Hodgkin’s Lymphoma
Patient Presentation
A 21 year old college senior, E.K., presented to her primary care doctor with a singular enlarged cervical lymph node that had become increasingly large over a three week period. Patient reports no cold/infection like symptoms prior to the increasing size. The lymph node was not tender and other than the increasing size, did not bother this senior about to graduate. The primary care doctor sent the patient for a CT scan of the neck with IV contrast.
Differential Diagnosis
The primary care doctor believed the swollen lymph node to simply be lymphadenopathy, cat scratch disease or a benign swollen lymph node. The doctor told the patient she was too young and healthy to have any significant issue/disease from this lymph node and told her the CT scan was inconclusive.
Diagnosis
The college student returned to school and within two weeks another lump had appeared on her right cervical lymph nodes as well as her clavicle region. She decided to schedule a visit with her ear, nose and throat doctor. The otolaryngologist was much more concerned than the primary care doctor had been. He sent the patient for an MRI of her neck and also performed a needle aspiration biopsy in his office. The MRI returned suggestive of a “lymphoma” and the needle aspiration biopsy on her lymph node was inconclusive. The next step was a lymph node biopsy of her cervical lymph nodes. The outpatient surgical procedure was scheduled and two large right cervical lymph nodes were removed and sent for pathology. A week later at a return visit for suture removal, the diagnosis was given to this young patient, Hodgkin’s lymphoma. The tissue had revealed Reed-Sternberg cells as well as the Epstein-Barr virus. Reed Sternberg cells are the characteristic cell of Hodgkin's lymphoma and can only be seen under a microscope. It is believed the patient also displayed Epstein-Barr cells in her lymph nodes because she had previously been diagnosed with mononucleosis, a factor in her development of this cancer. The patient was referred to an oncologist the next day to be evaluated for treatment. Blood tests were drawn and the patient was sent for a PET/CT scan to stage the cancer. The PET/CT staged the cancer at IIA; the cancer involved more than one lymph node on one side of the diaphragm. This patient had diseased lymph nodes in her neck, clavicle area, and her chest, some the size of golf balls. The “A” in her staging meant she did not suffer from night sweats, or any other ill effects of the cancer other than the swollen lymph nodes.
Treatment
The oncologist recommended the most common form of treatment for Hodgkin’s lymphoma, chemotherapy. The patient first underwent pulmonary function tests as well as an echocardiogram to establish baseline functioning, as some of the chemotherapy drugs could damage her lungs and heart. The patient started on a chemotherapy regimen called ABVD, a combination of four chemotherapy drugs given intravenously every other Friday for six months. The patient had a mediport placed to eliminate damage to her veins and also had to receive Neupogen® shots due to her increasing neutropenia following chemotherapy weeks.
Outcome
The patient continued with college and finished her last semester while coming home every other Friday for chemotherapy. The patient eventually lost her hair and suffered from the usual side effects associated with chemotherapy treatment. She was able to graduate on time and finish chemotherapy. The patient had a clean PET/CT scan half-way through her treatment course but finished the remainder in hopes to cure her cancer. Hodgkin’s Lymphoma is one of the cancers that can be cured following treatment. This patient continued to meet with her oncologist every six months and had a PET/CT scan at that time. The patient is now a healthy 25 year old with no evidence of disease and within the next two years expects to be “cured” of her cancer. She will continue to be followed by her oncologist due to the chance of developing another cancer later in life and she continues to have a suppressed immune system because the cancer damaged her lymphatic system.
Case created by Erica Kunkel, 2011.