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Hodgkin’s Lymphoma
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Hodgkin’s Lymphoma Case Study
Kamille Laffins
Argosy University, Eagan Mn
March 31st, 2015
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Introduction
Within the past month and half I was able to be a part of a young man’s journey through
radiation therapy treatment for his Hodgkin’s lymphoma cancer. I followed him from his first
moment in my radiation oncology department until his follow up appointment. Throughout this
paper we will refer to this young man as Kylan. In this case study I will talk about Kylan’s
consultation, his experience in simulation, the treatment-planning aspects of his treatment and his
daily experience of treatment. I will also cover how well Kylan tolerated the process of receiving
radiation therapy. I will then conclude this case study with a research section that will discuss
Hodgkin’s lymphoma treatment options that are available currently.
Consultation
Kylan is a 21-year-old man with a diagnosis of Hodgkin’s lymphoma. For the first part
of Kylan’s consultation he met with one of my department’s nurses. She asked him the routine
first day questions. Those typically are to get an overall feeling of the patient’s well-being. At the
time of Kylan’s consultation he presented with little pain in the upper left shoulder region where
his mass is. He did have some pain in his jaw that was related to the last course of chemo he
received. He received four rounds of chemo, and his last round was to be three weeks before he
started his radiation treatment.
During the consultation Kylan was asked about his past medical history. He informed the
nurse and the doctor that prior to his Hodgkin’s diagnosis he has no previous illnesses. He had no
other symptoms, specifically no weight loss, fevers, chills, night sweats, alcohol intolerance,
pruritus, or other side effects. He has had no previous radiation, cancers, or collagen vascular
disorders. He has no nausea, fatigue, or any complaints, or family history of cancer. He was a
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healthy 21 year old man who was going to college. But not with the diagnosis he took a year off
to treat his cancer. At first Kylan presented with a painless lump in the clavicular area on his left
side. He ignored it for months until he started college and was able to see a nurse practitioner at
the school. They informed him to go to his primary care physician in order to have it looked at in
more depth.
After visiting with his primary care physician he underwent surgical excision. This was
done on September 25. The doctor described the area as multilobulated large collection of lymph
nodes in the supraclavicular fossa. This area was excised with pathology showing classical IIA
nodular sclerosing type Hodgkin lymphoma. Staining was positive for CD15 and negative for
CD20. A subsequent bone marrow biopsy was negative. Kylan did undergo imaging with a CT
scan of the chest, abdomen, and pelvis, as well as the mediastinum. There were postoperative
changes in the left supraclavicular fossa. With this change he underwent a PET scan on October
3rd. This PET scan showed an increase uptake in the operative bed in the left supraclavicular
fossa as well as in the mediastinum with bilateral involvement more prominent on the left than
the right. Other pertinent findings include LDH of 217 at presentation, a white blood cell count
of 5.4, hemoglobin of 12.6, platelet count 251,000.
After Kylan’s diagnosis he met with a chemotherapy doctor at my hospital. Prior to
receiving chemotherapy Kylan’s mediastinal mass measured 1x5.6x7.3cm. Kylan started his first
or four rounds of chemotherapy on October 27th. The treatment outlined by his chemotherapy
doctor was patterned after chemotherapy protocol AHOD 0031 for his stage IIA Hodgkin
Lymphoma. His chemotherapy consisted of ABVE/PC, or Adriamycin, bleomycin, vincristine,
etoposide, prednisone, and Cytoxan. He tolerated his chemotherapy reasonably well with some
abdominal discomfort and constipation. He began his second round of chemotherapy on
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November 18th. He then underwent a repeat PET scan on December 2nd to find complete
resolution of the areas of prior FDG avidity. He began his third cycle of chemotherapy on
December 9th, and the fourth on December 29th. He tolerated his chemotherapy reasonable well
but did require hospitalization for neutropenic fever after his last cycle. He also requires
transfusion after his last cycle of chemotherapy.
At the end of the consultation and receiving his past history of treatments Kylan was told
what would happen with his radiation treatments. He was informed about the simulation process
and how that differed from the actual treatments. He was also told about the future health risks
he could get after receiving radiation therapy. Kylan was very calm about the process and did not
have any questions, and was ready to go to the CT simulation room.
Simulation
Kylan was very calm in the simulation room. He was in the room with me, and our lead
therapist who is in CT simulation a lot. I informed his again about what we would be doing. We
have three verification questions that we ask every patient in order to make sure we in fact do
have the correct patient. We then took an identification photo for his chart. Kylan was the
instructed to undress from the waist up. I positioned him supine on the table with a Vac-Lok
under his torso. The Vac-Lok went from the top of his skull to the middle of his abdomen. In the
Vac-Lok we placed a clear-B head holder. This insured that his head would always be straight
for the treatments and in the same position. We ensured that his body was straight by using our
lasers. We then gave him a grip-ring to hold onto. This made sure that his arms would always be
in the same position for his treatments. He would hold it on his lower abdomen so that his
shoulders were pulled slightly down. Kylan also had a regular bolster under his knees for his
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comfort. After his body was positioned we then used the vacuum to harden the Vac-Lok so it
would keep the contours of Kylan’s body for his treatments.
Before we started the scan I made sure that Kylan understood what would happen. I
informed him that it was incredibly important to not move until we were completed with
everything. I stepped out of the room and proceeded with the scout scans. These scans are to
ensure that the patient is straight and that the CT scan will cover all anatomy you want. After the
doctor approved the scout scans I proceeded with the CT scan. We scanned from below the
orbits to about T-10. After the scan was completed I went to inform Kylan that the doctor was
choosing the exact spots he wanted to treat and that I would be coming back in to place tattoos.
After the doctor confirmed his isocenter I was able to use the lasers in order to two-point. I
placed two lateral tattoos on Kylan’s abdomen and a CA tattoo on his left supraclavicular region.
I also took photos to later place in the chart.
After the simulation was completed I was able to get Kylan off of the table. I had him get
dressed again and went over some patient education. I gave him a packet of information on skin
care and what to expect will happen through his treatment. I told him about the side effects he
could expect to have throughout treatment. Those included fatigue, loss of hair in the treatment
room, reddening of the skin where we are treating, loss of appetite, and the possibility of it
becoming harder to swallow. Again he was asked if he had any questions to which he denied. I
also let him know that if at any time during his treatments he had questions he would be able to
ask a therapist, or sit in with the nurse or the doctor. He was then done with his simulation and
went to the front desk to schedule his initial treatment day.
Planning
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After simulation Kylan’s CT scan was then sent to dosimetry so his plan could be
created. The doctor had contoured the CTV, heart and had already placed the beams he wanted to
use for treatment. He wanted to treat Kylan AP-PA. The dosimetrist and I started with cleaning
up the doctors contours, making sure that the margins were where they should have been placed.
We then contoured the spinal cord because it was within the treatment field. The lungs were both
contoured and a total lung dose was created so in the end we could see the total lung dose Kylan
would receive to both lungs.
After contouring the anatomy that would be within the treatment field we started
to change the beam energies and weighting. At first our PA field had several hot spots for
changing the beam weighting helped eliminate any hot spots. We decided after several attempts
that the step-and-shoot approach would be the best for Kylan’s treatment. The treatment plan
then created a dose grid which showed what dose the body parts we had contoured were
receiving. Our final plan ended up having the beam weighting of 54% AP and 46% PA with 97%
coverage. We did not have any wedges with the plan since the MLC could cover the region
better. Kylan was going to receive 14 fractions at 150 cGY, for a total of 2,100cGy. He would
receive treatment five days a week. Monday through Friday with no boost.
One of the main questions I encountered while planning this treatment was why
we chose to use a 6X beam and not 18X. This was because of the lung tissue interface. This
simply means that if you increase the beam energy with a dense tissue next to a non-dense tissue,
you will create a hot spot. This ends up meaning that you want to use the lowest energy possible
in order to avoid creating any hot spots.
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After the plan was created in dosimetry we needed the doctor’s approval. We
waited and had to adjust some percentages on the DVH, but once he was happy with the plan it
was sent over to out physicists. They then looked over the plan and approved it. Once this whole
process is done we could then begin treating Kylan.
Treatment
On the first day of treatment Kylan seemed to be a little nervous but denied having any
questions. He set up fairly well and seemed to lay comfortably in the Vac-Lok. We started with
imaging his treatment fields, at 0 and 180. We also took a MV of a lateral field at 90 degrees. We
had a few millimeter shifts to adjust to, but after that the doctor approved them and we were able
to treat. The first day went pretty smoothly for Kylan. We informed him of his doctor visit day
and that his next treatment would go much faster than his first day. We also told him that every
five days we would take an x-ray again to assure the doctor that we are treating the correct region
and that he was still positioned correctly. Throughout his treatment we only had to move him
once, and the move was only a couple millimeters shift.
Every Tuesday Kylan would meet with one of our nurses, the doctor, and me. I was only
in the room to watch what happened at weekly treatment. I learned that for most of these checkups we ask about skin care, fatigue, and pain. In the beginning Kylan denied having pain or any
type of skin irritation. Toward the end of his treatments Kylan’s skin on his back began to
become red. The nurses instructed him to put aquafor on the skin to sooth it. This seemed to help
with the irritation. The doctor closely monitored the skin and wanted to ensure that Kylan was
still getting enough exercise to fight any fatigue that could set in.
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Once Kylan was finished with his treatment he was scheduled to come back to the
department in three weeks to visit with the doctor and the nurse for a follow-up appointment. In
this visit the nurse asked how his skin had been and if he had been experiencing any type of side
effects. Kylan denied any type of irritation or side effects. The doctor told Kylan that the
radiation was still having effects on him and that it would not be unusual if he was experiencing
side effects. They again went over the life-long side effects that Kylan should be aware of, and
stressed the importance of wearing sun screen in the treated area and always wearing a shirt
while outside. Kylan seemed to be relieved to be fully done with treatment and the follow up.
The doctor then said to call if at any time he had questions, and sent him on his way to live his
now post cancer treatment life.
Hodgkin’s lymphoma
Hodgkin’s lymphoma is a disease of the lymphatic system. It is one of two cancers that
affect the lymphatic system; the other type of cancer is non-Hodgkin’s lymphoma which is far
more common than Hodgkin’s lymphoma. There are subtypes of Hodgkin’s lymphoma. People
diagnosed with classical Hodgkin’s lymphoma have large abnormal Reed-Sternberg cells in their
lymph nodes (Mayo, 2015). Subtypes of classical Hodgkin’s lymphoma are: nodular sclerosis
Hodgkin’s lymphoma, mixed cellularity Hodgkin’s lymphoma, lymphocyte-depleted Hodgkin’s
lymphoma, lymphocyte-rich classical Hodgkin’s lymphoma (Mayo, 2015). As Hodgkin’s
lymphoma progresses it compromises the way the person’s body can fight off infection. This
particular type of cancer is rare compared to a different cancer, such as breast cancer. Hodgkin’s
lymphoma is less than one percent of all cancer cases (Cancer Research UK, 2014).
Etiology
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The most common symptoms typically include swollen or tender lymph nodes in the
neck, armpit, and/or groin. These are typical sites for tenderness since this is where a patient’s
lymph nodes are. Some other symptoms for Hodgkin’s lymphoma are persistent fatigue, fever
and chills, night sweats, unexpected weight loss (up to as much as ten percent or more of their
body weight), loss of appetite, itching, and increased sensitivity to the effects of alcohol or pain
in their lymph nodes after drinking alcohol (Mayo, 2015). Not much is known about the etiology
of Hodgkin’s lymphoma, like almost all other cancers. Doctors know that most Hodgkin's
lymphoma occurs when an infection-fighting cell called a B cell develops a mutation in its DNA.
The mutation tells the cells to divide rapidly and to continue living when a healthy cell would
die. The mutation causes a large number of oversized, abnormal B cells to accumulate in the
lymphatic system, where they crowd out healthy cells and cause the signs and symptoms of
Hodgkin's lymphoma (Mayo, 2015).
Epidemiology
Hodgkin’s lymphoma is an uncommon disorder with an annual incidence of 2–3 per 100,000
in Europe and the USA (Thomas, 2002). Hodgkin’s lymphoma is most often diagnosed in
people between the ages of 15 and 30, as well as those older than 55. Also, males are slightly
more likely to develop Hodgkin’s lymphoma. People who have had illnesses caused by the
Epstein-Barr virus (such as infectious mononucleosis) are more likely to develop Hodgkin’s
lymphoma than people who haven’t had Epstein-Barr infections (Mayo, 2015). Another factor
that increases your risk of obtaining Hodgkin’s lymphoma is to have a close family member who
has Hodgkin’s lymphoma or non-Hodgkin’s lymphoma. Also having a compromised immune
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system, such as having HIV or AIDS from having an organ transplant requiring medications to
surpass the immune response increases the risk of Hodgkin’s lymphoma (Mayo, 2015).
Diagnostic Methods
Many people with Hodgkin’s lymphoma initially present with painless swelling of lymph
nodes in your neck, armpits or groin, persistent fatigue, fever and chills, night sweats, u
unexplained weight loss, or loss of appetite (Mayo, 2015). Diagnosis begins with a physical
exam paying special attention to the lymph nodes and other areas of the body that might be
affected, including the spleen and liver. Because infections are the most common cause of
enlarged lymph nodes, especially in children, the doctor will look for an infection in the part of
the body near any swollen lymph nodes. Next the doctor could order blood tests for signs of
infection or other problems (Mayo, 2015). Typically enlarged lymph nodes are caused by some
type of infection, and not Hodgkin’s lymphoma. So the doctor may wait a few weeks while
prescribing antibiotics to see if the swelling goes down. If the lymph node stays the same size
they will order a biopsy to see if it is indeed Hodgkin’s lymphoma. After the biopsy a CT scan,
MRI are obtained to evaluate the size and location of the mass. Also a PET scan may be obtained
to see if/where other cancer could be in the body.
Staging
Hodgkin’s lymphoma very rarely starts in an organ other than a lymph node, but it can
invade surrounding organs. Staging is based on: your medical history (if you have certain
symptoms), the physical exam, biopsies, imaging tests, which typically include a chest x-ray, CT
scan of the chest/abdomen/pelvis, and PET scan. It is also based on blood tests and bone marrow
aspiration. The staging system for Hodgkin disease is known as the Cotswold system, which is a
modification of the older Ann Arbor system. It has 4 stages, labeled I, II, III, and IV (American
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Cancer Society, 2014). With Hodgkin’s disease if organs outside of the lymph system are affects
the letter E is added to the stage. And if it involves the spleen the letter S is added.
Stage one for Hodgkin’s disease is where only one lymph nose or lymphoid organ is
affected. Stage one is also when the cancer is only found in one area of a single organ outside of
the lymph system. Stage two is defined as having disease within two or more lymph node areas
on the same side, above or below the diaphragm. It is also when the cancer extends locally from
one lymph node area into a nearby organ. Stage three of Hodgkin’s disease is where disease is
found on both sides of the diaphragm, or when it has also spread to a nearby organ, to the spleen,
or both. Stage four disease is when disease has spread widely through one or more organs
outside of the lymph system, also when it is found in organs in two distant parts of the body, or
in the liver, bone marrow, lungs, or cerebrospinal fluid (American Cancer Society, 2014).
Treatment Options
Treatment options for Hodgkin’s disease are dependent on the stage of the disease. Stages
one and two for Hodgkin’s lymphoma have favorable outcomes. They are usually treated with
chemotherapy alone. They usually receive four to six rounds of chemotherapy. Another option
for stage one and two Hodgkin’s lymphoma patients is to undergo two to four rounds of
chemotherapy along with radiation therapy to the original site of the disease (American Cancer
Society, 2014).
When Hodgkin’s lymphoma is at stage three or four doctors usually treat with more
intense regiments of chemotherapy. While some stage three and four Hodgkin’s lymphoma is
treated with at least six cycles of chemotherapy, most are treated with a more intense regimen for
at least twelve weeks (American Cancer Society, 2014). Radiation therapy would be given to
these patients after they complete chemotherapy if the original site of the disease was a larger
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mass. Some patients may not even respond to treatment, in which they would receive a stem cell
transplant.
Analysis
Current treatment options for Hodgkin’s disease corresponded with what treatment Kylan
receive. Kylan had stage II nodular sclerosing Hodgkin lymphoma. Current research says that
stage two Hodgkin’s lymphoma be treated with four to six rounds of chemotherapy. The only
alternative is that Kylan was also treated with radiation therapy to the location of his original
disease.
In the very beginning of Kylan’s treatment he had his mass surgically removed. After the
surgery they found that not all of the mass had been removed so he then went through four
rounds of chemotherapy and fourteen fractions of radiation therapy. In most cases with
Hodgkin’s lymphoma most patients will have some type of surgery to remove part or all of their
mass. The next step of their treatment would then be chemotherapy. So Kylan’s treatment
followed what is common practice. He did not have any type of biotherapy, as it is not a common
practice for Hodgkin’s lymphoma patients.
The role of radiation therapy for Kylan was a little different than it would be for other
Hodgkin’s lymphoma patients. Kylan’s mass was large in comparison to other Hodgkin’s
patients. So when the mass was not fully removed and after he went through chemotherapy his
doctors decided that it would be in Kylan’s best interest to go through radiation therapy. Because
of the mass’ size the radiation would give Kylan a better chance of his cancer to not reoccur later
on in life. After having surgery, chemotherapy and radiation therapy Kylan’s doctors are very
hopeful that Kylan will not have any reoccurring disease and will lead a long healthy life.
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References
Diagnosis of Hodgkin's Disease. (2014, July 10). Retrieved from
http://www.cancer.org/cancer/hodgkindisease/detailedguide/hodgkin-disease-diagnosis
Hodgkin's Lymphoma. (2015, January 1). Retrieved March 26, 2015, from
http://www.mayoclinic.org/diseases-conditions/hodgkinslymphoma/basics/definition/con-20030667
Hodgkin lymphoma Key Stats. (2014, November 27). Retrieved from
http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/hodgkinlymphoma/hodgkin-lymphoma
Thomas, R. (2011, April 17). Epidemiology and etiology of Hodgkin’s lymphoma. Retrieved
from http://annonc.oxfordjournals.org/content/13/suppl_4/147.full.pdf
Treating classic Hodgkin disease, by stage. (2014, January 1). Retrieved from
http://www.cancer.org/cancer/hodgkindisease/detailedguide/hodgkin-disease-treating-bystage