Comprehensive Report: Hodgkin's Lymphoma and the Lymphatic System

This report provides a detailed overview of Hodgkin's Lymphoma, a cancer affecting B-lymphocytes within the lymphatic system. It explores the structure and function of the lymphatic system, including lymph vessels, nodes, and organs like the spleen and thymus. The report discusses the disease's causes, symptoms, and diagnostic methods, emphasizing the presence of Reed-Sternberg cells. It also covers the classification and staging of Hodgkin's Lymphoma. Furthermore, the report examines various treatment modalities, including chemotherapy, radiotherapy, immunotherapy, and stem cell/bone marrow transplants, detailing their mechanisms and potential side effects. References to relevant research and medical publications are also included, providing a comprehensive understanding of the disease and its management.

The lymphatic System in Hodgkin’s Lymphoma
Introduction
Lymphatic System consists of the lymphatic vessels, lymph and lymph nodes, bone marrow and
organs like the spleen, tonsils, and thymus. It is involved in draining fluid from tissues,
absorption of fat-soluble vitamins and its main role is the promotion of the body’s immunity
through the production and development of lymphocytes. The lymphatic system acts as the first
line of defense in the body (inmate immunity).1
Lymph is milky in appearance due to fats absorbed into the lacteals and is the substance
transported within the lymphatic system. It carries away bacteria as well as cell debris from
tissues to lymph nodes. Lymphocytes and antibodies are within lymph and help in immune
surveillance. Lymph vessels are found all over the body except within the Central Nervous
System. They slow the entry of soluble substances and cells into the lymphatic system. Lymph
capillaries have greater permeability to interstitial fluid components than blood capillaries. The
lymph capillaries link to form larger lymph vessels that join forming the thoracic and right
lymphatic ducts which empty into the subclavian vein. Ducts eliminate fluid containing immune
activity by-products from zones of infection and inflammation. Lymph vessels contain valves
that help to ensure one direction flow of lymph. Adjacent muscle contract to push the lymph
along. Lymph passes to the lymph nodes. These are found throughout the body. Lymph nodes
exist as grape-lie clusters and filter waste and debris from lymph ducts. It is cells within lymph
nodes that neutralize and degrade these substances. Lymphocytes occur in the lymph nodes as
well and protect against pathogens such as bacteria and viruses. Macrophages and antibodies are
also present in lymph nodes. The spleen is important for blood storage, fetal blood cell
production as well as the destruction of erythrocytes. In immunity, spleen caries out
phagocytosis of microbes and contains T and B-lymphocytes are activated in times of disease.
Lymphocytes enter the thymus and mature being able to distinguish self and foreign antigens. It
is from the thymus that T-lymphocytes are produced into the bloodstream.

Diagrams showing the Lymphatic system and valves within the lymphatic vessels.
Key:
M- Lacteals x- Abdominal lymph nodes, y- supratrochlear lymph nodes z- popliteal lymph
nodes
Hodgkin’s Lymphoma affects the B-lymphocytes which multiply without control and
accumulate in lymph nodes. The B lymphocytes, however, are incapable of providing the body
defense again pathogens. The cancerous cells are usually five times larger than the healthier cells
and the presence of Reed-Sternberg cells in a biopsy of lymph nodes is indicative of Hodgkin’s
Lymphoma. It may spread from one primary lymph node, for instance, those in the neck to other
lymph nodes in the body via lymph. Progression of the Lymphoma may be through a spread in
blood and affect organs within the lymphatic system and beyond the system. The body’s ability
to fight diseases is thus compromised (immune suppression). The main cause remains unknown.
It is associated with Epstein - Barr virus (EBV) and occurs in all ages but particularly in those
over 55 years and from 15 up to 40 years. Classification is based on the site of origin and spread.
It can be nodular predominant lymphoma or the classical kind
A typical case of a patient with Hodgkin’s Lymphoma is evaluated by an evaluation of the
previous family and personal medical histories. Tests are carried out with the physical
examination involving the checking lymph nodes that are swollen in neck, groin or underarm.
The swelling of the liver or spleen is also looked into. Laboratory tests include lung, liver, and
kidney function tests as well as an investigation of the presence of CD15 andCD30 proteins
which are found in the cells confirming Hodgkin’s Lymphoma - Reed-Sternberg. Blood count
and erythrocyte sedimentation assays can also be carried out. Imaging in the form of x-rays,
Positron emission tomography (PET /CT scan) and Magnetic Resonance Imaging (MRI) may be
done. Biopsies are done usually of a part of a tumor or a whole lymph node or the bone marrow.
Staging follows this with classification from stage 1 to 4. Symptoms tend to be lymph node
swelling with a painless lump and having a rubbery feel. This is usually on the neck, then
armpits and finally groin. In some cases, symptoms exist without enlarged nodes being observed.
(“B Symptoms “– nonspecific and common in infection but not in malignancies. These include
fever, night sweats, and weight loss) others are itchy skin, fatigue, enlarged spleen and paining
lymph nodes following alcohol consumption.2
Treatment of Hodgkin’s Lymphoma depends on several factors. These include the stage of
cancer, the general health state of the individual, age and at times the preferences of the patient.
Other factors to consider are potential long and short-term toxicities and potential for relapse.
The common therapies are Chemotherapy, Radiotherapy, and Immunotherapy, Transplantation
of bone marrow or stem cells and use of steroids. Localized Hodgkin’s is treated with radiation
therapy or with both chemotherapy and radiation. Chemotherapy is used where the beam cannot
reach all regions.

Radiotherapy: It may be enough for early-stage nodular lymphoma. Radiation destroys
lymphoma cells preventing the spread and reducing sizes of tumors in the spleen or the lymph
nodes. This is through the use of x-ray radiation. The uncontrolled proliferation of cancerous
tissues makes them more prone to radiation. This therapy method is the oldest. Nevertheless, it
can have long term consequences among them skin changes, lung inflammation, heart problems
and the possibility of second cancer. Immediate effects include reddening or darkening of the
skin, weakness, and tiredness, body hair loss, and diarrhea. There is a shift towards an integration
of radiotherapy with chemotherapy, particularly for early stages.3
Chemotherapy: Also called antineoplastic agents. They are based on the use of cytotoxic drugs
that kill cancerous cells in the blood or cytostatic drugs that inhibit proliferation. Chemotherapy
may take the form of salvage or induction. The rapidly dividing cancer cells are more susceptible
to the effects of chemotherapy. This happens through the arrest of the cell cycle. This can be
through nonspecific means which halt the cycle in any step, the resting state included. Specific
mechanisms target specific steps within this cycle. They can also include alkylating agents,
topoisomerase inhibitors, mitotic inhibitors, antimetabolites, antibiotics, enzymes, tyrosine
kinase inhibitors, and proteasome inhibitors. Pyrimidine and purine inhibitors ensure DNA
replication and synthesis of nucleotide constituents are halted. Age, dosage levels and type of the
drug determine the side effects. There is generally: hair loss, fatigue, loss of appetite, diarrhea,
weight loss, and bleeding.
Immunotherapy:
Stimulate the immune system and help in the identification and killing of cancerous cells. Also
referred to as targeted therapy: Discriminate cancers from healthy cells by targeting their
elimination and improving immunity by seeking cancer cells with particular surface proteins. .
Brentuximab which targets the CD30 protein in the lymphoma cells. The drug sticks to CD30
protein and delivery is done to the cell and then the cancer cell is killed. And Rituximab (adhere
to CD20 proteins on cancer cells which are recognized by the immune system and killed). These
are used as monoclonal antibodies. Common side effects are allergies, tiredness, skin rashes, and
diarrhea. Stem cell and Bone marrow transplants:
Usually after high doses of Chemotherapy or with patients who have a relapse or have a poor
response to previous treatments. This helps the production of new blood cells. Transplant of stem
cells is preferred since blood cells often recover much quicker and the ease of collecting these
cells, unlike bone marrow.
Common side effects are graft- versus- host disease where the donor cells attack the recipient’s
blood cells, increased risk of infections and bleeding.

REFERENCE LIST
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lymphoma: A young radiation oncologists’ perspective. Reports of Practical Oncology &
Radiotherapy Volume 17, Issue 5, September–October 2012, Pages 246-250.
https://doi.org/10.1016/j.rpor.2012.05.003 Elsevier
A Waugh and A Grant Ross and Wilson Anatomy and Physiology in Health and Illness,
Elsevier,2004.
CancerResearchUK What is
Lymphoedema?cancerresearchuk.org/about-cancer-/coping/physically/lymphedema-and-
cancer/what-lymphoedema-is/ (accessed 16 March 2020).
R Meyer, M Gospodarowicz, J Connors, R Pearcey, W Wells, J Winter, S Horning, A Dar, C
Shustik, D Stewart, and M Crump. ABVD alone versus radiation-based therapy in limited-stage
Hodgkin's lymphoma. New England Journal of Medicine. 2012 Feb 2;366(5):399-408.
Y Nieto, U Popat, P Anderlini, B Valdez, B Andersson, P Liu, C Hosing, EJ Shpall,A Alousi, P
Kebriaei, and M Qazilbash. Autologous stem cell transplantation for refractory or poor-risk
relapsed Hodgkin's lymphoma: effect of the specific high-dose chemotherapy regimen on
outcome. Biology of Blood and Marrow Transplantation. 2013 Mar 1;19(3):410-7.
W Townsend D Linch Hodgkin's lymphoma in adults. The Lancet. 2012 Sep 1;380(9844):836-47
1
1 1.Waugh Anne and Grant Allison Ross and Wilson Anatomy and Physiology in Health and
Illness, Elsevier ,2004
2.Townsend Wand Linch w Hodgkin’s Lymphoma in adults. The lancet .2012 sep
1:380(9844):836-47
3.Meyer R, Gospodarowicz M, Connors J, Pearcey R, Wells W , Winter J, Horning S , A Dar ,
Shustik C , Stewart D ,and Crump M. ABVD alone versus radiation-based therapy in limited-
stage Hodgkin's lymphoma. New England Journal of Medicine. 2012 Feb 2;366(5):399-408.