Childhood Hodgkin's Lymphoma: Diagnosis

Diagnosing Hodgkin's in a child can be difficult - a parent or loved one may see changes in their child. The symptoms of childhood Hodgkin's lymphoma may include any of the following: painless swelling of the lymph nodes in the neck or underarm area that does not go away within a few weeks; fever that does not go away; night sweats; and weight loss without dieting. A medical examination may lead to a diagnosis of Hodgkin's. It often seems the diagnosis comes as a surprise and a shock.

Making the Diagnosis:

Once the medical team has a suspicion of Hodgkin's Lymphoma, if the lymph nodes don't feel normal when examined by a doctor, the doctor may need to extract a small piece of tissue and look at it under the microscope to see if there are any cancer cells. This is called a biopsy. The cells they look for are Reed-Sternberg cells, a cell specific to Hodgkin's Disease.

(Picture - Reed-Sternberg Cell)

(Picture - A Lymph Node Sample of Hodgkin's)

Other tests your medical team may do include the following:

• A physical exam including examining the lymph nodes
• Collecting a medical history and history of symptoms
• A complete blood work-up including checks for abnormal blood cell count, blood chemistry, and abnormal sedimentation rate
• A chest x-ray to view lymph nodes and to see if other organs are involved
• A computerized tomography (CT or CAT) scan, positron emission tomography (PET) scan and/or magnetic resonance imaging (MRI) scan of the chest, pelvis, and abdomen to determine the possible spread of the disease
• A gallium scan to check for radioactive intake of gallium in the lymph system indicating swelling and ultimately disease
• A bone marrow aspiration and biopsy to determine if the bone marrow has been affected by lymphoma; in this procedure the hip is numbed (ask for EMLA cream or similar to numb the site beforehand at home) and a needle is inserted into the bone; liquid bone marrow and a bone chip are extracted and the tissue is examined under a microscope

Certain medical centers may perform additional tests, including

• Exploratory surgery (staging laparotomy) to determine the extent of the disease. In some cases the spleen is removed if it is the only organ affected. A tissue sample may also be taken of the liver. The child may receive medicine to prevent infection.
• A lymphangiogram, a procedure during which a radio-opaque liquid is injected into the lymph system through the feet; the fluid travels throughout the lymph system and remains visible by x-rays for up to six months

Most centers will not perform these procedures, especially on children.

Examination Tip

There is a cream called EMLA that is used to dull skin pain. It is often used prior to pediatric biopsies and even some injections. It may not be routinely offered but it is worth asking for.

Once a biopsy sample is taken, it is classified into one of five types of Hodgkin's shown below. This typing is called the histology of the disease.

Types of Hodgkin's Lymphoma:

• Nodular sclerosis (NS). The lymph nodes in the lower neck, chest and collarbone usually contain normal and reactive lymphocytes and Reed-Sternberg cells separated by bands of scar-like tissues.
• Lymphocyte predominance (LP). The lymph nodes are composed largely of reactive lymphocytes and malignant L&H cells which have a "popcorn" appearance and very few Reed-Sternberg cells.
• Mixed cell (MC). The lymph nodes usually contain Reed-Sternberg cells and inflammatory cells.
• Lymphocyte depleted (LD). There are two different variations of this classification: one with sheets of differing malignant cells; the other with few Reed-Sternberg cells and lymphocytes with scar-like tissue.
• Nodular lymphocyte predominance Hodgkin's lymphoma

The medical team will also stage the spread of the lymphoma. There are four stages which depend on how far the cancer has spread through the body:

Stages of Hodgkin's Lymphoma:

• Stage I: Cancer is found in only one lymph node area or in only one area or organ outside of the lymph nodes.
• Stage II: Either of the following means the disease is stage II:
• Cancer is found in two or more lymph node areas on the same side of the diaphragm (the thin muscle under the lungs that helps you breath).
• Cancer is found in only one area or organ outside of the lymph nodes and in the lymph nodes around it. Other lymph node areas on the same side of the diaphragm may also have cancer.
• Stage III: Cancer is found in lymph node areas on both sides of the diaphragm. The cancer may also have spread to an area or organ near the lymph node areas and/or to the spleen.
• Stage IV: Either of the following means the disease is stage IV:
• Cancer has spread in more than one spot to an organ or organs outside of the lymph system. Cancer cells may or may not be found in the lymph nodes near these organs.
• Cancer has spread to only one organ outside of the lymph system, but lymph nodes far away from that organ are involved.

Staging is also dependent on whether the child has had a group of symptoms including night sweats, fever, or weight loss. A child who has had one or more of these are grade "B" while patients who have none grade "A". Itching and back pain are not symptoms which rate the "B" designation but can be common in many cases where "B" symptoms are evident.

The letter "E" is used when the disease has spread to other organs such as the bone marrow, lung, spleen, etc.

Please look at the treatment and resource sections for more information on Childhood Hodgkin's Lymphoma. Note - physician information is often technical. Take the information you find to discuss with your doctor and medical team. A glossary is available if terms are unfamiliar.

Related Articles

Childhood lymphoma

Childhood Hodgkin's Lymphoma: Treatment

Childhood Hodgkin's Lymphoma: Chemotherapy

Childhood Lymphoma: Radiotherapy

Childhood Hodgkin's Lymphoma: Introduction

Childhood Lymphoma: Resources

Childhood Lymphoma: Just for Kids & Teens

Resources

Hodgkin's Disease, Peter M. Mauch (Editor), James O. Armitage (Editor), Volker Diehl (Editor), June 1999

- Chapter 30: Pediatric Hodgkin's Disease.
How Is Hodgkin (sic) Disease in Children Diagnosed? - ACS.
Childhood Hodgkin's Diagnosis - curehodgkins.com - this mostly copies information from this page (!)

Testing

Blood Count and Sedimentation Rate Information
Blood Counts for KidsUniversity of Iowa
The Bone Marrow Biopsy - MedlinePlus
Tissue Testing(Biopsy)
MRI Scans - detailed information
CT and PETScan Information
Gallium Scans - detailed information
Lymphoma: Methods and Protocols, Illidge & Johnson, 2005, more for professionals but cutting edge.

Hodgkin's Typing and Staging

The NCI Data Sheet for Pediatric Hodgkin's (Patient)
Hematopathology - Hodgkin's Types (more technical) - Dr. David Weissmann

Other pages you may want to visit:

Lymphoma Information Network
Adult Hodgkin's Lymphoma Resource Pages