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Lymphocyte-Rich Classical Hodgkin Lymphoma

Last updated Nov. 1, 2018

Approved by: Maulik P. Purohit MD MPH

Lymphocyte-Rich Classical Hodgkin Lymphoma (LRCHL) is a rare subtype of classical Hodgkin lymphoma that is generally seen in middle-aged adults.


What are the other Names for this Condition? (Also known as/Synonyms)

  • LRCHL (Lymphocyte-Rich Classical Hodgkin Lymphoma)
  • Lymphocyte-Rich CHL

What is Lymphocyte-Rich Classical Hodgkin Lymphoma? (Definition/Background Information)

  • Hodgkin lymphoma is a type of lymphoma that develops in the body's immune system, known as the lymphatic system. The function of the immune system is to protect the body from infections, diseases, as well as from substances deemed foreign and harmful to the body
  • Hodgkin’s lymphomas are broadly categorized into 2 main groups, depending on the types of cells affected and the extent of their malfunction. These include:
    • Classical type of Hodgkin lymphoma: Individuals diagnosed with the classical type are generally reported to have abnormal cells known as Reed-Sternberg cells in their lymph nodes. The majority of Hodgkin lymphomas fall in this category
    • Nodular lymphocyte predominant type of Hodgkin lymphoma: Individuals with this type of cancer present with very few Reed-Sternberg cells. There is also the presence of large abnormal cells called “popcorn” cells, owing to their appearance
  • The classical types of Hodgkin’s lymphoma is further subdivided into the following 4 subtypes:
    • Nodular-Sclerosis Classical Hodgkin Lymphoma
    • Mixed Cellularity Classical Hodgkin lymphoma
    • Lymphocyte-Rich Classical Hodgkin Lymphoma
    • Lymphocyte-Depleted Classical Hodgkin Lymphoma
  • Lymphocyte-Rich Classical Hodgkin Lymphoma (LRCHL) is a rare subtype of classical Hodgkin lymphoma that is generally seen in middle-aged adults
  • The risk factors for developing the condition include a family history of the condition, being immune-compromised, and history of Epstein-Barr virus infection
  • The exact cause of this type of cancer is unknown. In the majority of cases, a mutation in a type of lymphocytes known as B-lymphocytes is reported. This mutation leads to enlargement of such lymphocytes, causing them to block the lymphatic system and the exclusion of healthy cells from the system
  • A vast majority of the malignancy is observed in the peripheral lymph nodes followed by the mediastinum. Individuals may experience non-specific symptoms such as fever, fatigue, swollen lymph nodes, and unintended weight loss
  • The diagnosis of Lymphocyte-Rich Classical Hodgkin Lymphoma may be established through a biopsy of the affected lymph node or the tumor. However, other tests and exams (such as blood tests and imaging studies) may be performed to examine the severity and extent of lymphoma spread in the body. In a majority, the condition is diagnosed during the early stages
  • The treatment of Lymphocyte-Rich Classical Hodgkin Lymphoma depends on the type, the stage of the condition, and the size of the tumor. An individual may be recommended chemotherapy, radiation therapy, stem cell transplantation from his/her own body (autologous stem cell transplantation), or other treatment modes, to successfully combat the condition
  • Treatments, such as radiation or chemotherapy, for the treatment of this lymphoma type can give rise to potential complications. These could include the formation of other types of cancer (thyroid cancer or leukemia), abnormalities with the thyroid gland function, heart and lung health issues, and even infertility
  • Currently, Lymphocyte-Rich Classical Hodgkin Lymphoma is not preventable, because the cause of this cancer type is not known. However, leading a healthy lifestyle with a balanced diet, regular physical activity, and not smoking, are generally considered good preventive methods to decrease the likelihood of contracting any disease, including cancer
  • The prognosis of Lymphocyte-Rich Classical Hodgkin Lymphoma depends on the stage of the cancer when it is diagnosed, the extent of spread, and whether any vital organ is affected. If the cancer is diagnosed in its early stages, the prognosis is reported to be excellent. Nevertheless, in case of LRCHL, the prognosis is much better when compared to other subtypes of classical Hodgkin lymphoma

Who gets Lymphocyte-Rich Classical Hodgkin Lymphoma? (Age and Sex Distribution)

  • Lymphocyte-Rich Classical Hodgkin Lymphoma is a rare subtype of Hodgkin lymphoma; it accounts for about 5% of all Hodgkin lymphomas (i.e., 1 in 20 cases of all Hodgkin lymphoma is LRCHL)
  • It is normally observed in middle-age adults; median age 43 years
  • Even though both male and female genders are affected, this type of lymphoma affects males more (male-female ratio is 2:1)
  • The condition is found worldwide and no racial or ethnic predilection is observed in its occurrence

What are the Risk Factors for Lymphocyte-Rich Classical Hodgkin Lymphoma? (Predisposing Factors)

Studies have reported the following risk factors for Lymphocyte-Rich Classical Hodgkin Lymphoma development and these include:

  • A family history of the lymphoma
  • Being a middle-aged male
  • Having been infected with Epstein-Barr virus (EBV, a causative organism for mononucleosis)
  • Being immune-compromised due to conditions such as HIV infection and AIDS
  • Obesity

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Lymphocyte-Rich Classical Hodgkin Lymphoma? (Etiology)

The exact cause of Lymphocyte-Rich Classical Hodgkin Lymphoma is not known. However, the possible causes that are being actively researched upon include:

  • Genetic mutation: The majority of these types of cancer ensue as a result of a genetic mutation in the B-lymphocyte.
    • This mutation is reported to facilitate uncontrolled proliferation of B cells, as well as their extended lifespan
    • These properties ensure that the abnormal cells outnumber and outlive normal healthy cells, leading to the cancer
  • Epstein-Barr virus infection: Having been infected with EBV might lead to mutation(s) in the B-lymphocytes, causing the abnormal Reed-Sternberg cells to develop

Note: In LRCHL, the lymphocytes appear very small under the microscope, with the presence of very few Reed-Sternberg cells.

What are the Signs and Symptoms of Lymphocyte-Rich Classical Hodgkin Lymphoma?

The following signs and symptoms Lymphocyte-Rich Classical Hodgkin Lymphoma may be observed:

  • Majority of the malignancy involves the peripheral lymph nodes. After the peripheral lymph nodes, the most common site is the mediastinum (1 in 6 cases or about 16% of the cancers)
  • Swollen or enlarged lymph nodes may be observed, which are often painless
  • It is uncommon to find large tumor masses (bulky disease)
  • Due to mediastinal involvement, there can be associated cough, chest pain, and breathing difficulties

There may be other signs and symptoms that include:

  • Pain in the lymph nodes after alcohol ingestion; increased sensitivity to alcoholic drinks
  • Appetite loss
  • Fatigue
  • Itching of skin

‘B’ symptoms, such as fever, excessive sweating, and accompanying 10% weight loss (observed over 6 months), are not commonly observed in this subtype of classical Hodgkin lymphoma (in comparison to other subtypes). Only 10% of the affected individuals are noted with ‘B’ symptoms.

How is Lymphocyte-Rich Classical Hodgkin Lymphoma Diagnosed?

In order to diagnose Lymphocyte-Rich Classical Hodgkin Lymphoma accurately, a healthcare provider might perform or request many of the following tests and exams:

  • A thorough physical examination
  • An evaluation of the individual’s personal and family history (of lymphoma)
  • An assessment of the signs and symptoms
  • Blood tests that may include the following:
    • Complete blood count (CBC) to ascertain hemoglobin, red blood cells, white blood cells, and other components of blood
    • Blood chemistry to check for any abnormality in the amounts of certain chemicals in blood (released by organs and tissues)
    • Estimation of sedimentation rate to check for abnormality, which might denote an inflammation
  • Tissue biopsy: Biopsies of the affected region including swollen lymph nodes (partial or whole), bone marrow, or tumors to check for any malignancy through various tests performed by a pathologist. Many different types of biopsies could be performed depending on the type and extent of the cancer
  • Imaging studies of the affected region (chest) that may include x-rays, computed tomography (CT) scan, positron emission tomography (PET) scan, magnetic resonance imaging (MRI), and whole body bone scan

Note:

  • It has been generally noted that Lymphocyte-Rich Classical Hodgkin Lymphoma is diagnosed during the earlier stages (stage 1 or stage 2), in abouttwo-thirds of the cases
  • If the affected individual is pregnant, only ultrasound imaging and MRI scan may be employed to assess lymphoma occurrence and/or spread
  • Differential diagnoses, to eliminate other tumor types are often considered, before arriving at a definitive diagnosis

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Lymphocyte-Rich Classical Hodgkin Lymphoma?

The potential complications arising from Lymphocyte-Rich Classical Hodgkin Lymphoma could include those from the growth and spread of the lymphoma, as well as from the side effects of treatment measures (such as radiation or chemotherapy) employed.

  • Complications as a result of the malignancy:
    • Neurological symptoms such as headaches, changes in vision, or numbness of face
    • Meningitis
    • Anemia
    • Intestinal blockage
    • Kidney disease
    • Bone marrow involvement (in very rare cases)
  • Complications due to treatment of the cancer:
    • An allergic reaction to therapy
    • Fatigue, dizziness
    • Nausea, vomiting, and diarrhea
    • Heart, lung, and thyroid abnormalities
    • Infertility
    • Leukemia and other bone marrow diseases; development of other types of cancers
    • Vulnerability to infections owing to a weakened immune system
    • Birth defects in children, if the mother was pregnant and was treated with chemotherapy

Apart from the above complications, the condition can recur after being in remission, also known as Recurrent Lymphocyte-Rich Classical Hodgkin Lymphoma. This is seen to occur in about 20% of the cases.

How is Lymphocyte-Rich Classical Hodgkin Lymphoma Treated?

Once a definitive diagnosis has been made, staging is used to describe how far the cancer has spread. The staging helps describe:

  • The number of lymph nodes affected and their location(s)
  • If the condition has spread to the internal organs

The following stages are used for adult Lymphocyte-Rich Classical Hodgkin Lymphoma:

Stage I: It is subdivided into stage I and stage IE.

  • Stage I: The cancer is detected in a component of the lymphatic system, such as in the
    • Lymph node(s) at a particular site
    • Lymphatic tissue known as Waldeyer's tonsillar ring
    • Thymus
    • Spleen
  • Stage IE: Cancer is detected in an organ or tissue that is not a component of the lymphatic system

Stage II: It is subdivided into stage II and stage IIE.

  • Stage II: The cancer is detected in more than one lymph node groups, which could be located above or below the diaphragm
  • Stage IIE: Apart from the cancer being detected in two or more lymph node groups, it has also spread to the organ or tissue adjacent to the lymph nodes 

Stage III: It is subdivided into stage III, stage IIIE, stage IIIS, and stage IIIES.

  • Stage III: The cancer is detected in lymph node groups, which could be located above or below the diaphragm
  • Stage IIIE: Apart from the cancer being detected in two or more lymph node groups, it has also spread to the organ or tissue adjacent to the lymph nodes
  • Stage IIIS: The cancer is detected in lymph node groups, as well as in the spleen
  • Stage IIIES: The cancer is detected in lymph node groups, organ or tissue adjacent to the lymph nodes, as well as in the spleen

Stage IV: This is considered as an advanced stage of cancer, wherein the lymphoma is detected in several lymph nodes, organs, tissues, and at other locations, near and distant from the affected lymph nodes. The organs that have been found to contain metastasized cancer during this stage are the liver, lungs, bone marrow, and many others.

Grouping for treatment purposes: For the purpose of treatment, adult Lymphocyte-Rich Classical Hodgkin Lymphoma may be grouped into the following categories.

  • Early favorable: Generally, stage I or stage II without certain risk factors that include large-sized tumor, cancer in multiple lymph nodes, cancer that has spread to the organs, and the presence of typical symptoms (fever, weight loss)
  • Early unfavorable: They include stage I or stage II cancers with one or more risk factors such as:
    • Multiple lymph nodes with cancer (3 or more)
    • Large-sized tumor in the chest (about or larger than 10cm)
    • Cancer spread to the organs or tissues
    • Blood sedimentation rate being high (blood settles to the bottom of a tube at a faster rate than normal)
    • Fever
    • Weight loss
    • Night sweats
  • Advanced favorable: Stage III or stage IV with not more than 3 risk factors such as:
    • Male gender
    • Age over 45 years
    • Low hemoglobin levels (below 10.5)
    • High white blood cell (WBC) number (at or above 15,000)
    • Low lymphocyte count (less than 8% of WBCs)
    • Stage IV Hodgkin’s lymphoma
    • Low blood albumin (less than 4)
  • Advanced unfavorable: Stage III or stage IV with 4 or more risk factors as mentioned under ‘advanced favorable’

Each stage of adult Lymphocyte-Rich Classical Hodgkin Lymphoma could include the following categories:

  • Category A: The patient does not have symptoms such as unintended weight loss, fever, or profuse sweating in the nights
  • Category B: The patient has fever, night-sweats, and weight loss symptoms
  • Category E: Cancer has spread to an internal organ or tissue, which is not a component of the lymphatic system (may be adjacent to the affected site)
  • Category S: Cancer has spread to the spleen

Following a definitive diagnosis of Lymphocyte-Rich Classical Hodgkin Lymphoma, and determination of the extent and spread of the condition, some standard and some newer therapy regimens may be adopted such as:

  • Chemotherapy: It is the treatment with drugs to either kill the cancer cells or stop their proliferation. The type of cancer, the size of tumor, and the extent of spread dictates the kind of chemotherapy recommended. Sometimes, a mixture of chemotherapeutic drugs may be necessary
  • Radiation therapy: It is the use of high-energy radiation to kill cancer cells or stop the proliferation of malignant cells. This type of treatment is mainly of 2 types:
    • External, or the radiation emitting device is placed outside the body, and
    • Internal, when a radioactive source sealed in a container is placed directly near the cancer, inside the body
  • Surgery: This modality may be used for diagnostic as well as for treatment purposes.
    • Laparotomy: An incision is made in the affected area to check for cancer in the internal organs. If a tumor is detected, then the same is removed during the procedure
    • Rarely, when feasible, a surgical excision of the tumor may be performed
  • Transplantation of stem cells or bone marrow:
    • Stem cells are undifferentiated cells that are capable of differentiating into many different types of cells. While embryos are rich in these types of cells, adult humans also possess such cells. They have been used in medicine to heal and replenish damaged tissue. In cancer therapy, stem cells are being used for the generation of healthy blood-forming cells. High-dose chemotherapy and high-energy radiation therapy are known to harm the blood forming cells. In order to help patient make healthy blood cells following such therapies, stem cells could be harvested from the patient himself/herself (autologous), or from a close relative such as a sibling (allogeneic).  Stem cells are generally derived from circulating blood, umbilical cord blood, or bone marrow
    • Bone marrows (of large bones) are seats of generation for different types of blood cells. In order for the patient to have healthy circulating blood cells, the marrow could be harvested before therapy and re-injected into the patient. This procedure is known as bone marrow transplantation. It is reported that within a few weeks of transplantation, the healthy bone marrow cells start generating new white blood cells and red blood cells
  • Monoclonal antibody therapy: This is a kind of immune therapy, where cells from the immune system of a single type are propagated in the laboratory and introduced into the patient. The cells recognize the cancer cells by their unique chemical signature. It then attaches to the cancer cells and destroys them. The antibodies can be also be used to deliver drugs or radiation in a targeted manner, to the cancer cells

Pregnancy: If a pregnant woman develops Lymphocyte-Rich Classical Hodgkin Lymphoma, then the treatment options offered may vary from the above-mentioned list. It usually depends upon the site of the cancer, its rate of proliferation (how fast the cancer cells are growing), how advanced the pregnancy is, and, whether the woman wishes to continue with the pregnancy.

Some of the options offered during pregnancy may include:

Watchful waiting: Usually during the first trimester

  • Watchful waiting is the term used for monitoring the pregnant patient without any treatment. If there is no change in her health status, the pregnancy may be allowed to advance till 32-36 weeks, when labor may be induced. The treatment could be commenced after delivery
  • However, if any of the symptoms change, treatment might be initiated sooner than anticipated

Chemotherapy: Throughout the pregnancy period

  • Chemotherapy may be recommended for pregnant women with a single drug or a combination of therapeutic drugs

Radiation therapy: During the first and second half of pregnancy

  • If the affected area is above the diaphragm (a thin membrane separating the chest from the abdomen), radiation therapy may be attempted with a lead shield to protect the developing fetus
  • This therapy may be recommended in the second half of the pregnancy to aid in breathing, if a large tumor is detected in the chest area

Note: A lead shield may not be able to protect the fetus from radiation and consequent developmental defects.

Steroid therapy during the second half of pregnancy: Since steroids help hasten lung growth and maturity in a developing fetus, steroid therapy may be recommended in a pregnant woman if labor is induced early, so that treatment for cancer can begin.

As elaborated previously, Hodgkin’s lymphoma is divided into various groups to facilitate making the right treatment choices. The treatment options for the various groups are:

  • Early favorable Hodgkin’s lymphoma:
    • Chemotherapy (with a combination of several drugs, known as combination chemotherapy)
    • Radiation therapy to the affected parts
    • Combination chemotherapy and radiation therapy 
  • Early unfavorable Hodgkin’s lymphoma:
    • Chemotherapy (with a combination of several drugs)
    • Combination of chemotherapy and radiation therapy to affected parts of the body 
  • Advanced favorable Hodgkin’s lymphoma:
    • Combination chemotherapy
    • Combination of chemotherapy and radiation therapy to affected parts of the body 
  • Advanced unfavorable Hodgkin’s lymphoma:
    • Combination chemotherapy
    • Clinical trials for new therapeutic drugs, as well as combination of drugs and stem cells

Treatment options for recurrent Lymphocyte-Rich Classical Hodgkin Lymphoma may include:

  • Combination chemotherapy
  • Radiation therapy
  • Chemotherapy and radiation therapy
  • Chemotherapy with stem cell transplant
  • Chemotherapy, transplantation, and radiation therapy
  • Clinical trial therapies including therapeutic drugs, radiation, stem cell transplantation, and monoclonal antibodies, either singly or in combination of various therapies
  • Medical care to alleviate symptoms and offer emotional support; to help improve the quality of life

How can Lymphocyte-Rich Classical Hodgkin Lymphoma be Prevented?

The exact cause of Lymphocyte-Rich Classical Hodgkin Lymphoma is unknown, and hence, no guidelines exist for the prevention of this type of cancer. However, by addressing some risk factors that are common to many illnesses as well as to cancer, the condition may be avoided. It includes the following factors:

  • Adhering to a healthy diet, including eating fresh vegetables and fruits
  • Regular physical activity
  • Smoking cessation
  • Regular visits to a healthcare professional, especially with advancing age
  • Closely monitor individuals who have poor immune systems and are receiving immunosuppressants for various reasons
  • If an individual is diagnosed with this lymphoma type, keeping accurate documentation filed, can help start follow-up care without any delay; especially in case of cancer recurrence
  • Follow-up visits with a healthcare professional as recommended, for monitoring health after cancer treatment

What is the Prognosis of Lymphocyte-Rich Classical Hodgkin Lymphoma? (Outcomes/Resolutions)

  • The prognosis of Lymphocyte-Rich Classical Hodgkin Lymphoma is considered to be good, with early diagnosis and prompt treatment. 95% of the affected individuals are noted to have complete remission
  • This subtype of cancer is a less aggressive form of classical Hodgkin lymphoma, and as such, its prognosis is better than other classical forms of Hodgkin lymphoma. However, 1 in 5 cases are known to recur
  • Progression to bone marrow failure is usually associated with a short survival period. In LRCHL, only 2% of the cases are known to involve the bone marrow
  • Several factors may contribute to the final outcome of the condition and these include:
    • Stage of tumor: Early stages with localized cancer are reported to have better outcomes than later stages
    • Age: Younger patients are known to have a better outcomes than older patients
    • Health: Overall good health of an individual portrays a better outcome than poor health
    • Tumor size: Individuals with smaller-sized tumors generally have better outcomes than those with larger tumors. Bulky disease is generally not observed with Lymphocyte-Rich Classical Hodgkin Lymphoma
    • Metastasis: If the cancer has spread to other parts of the body, particularly to the vital internal organs, the recovery may be hampered
    • Response: When an individual’s body tolerates harsh cancer therapies and responds favorably to the treatments undertaken, then the outcome is generally improved
    • Removability of tumor: When the tumor can be surgically removed (and completely), it can have an impact on the outcome
    • Recurrence: If the tumor is recurrent, then the outcome may not be favorable

Additional and Relevant Useful Information for Lymphocyte-Rich Classical Hodgkin Lymphoma:

General information on the lymphatic system: It is a component of the circulatory system and consists of the following components.

  • Lymphocytes: These are the main white blood cells found in the lymph. They protect the body from infections, foreign entities, and tumors
    • Spleen: An organ located adjacent to the stomach that makes lymphocytes
    • Tonsils: Located at the back of the throat; this organ also makes lymphocytes
    • Thymus: An organ located in the chest, where lymphocytes grow and mature
    • Bone marrow: It is the soft center of the large bones that makes red blood cells, white blood cells, and platelets
  • Lymph: Colorless liquid that carries lymphocytes through the lymphatic system
  • Lymph vessels: A network of thin tubes that collect lymph from different parts of the body and return it to the bloodstream
  • Lymph nodes: These structures, located along the lymph vessels in clusters and dispersed throughout the body (neck, underarms, and groin), store the lymphocytes

Additionally, there are lymph tissues, which are also located in the stomach, thyroid gland, brain, and skin.

For more information on clinical trials, please visit the following website - www.clinicaltrials.gov.

What are some Useful Resources for Additional Information?


References and Information Sources used for the Article:


Helpful Peer-Reviewed Medical Articles:


Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: May 2, 2016
Last updated: Nov. 1, 2018