Hodgkin lymphoma (Hodgkin disease) is a rare cancer of unknown cause that spreads along the lymphatic system. Disease occurrence has a familial pattern. It is somewhat more common in men than in women and has two peaks of incidence: one from age 15 to 34 and the other after 60 years of age. It is seen more commonly in patients receiving chronic immunosuppressive therapy (e.g., for kidney transplantation), in veterans of the military who were exposed to the herbicide Agent Orange, and in patients with IgA or certain types of IgG deficiency. The 5-year survival rate is 90% for more limited disease (stage I or II), and 65% for those with more extensive disease (stage IV).

Unlike other lymphomas, Hodgkin lymphoma is unicentric in origin in that it initiates in a single node. The disease spreads by contiguous extension along the lymphatic system. The Reed-Sternberg cell, a gigantic morphologically unique tumor cell that is thought to be of immature lymphoid origin, is the pathologic hallmark and essential diagnostic criterion for Hodgkin lymphoma. The cause of Hodgkin lymphoma is unknown, but a viral etiology is suspected. Although fragments of the Epstein-Barr virus have been found in some Reed-Sternberg cells, the precise role of this virus in the development of Hodgkin lymphoma remains unknown. Hodgkin lymphoma is customarily classified into five subgroups, based on pathologic analyses that reflect the natural history of the malignancy and suggest the prognosis. Most patients with Hodgkin lymphoma have the types currently designated nodular sclerosis or mixed cellularity. The nodular sclerosis type tends to occur more often in young women (and at an earlier stage) but has a worse prognosis than the mixed cellularity subgroup, which occurs more commonly in men and causes more constitutional symptoms.

• Painless enlargement of the lymph nodes occurs on one side of the neck. Individual nodes are firm; common sites are the cervical, supraclavicular, and mediastinal nodes.
• Mediastinal lymph nodes may be visible on x-ray images and are large enough to compress the trachea and cause dyspnea.
• Pruritus is common and can be distressing; the cause is unknown. Herpes zoster infection (shingles) is common.
• Some patients experience brief but severe pain after drinking alcohol, usually at the site of the tumor.
• Symptoms may result from the tumor compressing other organs, causing cough and pulmonary effusion (from pulmonary infiltrates), jaundice (from hepatic involvement or bile duct obstruction), abdominal pain (from splenomegaly or retroperitoneal adenopathy), or bone pain (from skeletal involvement).
• Constitutional symptoms, for prognostic purposes referred to as B symptoms, are found in 40% of patients and are more common in advanced disease; these include fever (without chills), drenching sweats (particularly at night), and unintentional weight loss of more than 10% of body weight.
• Mild anemia develops; leukocyte count may be elevated or decreased; platelet count is typically normal, unless the tumor has invaded the bone marrow, suppressing hematopoiesis.
• Impaired cellular immunity (evidenced by an absence of, or decreased response to, skin sensitivity tests such as candidal infection, mumps) may be noted.
• Erythrocyte sedimentation rates (ESR) and serum copper level evaluations are sometimes used to assess disease activity.

• Because many manifestations are similar to those occurring with infection, diagnostic studies are performed to rule out an infectious origin for the disease.
• Excisional lymph node biopsy and the finding of the Reed-Sternberg cell confirm the diagnosis.
• Assess for any B symptoms; perform physical examination to evaluate the lymph node chains as well as the size of the spleen and liver.
• Chest x-ray and a CT scan of the chest, abdomen, and pelvis are used; positron emission tomography (PET) scan may identify residual disease.
• Laboratory tests include complete blood cell count, platelet count, ESR, and liver and renal function studies.
• Bone marrow biopsy and sometimes bilateral biopsies can be used.
• Bone scans may be performed.

The goal in the treatment of Hodgkin lymphoma is cure. Treatment is determined by the stage of the disease instead of the histologic type. Treatment of limited-stage Hodgkin lymphoma commonly involves a short course (2 to 4 months) of chemotherapy followed by radiation therapy to the specific involved area. Combination chemotherapy with doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban), and dacarbazine (DTIC) is referred to as ABVD and is considered the standard treatment for more advanced disease (stages III and IV and all stages with B symptoms). Other combinations of chemotherapy may afford higher response rates but result in more toxicity. Chemotherapy is often successful in obtaining remission even when relapse occurs. Transplantation is used for advanced or refractory disease. The development of complications from treatment may not occur for years, so long-term surveillance is crucial. In large, population-based studies of Hodgkin lymphoma survivors, the estimated risk of developing a second cancer was between 18% and 26%. Hematologic malignancies are the most common; solid tumors can also occur. Cardiovascular toxicity is the second leading cause of death after malignancy.

See “Nursing Management” under Cancer in Section C for additional information about nursing interventions for patients undergoing chemotherapy and radiation treatments.

• Address the potential development of a second malignancy with the patient when treatment decisions are made; it is also important to tell patients that Hodgkin lymphoma is often curable.
• Encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol, and exposure to environmental carcinogens and excessive sunlight.
• Screen for late effects of treatment (e.g., immune dysfunction, herpes infections [zoster and varicella]; pneumococcal sepsis).
• Provide education about relevant self-care strategies and disease management.

For more information, see Chapter 34 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.