Hodgkin’s Lymphoma is a cancer of the lymphoid tissue. It is characterized by lumps or lymphadenopathy which may appear in any part of the body but commonly involves the neck, armpits, and groin. 

Lymph nodes may sometimes enlarge inside the body such as inside the thorax and abdominal cavity. Because these are hidden areas, these patients may have advanced disease when they are diagnosed.

Apart from lymphadenopathy, patients may have other non-specific symptoms like:

• Fever: Having an unexplained fever can be a symptom of Hodgkin's lymphoma
• Night Sweats: Waking up drenched in sweat during the night is a symptom of Hodgkin's lymphoma.
• Weight loss: Losing weight without trying is a symptom of Hodgkin's lymphoma.
• Fatigue: Constant tiredness or weakness is a common symptom of Hodgkin lymphoma.
• Cough and chest pain: Pain or pressure in the chest can be a symptom of Hodgkin's lymphoma.
• Shortness of breath: Difficulty breathing can be a symptom of Hodgkin's lymphoma.
• Abdominal Pain
• Itching: Itching, especially at night, can be a symptom of Hodgkin's lymphoma.
• Bone pains
• Tonsil enlargement, and 
• enlarged spleen and liver.

Some patients may have central nervous system-related signs and symptoms. It is also likely that patients may be getting treatment for tuberculosis. This is because Tuberculosis and Lymphoma have similar signs and symptoms like fever, cough, and enlarged lymph nodes.

In addition, sometimes the investigations are not very clearly suggestive of lymphoma and patients are given a therapeutic trial of anti-Tuberculous therapy.

Classification of Hodgkin's Lymphoma:

The WHO (World Health Organization) has classified Hodgkin's Lymphoma into five different types:

1. Nodular sclerosing

2. Mixed cellularity (see the image below)

3. Lymphocyte depleted

4. Lymphocyte rich

5. Nodular lymphocyte predominant

Hodgkin’s Lymphoma Treatment:

The treatment of Hodgkin's Lymphoma depends on the stage, functional status of the patient, type of Hodgkin's Lymphoma, and prognosis. The four principles of treatment include:

• Radiation therapy,
• Induction therapy,
• Salvage Therapy, and 
• Hematopoietic Stem Cell Transplant

However, we will discuss treatment with drugs only.

FDA-approved drugs for the treatment of Hodgkin's Lymphoma:

Hodgkin's Lymphoma is a potentially curable cancer of the lymphoid tissues. Timely treatment and appropriate combination therapy are essential to slow the progression of the disease, improve survival rates, and may cure the disease.

 The following list of medications has been approved by the FDA for the treatment of patients with Hodgkin's Lymphoma [Ref]:

Until very recently, newer drugs have been approved by the FDA which have markedly improved the survival rates, especially in patients with poor prognoses.

Latest Approved Drugs for the Treatment of Hodgkin's Lymphoma:

The three drugs that have been approved recently include Brentuximab Vedotin, Nivolumab, and Pembrolizumab.

Brentuximab Vedotin has been added to one of the induction regimens (A+AVD). It is also recommended as a maintenance treatment for patients after autologous HST.

Nivolumab (Opdivo) has got approval for patients who have progressed or relapsed after Autologous Hematopoietic Stem Cell Transplantation.

Pembrolizumab (Keytruda) is indicated for the treatment of classical Hodgkin's Lymphoma in patients who have relapsed after 3 or more prior therapies.

Treatment Regimens: Induction Chemotherapy:

Induction chemotherapy regimens are given for a total of six cycles administered every 28 days:

• MOPP
  • Mechlorethamine, Vincristine (Oncovin), Procarbazine, and Prednisone
• ABVD
  • Doxorubicin (Adriamycin), Bleomycin, Vinblastine, Dacarbazine
• A+AVD
  • Brentuximab vedotin (Adcetris), Doxorubicin, Vinblastine, Dacarbazine
• Stanford V
  • Doxorubicin, Vinblastine, Mustard, Bleomycin, Vincristine, Etoposide, Prednisone
• BEACOPP
  • Bleomycin, Etoposide, Doxorubicin, Cyclophosphamide, Vincristine, Procarbazine, Prednisone

A+AVD has replaced ABVD. The inclusion of Brentuximab Vedotin (Adcetris) is superior to ABVD and has resulted in better survival rates.

Salvage Therapy:

Salvage chemotherapy is given to those who fail the initial induction chemotherapy. These include:

• ICE
  • Ifosfamide, Carboplatin, Etoposide
• DHAP
  • Cisplatin, Cytarabine, Prednisone
• ESHAP
  • Etoposide, Methylprednisolone, Cytarabine, Cisplatin

Hodgkin's Lymphoma Treatment List in Pakistan:

Almost all the drugs are available in Pakistan. Adcetris (Brentuximab Vedotin), Keytruda (Pembrolizumab), and Opdivo (Nivolumab) are costly medicines but best for patients with refractory disease.