Understanding Hodgkin Lymphoma: The Diagnosis

How does Hodgkin lymphoma progress?

Hodgkin lymphoma develops when a lymphocyte becomes abnormal. That abnormal cell is called the Reed-Sternberg cell. This cell divides and gives rise to new dividing abnormal cells.   This process causes more and more abnormal cells to exist. What makes Hodgkin lymphoma unusual is that the abnormal Reed-Sternberg cells sends out messengers that attract millions of normal cells.  For this reason, most of the cells in a Hodgkin lymphoma tumor are actually normal.  This buildup of abnormal Reed-Sternberg cells and normal cells creates a mass of tissue. This is called a tumor or growth.

There are 2 main types of Hodgkin lymphoma:

  • Classical: This is the most common kind of Hodgkin lymphoma.
  • Nodular lymphocyte-predominant Hodgkin lymphoma: This kind is rare, and treated very differently.  It’s important that your doctor find out which kind of Hodgkin lymphoma you have to plan the appropriate treatment.

What can I expect from the diagnosis process?

Understanding the Diagnosis Process

Having swollen lymph nodes is one major sign of Hodgkin lymphoma. Keep in mind that swollen lymph nodes can also happen naturally in response to infection and inflammation. If you do have swollen lymph nodes, your doctor may want to investigate further.

To diagnose Hodgkin lymphoma, your doctor may want you to have a:

Physical exam: Your doctor will check for swollen lymph nodes in your neck, underarms, and groin. Your doctor will also check to see if your spleen or liver are swollen.

Blood tests: The doctor may order a complete blood count (CBC). This test checks your blood for the number and type of white blood cells.  Your doctor may ask for a number of other tests for blood factors that are commonly abnormal in patients with Hodgkin lymphoma, like the erythrocyte sedimentation ratio, or ESR.   

Chest X-rays: These are used to reveal swollen lymph nodes or other signs of disease in your chest.

Biopsy: The only definite way to diagnose Hodgkin lymphoma is through a biopsy. Your doctor may want to biopsy your lymph node or tumor if there is one. There are three different kinds of biopsies:

  • An excisional biopsy removes an entire lymph node.
  • An incisional biopsy removes just part of a lymph node
  • A core needle biopsy. This type of biopsy is not preferred because it only removes a very tiny piece of tissue.  Because Hodgkin lymphoma contains mostly normal cells, this procedure can sometimes not lead to the correct diagnosis.
  • Although there is a fourth way to sample a lymph node or tumor, called a fine needle aspiration, it is not used to diagnose any form of lymphoma. You should know what kind of biopsy your surgeon wants to obtain.

When diagnosing Hodgkin lymphoma, it’s best to remove the entire lymph node. Then the tissue is checked for the presence of abnormal Reed-Sternberg cells, and important tests can be done to confirm the diagnosis. If these cells are there, then your doctor can make the diagnosis of Hodgkin lymphoma.

Hodgkin lymphoma usually spreads from one group of lymph nodes to another. For example, if Hodgkin lymphoma starts in the lymph nodes in your neck, it might spread to the lymph nodes above your collarbone. From there, it could spread to the lymph nodes under your arms. Hodgkin lymphoma spreads in a way that doctors can predict, and it spreads to the closest cells to the affected nodes.

Over time, the Hodgkin lymphoma cells can invade your blood vessels. This allows them to spread to almost any other part of your body. For example, it can spread to your liver, lungs, bone, and bone marrow. To know the extent of Hodgkin lymphoma, your doctor will probably order one or more of these tests:

CT scan (CAT scan or computed tomography): The CT scan is an X-ray test that produces detailed pictures of your body. Instead of taking one picture, like a regular X-ray does, a CT scanner takes many pictures. It does this by rotating around you while you lie on a table. Then a computer combines all these images. That produces 3-dimensional pictures. CT scans can help find tumors in your bladder, kidneys, and other organs. It can also show any swollen lymph nodes that might have cancer.

Before any pictures are taken, you may have to drink 1 to 2 pints of a liquid. It is called oral contrast. This fluid helps outline your intestine. This helps the doctor see the differences between your normal body and any potential tumors. You may also receive an IV (intravenous line) in your arm or hand. A different type of contrast dye can be injected through the IV. Its purpose is also to outline blood vessels in your body, which helps the radiologist (doctors who read x-ray films and CT scans) see the structures of your body (anatomy) more clearly..

The injection may make you feel flushed or warm. It is a little uncomfortable, but not painful. Many patients say that having to lie still is difficult.

A CT scan can also be used to guide a biopsy needle in a tumor. This procedure is called a CT-guided needle biopsy. In this procedure, the radiologist puts a biopsy needle through your skin and into the mass. Then a tissue sample is removed and examined under a microscope.

MRI scan (magnetic resonance imaging): MRIs are similar to CT scans. An MRI scan provides detailed pictures like CT scans. The difference is that MRI scans use radio waves and strong magnets instead of X-rays. The energy from the radio waves produces patterns. A computer takes these and turns them into detailed images of specific parts of your body.

MRI scans are often little more uncomfortable than CT scans. For one thing, an MRI takes up to an hour. You may be placed inside a narrow tube. This can feel confining.  Again, you must lie completely still. There are newer, open MRI machines in many hospitals and clinics around the country.

PET scan (positron emission tomography): For this test, a special kind of radioactive sugar is put into your vein. The sugar then collects in places that have cancer. A scanner can then identify these places. Lymphoma cells use sugar faster than normal cells, so areas with lymphoma show up brighter in the pictures.  Recently, PET scans have been used to determine the kind of response your lymphoma has had to chemotherapy.  Having your PET can be negative (that is, no evidence of Hodgkin lymphoma as seen by the PET scan), has been associated with a very good outcome to treatment.

Bone marrow biopsy. Your doctor may need to perform a bone marrow biopsy, though many patients with Hodgkin Lymphoma will not need one.  Early stage Hodgkin lymphoma rarely goes to the bone marrow.  If necessary, your doctor will use a thick needle to remove a small sample of bone and bone marrow. These are taken from your hipbone or another large bone. You will be given local anesthesia to control the pain.

Next: How do I know how serious my cancer is? 

Return to "Hodgkin Lymphoma: An Introduction."