A.J. Costin, Callie Eaves, Dan Purdy, and Lauren Willis from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.
Hodgkin's Lymphoma is a form of cancer with unknown etiology. Important clinical features include: origination and spread of cancer within lymph nodes. The most frequently listed symptoms include: painless, swollen lymph nodes, and constitutional symptoms. A non-specific symptom not commonly mentioned in research but commonly experienced by patients is low back pain (LBP). Perhaps, LBP and lymphoma are rarely linked due to the sheer commonality of LBP. Lymphoma related LBP can occur due to swollen lymph nodes in the abdominal region putting pressure on the muscles, nerves, and other tissues complimenting to LBP, and the incidence of metastases is high, such as in this case. The following case presents a 61-year-old male complaining of LBP and hip pain that is not reproduced with movement and is accompanied by symptoms of fatigue and generalized deconditioning. 
- Demographic Information: Mr. Hodgkin's is a 61 year old caucasian male. He has worked as an electrical engineer for 30 years.
- Medical diagnosis: Referred from primary care physician to therapy for low back pain (LBP) due to history of disc herniation. No recent imaging. MRI from 5 years ago.
- Co-morbidities: HTN, BMI = 27, hyperlipidemia
- Previous Physical Therapy: Mr. Hodgkin's has received prior physical therapy for disc herniation at L4-L5 five years ago.
Mr. Hodgkins reports a four month history of pain in his low back and recently the pain has moved into his left hip. He states this pain is different from his previous low back pain; it is lower into his hip and this is the first time that he has experienced hip pain. His chief complain is that when he comes home from work he is too tired to go fishing or work in his wood shop. He states his doctor instructed him on dieting and exercise to lose weight and decrease his HTN and cholesterol, but he states he just hasn't had the energy to exercise or perform his usual hobbies. However, he has lost some weight even though he's not sure how much. Pt reports the pain wakes him up at night and can't seem to get comfortable and sitting for long periods of time at work bothers him. He says he recently started doing some of the stretches and light exercises that were given to him by his last therapist; they helped a little at first but doesn't seem to be making much of a difference.
- Patient's Past Medical History: Patient reports HTN and high cholesterol both managed medically. The patient was hospitalized 10 years ago for infectious mononucelosis, and he reports his mother passing away from breast CA 10 years ago. Patient reports no other significant past medical history (liver, lungs, DM, kidneys), and he does not smoke and rarely drinks alcohol socially because he notices that drinking makes his pain worse.
- Medications: lisinopril, Crestor, and Aleve (prn)
- Patient Goals: His primary goal is to decrease his pain and increase his stamina so that he can return to fishing and working in his woodshop.
- Self Report Outcome Measures: Numeric Pain Rating (0-10) is 4 at best and 5 at worst and the pain is constant; Oswestry Disability Index (46%)
- Physical Performance Measure: 2 minute walk test, RPE: 16 (distance 125 meters; cardiovascular response WNL, decreased distance likely due to fatigue and need for rest breaks)
- ROM: Lumbar ROM 75% of normal, no increase in pain with movement; Hip ROM 75% of normal, no increase in pain with movement. All other ROM measurements within functional limits, no pain.
- Reflexes: +2 for L3/4, L5, and S1
- Sensation: Normal
- MMT: 4+/5 on LE general exam
- Palpation: Hip pain not reproduced with palpation, pain over center of sacrum present with palpation, positive Castell's percussion
- Special Tests: + Slump Test, SLR negative bilaterally, - FABER test
Mr. Hodgkin's presents to physical therapy with LBP and left hip pain. He has a history of LBP and has responded well to prior physical therapy. The symptoms that he presents with now are inconsistent with his former symptoms and inconsistent with musculoskeletal pain. The following symptoms warrant the need for further systemic screening by his primary care physician: pain is constant and not reproduced with movement, fatigue present with low intensity activity, general malaise, history of cancer in primary family member, history of infectious mononucleosis, non-intentional weight loss, + Castell's, and positive lumbar percussion test.
Summarization of Examination Findings
1. Cancer - Metastasis to the Lumbar/Sacral Area
The following findings pointed toward this potential working diagnosis: age, constant, non-acute pain that is not reproduced with movement and wakes patient up at night, fatigue, deconditioning, weight loss, no improvement with pain with exercise program, history of infectious mononucleosis, pain increases with drinking alcohol, primary family member has had CA, and positive Castell’s Percussion and lumbar percussion tests.
2. Biomechanical Lumbar Dysfunction (possible herniation) with referred pain to hip area
The following findings pointed toward this potential working diagnosis:previous history of disc herniation and positive response to physical therapy, age, possible radiculopathy, complains of increased pain in flexion (seated position), decreased lumbar ROM, and positive Slump’s Test.
3. Reoccurence of Epstein Barr Virus/mononucleosis
The following findings pointed toward this potential working diagnosis: weight loss, fatigue, positive Castell’s Percussion, and history of the disease.
Mr. Hodgkin's returned to his PCP. After further medical screening and testing, he was diagnosed as having Hodgkin's lymphoma with metastasis to lumbar spine area (L5-S1). Patient began chemotherapy and radiation treatment after having surgery to remove pelvic malignant lymph nodes. He continued physical therapy per PCP order to increase cardiovascular/pulmonary health, improve strength and flexibility, improve lymphedema and reduce fatigue and symptoms produced from the cancer and treatments.
Phases of Interventions
- Phase I - primary goal decrease fatigue, decrease risk of falling, and promote endurance. Intervention includes patient education of fatigue managment, falls risk assessment, general aerobic exercise including cycle ergometer, ambulation, cycling (monitoring cardiovascular/pulmonary response), and stretching to promote flexibility. Begin lymphedema treatment and educate patient on lymphedema managment at home. Include balance training and address falls risk due to any vestibular issues or other balance issues caused by cancer treatment.
- Phase 2 - Continue stretching, general aerobic exercise program, and lymphedema management at home; begin progressive resistance exercise (PRE) to improve strength and promote function with ADLs and all community invovlement. Include interventions to improve functional movement and promote correct movement patterns (gait training, squat training, posture, ADLs)
- Phase 3: Promote independence with ADLs, IADLs and all strength training and aerobic exercises. Reintegration into community living. Address patient goals; promote patient's abiility to fish and continue wood working.
Dosage and Parameters:
- Aerobic training: Begin with low impact aerobic traning (cycle ergometer, bicycle) progressing to ambulation over ground. Begin at 10 minutes per day and progress to 30 minutes a day, 3-4 times/week.
- Strength and resistance training: Functional closed chain exercises (mini-squats, lunge matrix, stair training, etc.) for LE, resistance band/weight training for posture stabilizers and UE, increase core strength). Perform 8-12 reps of each exercise, 2-3 sets, to point of fatigue but not beyond that point. 20-30 minutes, 2-3 times per week and progress as tolerated
Rationale for Progression
- Progress patients to maintain/improve level of fitness during treatment and promote overall better quality of life. Progress patient as he can tolerate, being aware of affects of medical treatment. Coordinate with PCP and oncologist.
- Chemotherapy, radiation, proper diet, and psychological counseling
The Patient Health Questionaire (PHQ-9) was administered to assess quality of life/risk of depression once the patient was diagnosed with CA. Mr. Hodgkin's initial score was 14 indicated moderate depressive symptoms. At discharge, his score was 9 indicating he had moved from moderate depressive symptoms to mild depressive symptoms. The patient reported that therapy gave him something to do, helped him feel better throughout his CA treatment, and increased his quality of life.
At discharge, the patient's 2 minutes walk distance had increased and his RPE during the test had decreased to 12; the oswestry score had decreased to 27% disabled; and the patient's pain in his low back and hip had decreased. He did experience other side effects from the chemotherapy and radiation treatment, but these were non-PT related.
Low back pain, as in this case, is a very common musculoskeletal condition treated by physical therapy; however, it is also a common referral site for other systemic causes. In Mr. Hodgkin’s situation, it was critical that the physical therapist could correctly identify the red flags presented and was able to determine when it was necessary to refer to the appropriate discipline in order to not delay proper treatment.
According to Goodman and Fuller, “At the present time, standard protocols do not exist for problems associated with cancer and cancer treatments encountered by the physical therapist.” However, due to the side effects of cancer including cognitive impairments and post-surgical problems including limited ROM, soreness, disuse, pain, sensory loss, weakness, DVT, and lymphedema, the physical therapist can play a huge role in maintaining a cancer patient’s functional abilities and quality of life. Furthermore, emerging research suggests that physical exercise works to increase physical activity, improve general self-efficacy and mastery, decrease fatigue and distress, and leads to an increased quality of life in patients who complete cancer treatments. This research also demonstrated a direct correlation between physical activity and quality of life. This can be used to support the need for physical therapy for all cancer patients undergoing treatment and post-treatment. Currently, a protocol does not exist for these patients, but due to the support of the emerging research, one should be developed for this population. This also opens up the door for niche practices of physical therapy in oncology.
Hodgkin's Lymphoma - Physiopedia
Hodgkin's Lymphoma - American Cancer Society
Lymphoma Research Foundation
What You Need To Know About Hodgkin Lymphoma
- ↑Patterns of presentation of Hodgkin disease. Implications for etiology and pathogenesis.fckLRMauch PM1, Kalish LA, Kadin M, Coleman CN, Osteen R, Hellman S
- ↑Lymphoma Info. Lymphoma and Back Pain. http://www.lymphomainfo.net/articles/lymphoma/lymphoma-and-back-pain. Accessed March 27, 2015.
- ↑Wikipedia. Reed-Sternberg Cell. http://en.wikipedia.org/wiki/Reed–Sternberg_cell. Accessed March 29, 2015.
- ↑ 4.04.14.24.34.44.5Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.
- ↑The Lymphoma Club. What is Hodgkin's Lymphoma. http://www.lymphomaclub.com/lymphoma-101/what-is-hodgkins-lymphoma/. Accessed March 29, 2015.
- ↑Rehab Measures. Numeric Pain Rating Scale. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=891. Accessed March 26, 2015.
- ↑ 7.07.1Rehab Measures. Oswestry Disability Index. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1114. Accessed on March 27, 2015.
- ↑ 8.08.1Rehab Measures. 2 Minute Walk Test. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=896. Accessed March 26, 2015.
- ↑Physiopedia. Slump Test. http://www.physio-pedia.com/Slump_Test. Accessed March 27, 2015.
- ↑Physiopedia. Straight Leg Raise Test. http://www.physio-pedia.com/Straight_Leg_Raise_Test. Accessed March 27, 2015.
- ↑Physiopedia. FABER Test. http://www.physio-pedia.com/FABER_Test. Accessed March 27, 2015.
- ↑Mayo Clinic. Hodgkin's Lymphoma Symptoms. http://www.mayoclinic.org/diseases-conditions/hodgkins-lymphoma/basics/symptoms/con-20030667. Accessed March 27, 2015.
- ↑National Cancer Institute. Hodgkin Lymphoma. http://seer.cancer.gov/statfacts/html/hodg.html. Accessed March 29, 2015.
- ↑Olson K. Manual Therapy of the Spine. Saunders, Elsevier. 2008.
- ↑Centers for Disease Control and Prevention. Epstein-ball Virus and Mononucleosis.http://www.cdc.gov/epstein-barr/about-ebv.html. Accessed March 26, 2015
- ↑American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. Lipincott; Williams and Wilkins, 2013.
- ↑ 17.017.1Rehab Measures. Patient Health Questionnaire. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=954. Accessed March 27, 2015.
- ↑Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. Philadelphia, WB Saunders. 3rd edition, 2009.
- ↑Buffart, L. M., Ros, W. J. G., Chinapaw, M. J. M., Brug, J., Knol, D. L., Korstjens, I., van Weert, E., Mesters, I., van den Borne, B., Hoekstra-Weebers, J. E. H. M. and May, A. M. (2014), Mediators of physical exercise for improvement in cancer survivors' quality of life. Psycho-Oncology, 23: 330–338.
Herein, we report a case of classical Hodgkin’s lymphoma (HL) in an otherwise healthy 27- year-old female who came to the office of her general practitioner with flu-like illness and left supraclavicular swelling of uncertain nature, without other symptoms. An ultrasound of the neck detected many enlarged lymph nodes in the left supraclavicular region, and a chest X-ray showed left mediastinal enlargement. Subsequent Computed Tomography scan of the chest and abdomen confirmed the presence of many enlarged lymph nodes in the neck, mediastinum and liver, and a FDG-PET/CT scan showed multiple scattered consolidation lesions involving also the bones. The diagnosis of classical Hodgkin’s lymphoma, nodular sclerosis subtype, was made on a subsequent cervical lymph node biopsy.
Hodgkin's lymphoma, nodular sclerosis CHL (NSCHL), asymptomatic lymphadenopathy
The modern classification of Hodgkin’s disease was introduced by Lukes and Butler .
The Revised European American Lymphoma (REAL) classification in 1994 included Hodgkin’s lymphoma as one of the lymphoid neoplasms, and distinguished between 2 major types: nodular lymphocyte predominant Hodgkin’s lymphoma (NLPHL) and classical Hodgkin’s lymphoma (CHL). CHL was further classified into 4 subtypes: nodular sclerosis CHL (NSCHL), mixed cellularity CHL (MCCHL), lymphocyte-rich CHL (LRCHL), and lymphocyte-depleted CHL (LDCHL) .
The terminology recommended in the REAL classification was incorporated into the World Health Organization (WHO) classification of tumors of hematopoietic and lymphoid tissues, including the substitution of the term Hodgkin’s lymphoma for Hodgkin’s disease [3,4].
There are five types of Hodgkin lymphoma classified by the World Health Organization: nodular sclerosing, mixed cellularity, lymphocyte depleted, lymphocyte rich and nodular lymphocyte-predominant . Clinical presentation of Hodgkin lymphoma  is the following:
- a) Asymptomatic lymphadenopathy may be present (above the diaphragm in 80% of patients);
- b) Constitutional symptoms (i.e., unexplained weight loss [>10% of total body weight], unexplained fever, night sweats) are present in 40% of patients; these are known as "B symptoms";
- c) Intermittent fever is observed in approximately 35% of cases;
- d) Chest pain, cough, shortness of breath, or a combination of those may be present due to a large mediastinal mass or lung involvement;
- e) Patients may present with pruritus; pain at sites of nodal disease, precipitated by drinking alcohol, occurs in fewer than 10% of patients but is specific for Hodgkin lymphoma;
- f) Back or bone pain may rarely occur.
A family history is also helpful; in particular, nodular sclerosis Hodgkin lymphoma (NSHL) has a strong genetic component and has often been previously diagnosed in the family. Hodgkin lymphoma is a potentially curable lymphoma.
Here the authors report a classical presentation of Hodgkin's disease in an otherwise healthy 27-year-old female.
In August 2015 an otherwise healthy 27-year-old female comes to the General Practitioner's office after experiencing flu-like symptoms with swelling on the left side supraclavicular region of the neck. Her past and recent medical histories were fine and no other remarkable co-morbidities were reported. Her family history was unremarkable.
The patient did not report any systemic symptoms including night sweats; weight loss or fever. The physical examination confirmed the presence of fixedlymph nodes of hard consistency in the left latero-cervical and supraclavicular area with an estimated size of 2.4 cm and without the evidence of any other superficial lymphadenopathy or organomegaly.
Subsequently laboratory test analysis were prescribed: complete blood count with differential, hepatic and renal function tests; protein electrophoresis; lactate dehydrogenase (LDH); serum electrolytes; protein electrophoresis; serology tests for Epstein-Barr virus (EBV), toxoplasmosis, HIV, and erythrocyte sedimentation rate (ESR); and C-reactive protein (CRP) inflammatory tests. An ultrasound exam of the neck and a chest X-ray were also prescribed. The biochemical results showed increased ESR and CRP as well as a neutrophilic leukocytosis of approximately 13,000 leukocytes per microliter. The neck ultrasound confirmed the presence of enlarged lymph nodes in the left supraclavicular side (2.4 × 1.3 cm) of the neck, with pathological aspects that were consistent with a lymphoproliferative disorder. The chest X-ray showed a left mediastinal enlargement (Figure 1).
Figure 1. Chest X-ray showed a marked left mediastinal enlargement.
To accelerate diagnostic procedures the patient was admitted to the internal medicine department. Chest Computed Tomography (Figure 2) showed enlarged nodes in the left supraclavicular and cervical regions, in the upper mediastinum including paratracheal prevascular, subcarinal, bilateral lung hilum sites, and bilaterally in the axillas. The largest node was 10 × 5 cm in diameter.
Figure 2. Chest CT scan showed enlarged nodes in the supraclavicular and cervical regions, in the upper mediastinum including paratracheal prevascular, subcarinal, bilateral lung hilum sites, and bilaterally in the axillas.
The spleen was normal buta focal liver lesion of 3 × 2.7 cm inside the 4th segment was detected. Also a FDG-PET/CT scan (Figure 3) confirmed the presence of multiple pathological accumulations of enlarged lymphoadenopathy already described, but also more skeletral localizations.
Figure 3. FDG-PET/CT scan revealed marked hypermetabolic nodes bilaterally in the laterocervical, supraclavicular and axillary regions, in the mediastinum, and within the left para-aortic space. The spleen was normal. An area of slightly increased glucose metabolism was also described in the IV° segment of the liver.
Supraclavear lymph node biopsy, histologic examination and immunohistochemical analysis made the diagnosis of classical Hodgkin’s lymphoma (nodular sclerosis subtype) by finding the diagnostic Reed-Sternberg cells and CD30 positive (Figure 4).
Figure 4. The histologic examination of lymph node biopsy specimens showed Reed-Sternberg cells and CD30 positive
Finally, a bone marrow biopsy was done but was negative for lymphoma. Based on the complete staging workup the final diagnosis for this 27-year-old patient was classical HL, nodular sclerosis, stage IV A. Her international prognostic score was 1 due to the advanced stage.
Usually Hodgkin’s lymphoma occurs in the mediastinum and head and neck regions but its presentation may be insidious. Therefore the diagnosis could be tardive.
Because Hodgkin lymphoma is considered a curable malignancy and the differential diagnosis is broad, medico-legal problems may arise from failure to diagnose the disease in a timely manner, possibly due to the following factors: 1)The misinterpretation of B symptoms; A lack of follow-up for abnormal chest radiographs or physical examination findings; 3) A missed pathologic diagnosis because a needle biopsy was obtained rather than an excisional lymph node biopsy .
As this case study reportsa histologic diagnosis of Hodgkin lymphoma is always required. An excisional lymph node biopsy is recommended because the lymph node architecture is important for histologic classification.
Furthermore, the Ann Arbor classification  is used most often for Hodgkin lymphoma, as follows:
- Stage I: A single lymph node area or single extra-nodal site
- Stage II: 2 or more lymph node areas on the same side of the diaphragm
- Stage III: Lymph node areas on both sides of the diaphragm
- Stage IV: Disseminated or multiple involvement of the extra-nodal organs
Based on the clinical scenario, staging and degree of end-organ damage in patients with HL can be categorized into the following 3 groups:
- Early-stage favorable
- Early-stage unfavorable (bulky and non-bulky)
- Advanced-stage (this classification has impact in treatment selection and must be performed carefully in every patient with HL)
Our patient was promptly investigated and diagnosis of HL was timely. She was affected by Hodgkin's Disease (Nodular sclerosis classic HL) in advanced-stage (Stage IVA), but her prognostic score, based on the IPS score, can be categorized at good risk (IPS 0-1) .
In conclusion, this case report is anecdotal but emblematic because it stresses once again the importance of early diagnosis, staging and risk stratification of Hodgkin's disease in primary care settings and internal medicine, to improve the survival rate of patients.
The authors thank Dr. Luca Riccioni, pathologist, for his courtesy.
The authors declare no conflict of interest.
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- Harris NL, Jaffe ES, Stein H, Banks PM, Chan JK, et al. (1994) A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 84: 1361–1392. [Crossref]
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- Eichenauer DA, Engert A, Dreyling M, ESMO Guidelines Working Group (2014) Hodgkin's lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 6: iii55-58. [Crossref]
- NCCN Clinical Practice Guidelines in Oncology: Hodgkin Lymphoma. Version 2.2015. National Comprehensive Cancer Network.
- Carbone PP, Kaplan HS, Musshoff K, Smithers DW, Tubiana M (1971) Report of the Committee on Hodgkin's Disease Staging Classification. Cancer Res 31: 1860–1861. [Crossref]
- Hasenclever D, Diehl V (1998) A prognostic score for advanced Hodgkin's disease. International Prognostic Factors Project on Advanced Hodgkin's Disease. N Engl J Med 339: 1506-1514. [Crossref]