a radioactive tracer substance is first injected. A positron camera is then used to detect the radioactivity and produce cross-sectional images of the body. Like gallium scans, PET scans are very useful in determining response to treatment. While CAT scans shows the size of a lymph node, gallium and PET scans show if the lymph node is active (still has disease).
BLOOD TESTS
Blood tests are performed to determine whether different types of blood cells are normal in number and appearance when viewed under the microscope. These include tests of red blood cells, white blood cells, platelets, and sedimentation rate. Abnormalities in these blood cells may sometimes be the first sign of lymphoma. Certain blood tests can be used to determine how aggressive a tumor may behave or whether a tumor is affecting the liver, kidneys, or other parts of the body.
BONE MARROW EXAMINATION
Bone marrow, is the spongy material found inside our bones. Bone marrow contains immature cells called stem cells, which develop into three main types of cells found in the body: red blood cells that deliver oxygen and take away the waste product carbon dioxide; white blood cells that protect the body from infection; and platelets that help blood clot. Hodgkin’s lymphoma can spread to the bone marrow; therefore, doctors may want to examine the marrow to see whether cancer is present. Bone marrow is obtained by numbing the skin, tissue, and surface of the bone with a local anesthetic, and then inserting a thin needle into the pelvis or other large bone and withdrawing a small sample. The procedure can be briefly painful at the moment when the marrow is withdrawn. Patients should talk with their doctor and nurse if they would like a calming medication before the procedure.
MOLECULAR DIAGNOSTIC TESTS
Over the past decade, scientists have gained a deeper understanding of how disease works at the level of molecules such as genes and proteins. This understanding has led to powerful new diagnostic tools and treatments. These tools include PCR, which can detect small amounts of genetic material DNA and a variety of immunological techniques that detect the expression of specific proteins (antigens or markers) on the surface of tumor cells. Using these tests, doctors can sometimes detect cancer earlier, and they can more accurately classify tumor types. This information may help the physician choose the most appropriate treatment for the disease. Immunological and genetic tests can find evidence of cancer unseen by a pathologist's microscope. An advantage of molecular diagnostic tests is that they are usually highly accurate and require only very small amounts of tissue obtained from biopsies, fine-needle aspirates, or sometimes blood.
Researchers are currently developing ways to measure the activity of genes within the cells of a lymphoma sample. This technique, microarray analysis, may lead to even more accurate diagnoses based on a tumor's individual genetic characteristics and behavior. Currently, this method is being used in an experimental setting for assessing non-Hodgkin's lymphoma tumors, but in the future the technique may be useful for the routine diagnosis and treatment of Hodgkin’s lymphoma as well.
OTHER TESTS
Doctors may also order other tests to evaluate the health of organs that could be affected by treatments. Examples include echocardiograms or radionuclide tests to evaluate the heart, and pulmonary function tests to evaluate the lungs.
Different types of Hodgkin's lymphoma
Hodgkin’s lymphoma has been divided into subtypes according to how it looks under the microscope. The type of tumor provides important information that may affect treatment choices. In each type of Hodgkin's lymphoma, the tumor cells and the Reed-Sternberg cells are mixed with many normal cells. The abnormal cells are usually in the minority. In all types of Hodgkin's lymphoma, the cancerous cells are thought to be abnormal B-lymphocytes.
SUBTYPES OF HODGKIN'S LYMPHOMA
The most common subtype of Hodgkin’s lymphoma is nodular sclerosis, followed by mixed cellularity. Two rare subtypes are lymphocyte predominant, which is indolent, and lymphocyte depletion, which is aggressive. A recently described fifth subtype is lymphocyte-rich classical Hodgkin's lymphoma. Hodgkin’s Lymphoma is now divided into “classical” lymphoma and lymphocyte predominant Hodgkin’s lymphoma as follows:
CLASSICAL HODGKIN’S LYMPHOMA
1. Nodular sclerosis: In this type of Hodgkin’s lymphoma, the involved lymph nodes contain areas composed of Reed-Sternberg cells mixed with normal white blood cells. The lymph nodes often contain prominent scar tissue, hence the name nodular sclerosis (scarring). This subtype is the most common, making up 60% to 75% of all cases of Hodgkin’s lymphoma. It is more common in women than men, and it usually affects adolescents and young adults. The majority of patients are cured with current treatments.
Mixed cellularity: In this type of Hodgkin’s lymphoma, the involved lymph nodes contain many Reed-Sternberg cells in addition to several other cell types. Scarring is not apparent. Mixed cellularity accounts for about 5% to 15% of all cases of Hodgkin’s lymphoma. It primarily affects older adults. More extensive disease is usually present by the time this subtype is diagnosed.
Lymphocyte-rich: This disease is characterized by the presence of very few abnormal cells and classical Reed-Sternberg cells, but numerous normal lymphocytes. This recently identified form of Hodgkin's lymphoma is rare, accounting for only 5% of all Hodgkin's lymphoma cases. It is usually diagnosed at an early stage, in adults.
Lymphocyte depletion: This Hodgkin’s lymphoma subtype has few normal lymphocytes, but abundant Reed-Sternberg cells. It is found in less than 5% of Hodgkin’s lymphoma cases and is usually not diagnosed until the disease is widespread.
LYMPHOCYTE PREDOMINANT HODGKIN’S LYMPHOMA
In this type of Hodgkin’s lymphoma, most of the lymphocytes found in the lymph nodes are normal (not cancerous), hence the name lymphocyte predominant. This subtype makes up about 5% to 10% of cases. Typical Reed-Sternberg cells are not found in this subtype, but abnormal cells, sometimes referred to as popcorn cells, can be seen. Lymphocyte predominant affects more men than women and is usually diagnosed in people under 35 years of age. This subtype is usually diagnosed at an early stage and is not very aggressive. In many ways this form of Hodgkin’s lymphoma resembles low-grade non-Hodgkin’s lymphoma.
TUMOR BULK
Tumor bulk refers to how much tumor is present. In general, the smaller the tumor, the better the chances that it will be completely eliminated by treatment. Patients with small tumors (called non-bulky disease) generally have a better prognosis than those with large tumors (bulky disease).
CANCER STAGING AND WHAT IT MEANS
Stage is the term used to describe the extent of tumor spread in the body. Hodgkin’s lymphoma is divided into four stages, depending on how far the disease has spread. Stages I and II are localized, while stages III and IV are considered advanced, widespread, or disseminated. Stage is an important piece of information that helps to predict outcome or prognosis and determine approaches to treatment.
STAGES OF HODGKIN'S LYMPHOMA
Stage I (early disease): the cancer is found only in a single lymph node or region.
Stage II (locally advanced disease): the cancer is found in two or more lymph node regions on one side of the diaphragm (the breathing muscle that separates the abdomen from the chest).
Stage III (advanced disease): the disease involves lymph nodes both above and below the diaphragm.
Stage IV (widespread disease): the lymphoma is outside the lymph nodes and spleen AND has spread to one or more organs such as bone, bone marrow, skin or liver.
MEANING OF THE LETTERS "A," "B," OR "E" AFTER THE STAGE
Each stage of Hodgkin’s lymphoma is further divided into "A" and "B" categories, depending on the symptoms patients have when they are diagnosed. Some patients have symptoms that affect their entire body (called systemic symptoms systemic symptoms). Examples of these include fever, night sweats, and weight loss. Patients who have these symptoms will have the letter "B" after the stage of their disease. The "A" category is used to designate a person with no systemic symptoms.
The category "E" is used when the Hodgkin’s lymphoma spreads locally from a lymph into the closely surrounding tissue.
