Overview

Symptoms

The most common symptom of Hodgkin's 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 is highly unlikely that you have Hodgkin's lymphoma if you have swollen lymph nodes, as these glands often swell as a response to infection.

Read more information about lumps and swellings.

Other symptoms

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

• night sweats
• unexplained weight loss
• fever (high temperature)
• 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 lymphoma is in the abdomen (tummy), you may have abdominal pain or indigestion.

A few people with Hodgkin’s lymphoma have abnormal cells in their bone marrow when they are 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

In some cases, people with Hodgkin’s lymphoma may have pain in their affected lymph gland when they drink alcohol.

When to seek medical advice

See your GP if you have any of the above symptoms, particularly if you have persistently swollen glands with no other signs of infection.

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

Who can get it

Hodgkin's lymphoma is caused by a change (mutation) in the DNA of a type of white blood cell called B lymphocytes, although 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:

• having a medical condition that weakens your immune system, such as HIV
• having medical treatment that weakens your immune system –for example, taking medication 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

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.

Hodgkin lymphoma can occur at any age, although most cases are diagnosed in people in their early 20s or 70s. The condition is slightly more common in men than women.

Diagnosis

If you go to see your GP concerned about symptoms of Hodgkin lymphoma, they will ask about your health and carry out a simple physical examination.

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

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of Hodgkin lymphoma and refer people for the right tests faster.

To find out if you should be referred for further tests for suspected Hodgkin lymphoma, read the NICE 2015 guidelines on Suspected cancer: recognition and referral.

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.

Biopsy

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

Biopsies can often be carried out under a local anaesthetic (where the area is numbed). In some cases, the affected lymph node isn't easily accessible and a general anaesthetic may be required (where you're asleep).

A pathologist (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 lymphoma you have, which is an important factor in planning your treatment.

Further testing

If a biopsy confirms a diagnosis of Hodgkin's lymphoma, further testing will be required 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 kidney, are working.
• Bone marrow sample – another biopsy may be carried out to see if the lymphoma 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 your lymphoma 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 the testing is complete, it should be possible to determine the stage of your lymphoma. Staging means scoring the cancer by how far it has spread.

The main stages of Hodgkin lymphoma are:

• Stage 1: the cancer is limited to one 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: two 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's 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 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. In a few cases, chemotherapy may be combined with steroid medication.

Surgery is not 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 treatment for cancer where medicine is used to kill cancer cells. This medication can be given in a number of different ways depending on the stage of your cancer.

If doctors think that your cancer is curable, you will 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: this may be temporary or permanent

Most side effects should pass once your treatment has finished. However, 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 will destroy your bone marrow, leading to the problems mentioned above. You will therefore require 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 one part of the body.

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

Radiotherapy itself is painless, but it has some common side effects. These can vary, depending on which part of your body is being treated. For example, if the affected lymph nodes are in your throat, radiotherapy 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 is a risk of long-term problems, including infertility and permanently darkened skin in the treatment area.

Steroid medication

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

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

Common side effects of steroid medication include:

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

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

Rituximab

If you are diagnosed with a rare type of Hodgkin lymphoma called lymphocyte-predominant Hodgkin lymphoma, you may have chemotherapy in combination with a medication called rituximab.

Rituximab is a type of biological therapy called a monoclonal antibody. It attaches itself to the surface of cancerous cells and stimulates the immune system to attack and kill the cell.

It is given through a drip directly into a vein over the course of a few hours.

Side effects of the drug can include:

• flu-like symptoms, such as headaches, fever and muscle pain
• tiredness
• nausea
• diarrhoea

You may be given additional medication to prevent or reduce side effects. Any side effects should improve over time as your body gets used to the medication.

Brentuximab vedotin

Brentuximab vedotin is a relatively new drug used to treat a particular type of Hodgkin lymphoma.

It is available on the NHS for people with CD30-positive Hodgkin lymphoma who:

• have already had a stem cell transplant using their own cells or cannot have chemotherapy
• cannot have a stem cell transplant using their own cells, but have already had at least 2 other treatments

It is given in the same way as rituximab, but the treatment session takes around 30 minutes.

Side effects of brentuximab vedotin include:

• skin rash
• shortness of breath
• cough
• fever
• back pain
• chills
• headache
• feeling sick (nausea) or being sick (vomiting)

Follow-up

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

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

Want to know more?

For more information, see:

• Cancer Research UK: treating Hodgkin lymphoma
• Cancer Research UK: living with Hodgkin lymphoma
• Macmillan: treating Hodgkin lymphoma
• Macmillan: living with Hodgkin lymphoma

Your multidisciplinary team

During your treatment for Hodgkin lymphoma, you may see any of the following professionals:

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

Complications

Some people treated for Hodgkin lymphoma experience long-term problems, even if they have 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 are being treated.

If you have a weak immune system, you are more vulnerable to infections and there is 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 also make sure 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.

In some cases, it may be possible for men to store samples of their sperm and for women to store their eggs before treatment, so these 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 you're treated for Hodgkin lymphoma. Rarely, other types of cancer, such as leukaemia or other lymphomas, develop after only a few years.

You can help 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.