Structure of the lymphatic system

Structure of the lymphatic system;
The lymphatic system is the system of vessels, cells, and organs that carries excess fluids to the bloodstream and filters pathogens from the blood. The swelling of lymph nodes during an infection and the transport of lymphocytes via the lymphatic vessels are but two examples of the many connections between these critical organ systems.
This type of system is unique, as it returns lymph fluid via vessels to the cardiovascular system for eventual elimination of toxic byproducts by end organs, such as the kidney, liver, colon, skin, and lungs.
STRUCTURE OF LYMPHATIC SYSTEM
Lymph
Lymph is a fluid derived from blood plasma. It is pushed out through the capillary wall by pressure exerted by the heart or by osmotic pressure at the cellular level. Lymph contains nutrients, oxygen, and hormones, as well as toxins and cellular waste products generated by the cells. As the interstitial fluid accumulates, it is picked up and removed by lymphatic vessels that pass through lymph nodes, which return the fluid to the venous system. As the lymph passes through the lymph nodes, lymphocytes and monocytes enter it.
At the level of the gastrointestinal (GI) tract, lymph has a milky consistency that is attributable to fatty acids, glycerol, and rich fat content. Lacteals are lymph vessels that transport intestinal fat and are localized to the GI tract.
Lymphatic vessels
Lymphatic capillaries are blind-ended tubes with thin endothelial walls (only a single cell in thickness). They are arranged in an overlapping pattern, so that pressure from the surrounding capillary forces at these cells allows fluid to enter the capillary (see the image below). The lymphatic capillaries coalesce to form larger mesh-like networks of tubes that are located deeper in the body; these are known as lymphatic vessels.

The lymphatic vessels grow progressively larger and form 2 lymphatic ducts:
The right lymphatic duct, which drains the upper right quadrant, and the thoracic duct, which drains the remaining lymphatic tributaries.
Lymphatic vessels have 1-way valves to prevent any backflow; the pressure gradients that move lymph through the vessels come from skeletal muscle action, smooth muscle contraction within the smooth muscle wall, and respiratory movement.

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Lymphatic capillaries
Lymphatic capillaries, also called the terminal lymphatics, are vessels where interstitial fluid enters the lymphatic system to become lymph fluid. Located in almost every tissue in the body, these vessels are interlaced among the arterioles and venules of the circulatory system in the soft connective tissues of the body. Exceptions are the central nervous system, bone marrow, bones, teeth, and the cornea of the eye, which do not contain lymph vessels.

Lymphatic capillaries are interlaced with the arterioles and venules of the cardiovascular system. Collagen fibers anchor a lymphatic capillary in the tissue (inset). Interstitial fluid slips through spaces between the overlapping endothelial cells that compose the lymphatic capillary.
Lymphatic capillaries are formed by a one cell-thick layer of endothelial cells and represent the open end of the system, allowing interstitial fluid to flow into them via overlapping cells. When interstitial pressure is low, the endothelial flaps close to prevent “backflow.” As interstitial pressure increases, the spaces between the cells open up, allowing the fluid to enter. Entry of fluid into lymphatic capillaries is also enabled by the collagen filaments that anchor the capillaries to surrounding structures. As interstitial pressure increases, the filaments pull on the endothelial cell flaps, opening up them even further to allow easy entry of fluid.
In the small intestine, lymphatic capillaries called lacteals are critical for the transport of dietary lipids and lipid-soluble vitamins to the bloodstream. In the small intestine, dietary triglycerides combine with other lipids and proteins, and enter the lacteals to form a milky fluid called chyle. The chyle then travels through the lymphatic system, eventually entering the liver and then the bloodstream.
Lymph nodes
Lymph nodes are bean-shaped structures that are widely distributed throughout the lymphatic pathway, providing a filtration mechanism for the lymph before it rejoins the blood stream. The average human body contains approximately 600-700 of them, predominantly concentrated in the neck, axillae, groin, thoracic mediastinum, and mesenteries of the GI tract. Lymph nodes constitute a main line of defense by hosting 2 types of immunoprotective cell lines, T-lymphocytes and B-lymphocytes.
Lymph nodes have 2 distinct regions, the cortex and the medulla.
The cortex contains follicles, which are collections of lymphocytes. At the center of the follicles is an area called germinal centers that predominantly host B-lymphocytes while the remaining cells of the cortex are T-lymphocytes. Vessels entering the lymph nodes are called afferent lymphatic vessels and, likewise, those exiting are called efferent lymphatic vessels.

Extending from the collagenous capsule inward throughout the lymph node are connective tissue trabeculae that incompletely divide the space into compartments. Deep in the node, in the medullary portion, the trabeculae divide repeatedly and blend into the connective tissue of the hilum of the node. Thus the capsule, the trabeculae, and the hilum make up the framework of the node. Within this framework, a delicate arrangement of connective tissue forms the lymph sinuses, within which lymph and free lymphoid elements circulate.
A subcapsular or marginal sinus exists between the capsule and the cortex of the lymph node. Lymph passes from the subcapsular sinus into the cortical sinus toward the medulla of the lymph node. Medullary sinuses represent a broad network of lymph channels that drain toward the hilum of the node; from there, lymph is collected into several efferent vessels that run to other lymph nodes and eventually drain into their respective lymphatic ducts.

Thymus
The thymus is a bilobed lymphoid organ located in the superior mediastinum of the thorax, posterior to the sternum. After puberty, it begins to decrease in size; it is small and fatty in adults after degeneration.
The primary function of the thymus is the processing and maturation of T-lymphocytes. While in the thymus, T- lymphocytes do not respond to pathogens and foreign organisms. After maturation, they enter the blood and go to other lymphatic organs, where they help provide defense. Structurally, the thymus is similar to the spleen and lymph nodes, with numerous lobules and cortical and medullary elements. It also produces thymosin, a hormone that helps stimulate maturation of T -lymphocytes in other lymphatic organs.

The thymus lies above the heart. The trabeculae and lobules, including the darkly staining cortex and the lighter staining medulla of each lobule, are clearly visible in the light micrograph of the thymus of a newborn.
Spleen
The spleen, the largest lymphatic organ, is a convex lymphoid structure located below the diaphragm and behind the stomach. It is surrounded by a connective tissue capsule that extends inward to divide the organ into lobules consisting of cells, small blood vessels, and 2 types of tissue known as red and white pulp.
Red pulp consists of venous sinuses filled with blood and cords of lymphocytes and macrophages;
White pulp is lymphatic tissue consisting of lymphocytes around the arteries. Lymphocytes are densely packed within the cortex of the spleen.
The spleen filters blood in much the same way that lymph nodes filter lymph. Lymphocytes in the spleen react to pathogens in the blood and attempt to destroy them. Macrophages then engulf and phagocytose damaged cells and cellular debris. The spleen, along with the liver, eliminates damaged and old erythrocytes from the blood circulation; like other lymphatic tissue, it produces lymphocytes in an immunologic response to offending pathogens.
Therefore, the spleen conducts several important functions, as follows:
1) Extracts old and defective blood cells and platelets from the blood and breaks them down.

2) Removes foreign matter, bacteria, viruses and toxins form the blood.

3) Stores some of the products such as iron of old broken-down red blood cells for later reuse, or releases them to the blood to be taken to the liver or bone marrow for reuse stores blood platelets.

4) It contains T lymphocytes and B lymphocytes for immunologic response.

(a) The spleen is attached to the stomach.
(b) A micrograph of spleen tissue shows the germinal center. The marginal zone is the region between the red pulp and white pulp, which sequesters particulate antigens from the circulation and presents these antigens to lymphocytes in the white pulp.
Tonsils
Tonsils are aggregates of lymph node tissue located under the epithelial lining of the oral and pharyngeal areas. The main areas are the palatine tonsils (on the sides of the oropharynx), the pharyngeal tonsils (on the roof of the nasopharynx; also known as adenoids), and the lingual tonsils (on the base of the posterior surface of the tongue).
The fact that these tonsils are so closely related to the oral and pharyngeal airways, they may interfere with breathing when they become enlarged. The predominance of lymphocytes and macrophages in these tonsillar tissues offers protection against harmful pathogens and substances that may enter through the oral cavity or airway.

(a) The pharyngeal tonsil is located on the roof of the posterior superior wall of the nasopharynx. The palatine tonsils lay on each side of the pharynx.
(b) A micrograph shows the palatine tonsil tissue.
Lymph nodes
Lymph nodes function to remove debris and pathogens from the lymph, and are therefore sometimes referred to as the “filters of the lymph”. Any bacteria that infect the interstitial fluid are taken up by the lymphatic capillaries and transported to a regional lymph node. Dendritic cells and macrophages within this organ internalize and kill many of the pathogens that pass through, thereby removing them from the body. The lymph node is also the site of adaptive immune responses mediated by T cells, B cells, and accessory cells of the adaptive immune system; like the thymus, the bean-shaped lymph nodes are surrounded by a tough capsule of connective tissue and are separated into compartments by trabeculae, the extensions of the capsule. In addition to the structure provided by the capsule and trabeculae, the structural support of the lymph node is provided by a series of reticular fibers laid down by fibroblasts.

Lymph nodes are masses of lymphatic tissue located along the larger lymph vessels. The micrograph of the lymph nodes shows a germinal center, which consists of rapidly dividing B cells surrounded by a layer of T cells and other accessory cells.
The major routes into the lymph node are via afferent lymphatic vessels. Cells and lymph fluid that leave the lymph node may do so by another set of vessels known as the efferent lymphatic vessels. Lymph enters the lymph node via the subcapsular sinus, which is occupied by dendritic cells, macrophages, and reticular fibers. Within the cortex of the lymph node are lymphoid follicles, which consist of germinal centers of rapidly dividing B cells surrounded by a layer of T cells and other accessory cells. As the lymph continues to flow through the node, it enters the medulla, which consists of medullary cords of B cells and plasma cells, and the medullary sinuses where the lymph collects before leaving the node via the efferent lymphatic vessels.
Adenoid
Although it is often called the adenoids, there is only one adenoid. It is a single, small mass of lymphatic tissue in the back of the nose that contains lymphocytes. It is also sometimes called the pharyngeal tonsil.
The adenoid helps the body fight infection by trapping bacteria and viruses.
The adenoid is present in infants and children. It starts to shrink just before puberty so that most adults don’t have the adenoid.
Bone marrow
Bone marrow is soft, spongy tissue in the centre of most bones. It contains immature cells called stem cells. These stem cells develop into red blood cells, white blood cells or platelets. Red blood cells carry oxygen to and carbon dioxide from tissues in the body. White blood cells help the body fight infection and diseases. Platelets help blood to clot.
Function of lymphatic system
The lymphatic system is responsible for the removal and filtration of interstitial fluid from tissues, absorbs and transports fatty acids and fats as chyle from the digestive system, and transports many of the cells involved in immune system function via lymph.

Removal of Fluid
Interstitial fluid accumulates in the tissues, generally as a result of the pressure exerted from capillaries (hydrostatic and osmotic pressure) or from protein leakage into the tissues (which occurs during inflammation). These conditions force fluid from the capillaries into the tissues. One of the main functions of the lymphatic system is to drain the excess interstitial fluid that accumulates.
The lymphatic system is a blunt-ended linear flow system, in which tissue fluids, cells, and large extracellular molecules, collectively called lymph, are drained into the initial lymphatic capillary vessels that begin at the interstitial spaces of tissues and organs. They are then transported to thicker collecting lymphatics, which are placed with multiple lymph nodes, and are eventually returned to the blood circulation through the left and right subclavian veins and into the vena cava. They drain into venous circulation because there is lower blood pressure in veins, which minimises the impact of lymph cycling on blood pressure. Lymph nodes located at junctions between the lymph vessels also filter the lymph fluid to remove pathogens and other abnormalities.
Fluid removal from tissues prevents the development of edema. Edema is any type of tissue swelling from increased flow of interstitial fluid into tissues relative to fluid drainage. While edema is a normal component of the inflammation process, in some cases it can be very harmful. Cerebral and pulmonary edemas are especially problematic, which is why lymph drainage is so important; abnormal edema can still occur if the drainage components of the lymph vessels are obstructed.

Fatty Acid Transport
The lymphatic system also facilitates fatty acid absorption from the digestive system. During fat digestion, fatty acids are digested, emulsified, and converted within intestinal cells into a lipoprotein called chylomicrons. Lymph drainage vessels that line the intestine, called lacteals, absorb the chylomicrons into lymph fluid. The lymph vessels then take the chylomicrons into blood circulation, where they react with HDL cholesterols and are then broken down in the liver.

Immune Cell Transport
In addition to tissue fluid homeostasis, the lymphatic system serves as a channel for transport of cells involved in immune system function. Most notably, highly-specialised white blood cells called lymphocytes and antigen -presenting cells are transported to regional lymph nodes, where the immune system encounters pathogens, microbes, and other immune producers that are filtered from the lymph fluid. Much of the adaptive immune system response, which is mediated by dendritic cells, takes place in the lymph nodes. Lymphatic vessels, which uptake various antigens from peripheral tissues, are positively regulated by chemokines/cytokines secreted by various immune cells during inflammation. This allows antigens to enter lymph nodes, where dendritic cells can present them to lymphocytes to trigger an adaptive immune response.
While the lymphatic system is important for transporting immune cells, its transport capabilities can also provide a pathway for the spread of cancer. Lymph circulation is one of the main ways that tumors can spread to distant parts of the body, which is difficult to prevent.
Maintenance of hydrostatic pressure
When lymph fluid drains into the blood vessels in the neck region, the blood volume is increased and this helps maintain hydrostatic blood pressure(blood pressure generetaed by the fluid in th blood vessels).
HODKIN’S LYMPHOMA DISEASE

Scientists now conclude that Hodgkin’s disease (HD) is not a single disease with variants. Rather, HD represents a group of at least two diseases.
The two primary classifications of HD are: “classic” Hodgkin’s disease (cHD), and lymphocyte-predominant Hodgkin’s disease (LPHD).

Classic HD
“Classic” Hodgkin’s disease (cHD) is divided into four major subtypes:
1. Nodular sclerosis Hodgkin’s disease (NSHD)
2. Mixed cellularity Hodgkin’s disease (MCHD)
3. Lymphocyte depletion Hodgkin’s disease (LDHD)
4. Lymphocyte-rich classic Hodgkin’s disease (cLRHD) (provisional)

1) Nodular sclerosis Hodgkin’s disease (NSHD) is the most common subtype of HD and accounts for 65 to 80 percent of all cases. It tends to occur in adolescents and young adults (under 50 years), and it is the only form of HD that strikes more women than men. The disease typically arises in the lymph nodes of the chest and other sites above the diaphragm, the large abdominal muscle that controls breathing. Bulky tumor growth may occur in the mediastinum (organs and tissues of the middle chest) and it may spread to the tissues of the lungs. Many NSHD patients are diagnosed with Stage 2 disease.
2) Mixed cellularity Hodgkin’s disease (MCHD) accounts for about 15 to 30 percent of all cases of HD. It affects all age groups, but it does not specifically target young adults, as do some other forms of HD. MCHD is more common in men than in women. Along with LDHD, it is one of the HD variants that appears in association with human immunodeficiency virus (HIV) infection. MCHD also is the subtype that is most often positive for Epstein-Barr virus (EBV). This disease tends to affect the lymph nodes of the abdomen and the spleen more so than areas above the diaphragm.
3) Lymphocyte depletion Hodgkin’s disease (LDHD) is the least common form of HD and accounts for fewer than 1 percent of all HD cases. The disease affects more men than women, and it tends to occur in individuals who are older, HIV-positive, or residents of non-industrialised nations. The disease usually arises in the lymph nodes of the abdomen and pelvis (hip region), while sparing the nodes of the neck and underarms. LDHD is an aggressive form of HD, and most patients are diagnosed with advanced-stage disease.

4) The provisional subtype known as lymphocyte-rich classic Hodgkin’s disease (cLRHD) is a variant of lymphocyte predominant Hodgkin’s disease (LPHD); however, this lymphoma has the clinical behavior of classic HD. It may be diffuse (spread out) or nodular (knot-like) in character. Reed-Sternberg cells occasionally are detected in tissue samples, although the “popcorn cells” of LPHD are not. If, after treatment, the patient experiences a complete remission (lessening of the disease), relapse is very rare. This contrasts with the clinical course of LPHD, which is characterized by a high relapse rate.
Lymphocyte predominant Hodgkin’s disease (LPHD) is divided into two subtypes:
nodular lymphocyte predominant Hodgkin’s disease (nLPHD), and diffuse lymphocyte predominant Hodgkin’s disease (dLPHD).
Rituximab is a type of biological therapy called a monoclonal antibody. It attaches itself to the surface of cancerous cells and stimulates the immune system to attack and kill the cell. It’s given through a drip directly into a vein over the course of a few hours.
Side effects of the drug can include:
• flu-like symptoms, such as headaches, fever and muscle pain;
• tiredness;
• nausea;
• diarrhoea;
4) Nodular lymphocyte predominant Hodgkin’s disease (nLPHD) accounts for about 5 percent of all HD cases. It is three times more common in men than in women, and it primarily affects young adults in their third through fifth decades of life. Most patients (75 percent) are diagnosed at an early stage (e.g., Stage 1), and a majority (by some reports up to 90 percent) respond to therapy with a complete response. The peripheral lymph nodes (underarm, neck, ear, and groin nodes) are frequently involved, whereas the deep, intrathoracic (within the trunk) nodes are spared.
Classic Reed-Sternberg cells are not seen or are very uncommon in patient’s tissue samples. Instead, large, circular meshworks of cells take over the lymph nodes. These nodules contain unusual lymphocytes and histiocytes known as “L & H cells” or “popcorn cells,” as well as B-cells and scattered T-cells. The T-cells may be distributed in a nodular (knot-like) arrangement within the tissues.
Diagnosis of Hodgkin’s disease
Tests and procedures used to diagnose Hodgkin’s lymphoma include:
• Physical exam. The doctor checks for swollen lymph nodes, including neck, underarm and groin, as well as a swollen spleen or liver.
• Blood tests. A sample of the blood is examined in a lab to see if anything in the blood indicates the possibility of cancer.
• Imaging tests. Imaging tests used to diagnose Hodgkin’s lymphoma include X-ray, computerised tomography (CT) and positron emission tomography (PET).
• Surgery to remove a swollen lymph node. Minor surgery may be done to remove all or part of an enlarged lymph node for testing. The lymph node is sent to a laboratory for testing. A diagnosis of Hodgkin’s lymphoma is made if the abnormal Reed-Sternberg cells are found within the lymph node.
• A procedure to collect bone marrow for testing. A bone marrow biopsy may be used to look for signs of cancer in the bone marrow. During this procedure, a small amount of bone marrow, blood and bone are removed through a needle.
Staging Hodgkin’s lymphoma
Afterthe doctor has determined the extent of the Hodgkin’s lymphoma, the cancer will be assigned a stage. Cancer’s stage helps determine the prognosis and treatment options.
Stages of Hodgkin’s lymphoma include:
• Stage I. The cancer is limited to one lymph node region or a single organ.
• Stage II. In this stage, the cancer is in two lymph node regions or the cancer has invaded one organ and the nearby lymph nodes. But the cancer is still limited to a section of the body either above or below the diaphragm.
• Stage III. When the cancer moves to lymph nodes both above and below the diaphragm, it’s considered stage III. Cancer may also be in one portion of tissue or an organ near the lymph node groups or in the spleen.
• Stage IV. This is the most advanced stage of Hodgkin’s lymphoma. Cancer cells are in several portions of one or more organs and tissues. Stage IV Hodgkin’s lymphoma affects not only the lymph nodes but also other parts of your body, such as the liver, lungs or bones.
Additionally, the doctor uses the letters A and B to indicate whether you’re experiencing symptoms of Hodgkin’s lymphoma:
• A means that you don’t have any significant symptoms as a result of the cancer.
• B indicates that you may have significant signs and symptoms, such as a persistent fever, unintended weight loss or severe night sweats.
Treatments
Which treatment options are appropriate for your Hodgkin’s lymphoma depends on the type and stage of disease, overall health, and preferences. The goal of treatment is to destroy as many cancer cells as possible and bring the disease into remission.

Treatment of the disease in children is slightly different from the treatment used for adults. For teens with HL who are fully grown, the treatment is usually the same as that for an adult.
Treatment options depend on many factors, including:
• The type of Hodgkin disease;
• The stage (extent) of the Hodgkin disease;
• Whether or not the disease is bulky (large);
• Whether the disease is causing certain symptoms (known as B symptoms);
• Results of blood and other lab tests;
• A person’s age;
• A person’s general health;
Based on these factors, a person’s treatment might be a little different from the general outline below.
Chemotherapy
Chemotherapy is a drug treatment that uses chemicals to kill lymphoma cells. Chemotherapy drugs travel through the bloodstream and can reach nearly all areas of the body.
Chemotherapy is often combined with radiation therapy in people with early-stage classical type Hodgkin’s lymphoma. Radiation therapy is typically done after chemotherapy. In advanced Hodgkin’s lymphoma, chemotherapy may be used alone or combined with radiation therapy.
Chemotherapy drugs can be taken in pill form or through a vein in your arm, or sometimes both methods of administration are used. Several combinations of chemotherapy drugs are used to treat Hodgkin’s lymphoma.
Side effects of chemotherapy depend on the specific drugs you’re given. Common side effects include nausea and hair loss. Serious long-term complications can occur, such as heart damage, lung damage, fertility problems and other cancers, such as leukemia.
Radiation
Radiation therapy uses high-energy beams, such as X-rays and protons, to kill cancer cells. For classical Hodgkin’s lymphoma, radiation therapy can be used alone, but it is often used after chemotherapy. People with early-stage lymphocyte-predominant Hodgkin’s lymphoma typically undergo radiation therapy alone.
During radiation therapy, a patient lie on a table and a large machine moves around them, directing the energy beams to specific points on the body. Radiation can be aimed at affected lymph nodes and the nearby area of nodes where the disease might progress. The length of radiation treatment varies, depending on the stage of the disease.
Radiation therapy can cause skin redness and hair loss at the site where the radiation is aimed. Many people experience fatigue during radiation therapy. More-serious risks include heart disease, stroke, thyroid problems, infertility and other forms of cancer, such as breast or lung cancer.
Bone marrow transplant
A bone marrow transplant, also known as a stem cell transplant, is a treatment to replace thr diseased bone marrow with healthy stem cells that help the patient grow new bone marrow. A bone marrow transplant may be an option if Hodgkin’s lymphoma returns despite treatment.
During a bone marrow transplant, a patient’s blood stem cells are removed, frozen and stored for later use. Next the patient will receive high-dose chemotherapy and radiation therapy to destroy cancerous cells in the body. Finally, the stem cells are thawed and injected into the body through veins. The stem cells help build healthy bone marrow.
Targeted therapy
Targeted therapy uses medications designed to target specific vulnerabilities in your cancer cells. If other treatments haven’t helped or if your Hodgkin’s lymphoma returns, the lymphoma cells may be analysed in a laboratory to look for genetic mutations. The doctor may recommend treatment with a drug that targets the particular mutations present in your lymphoma cells.
Targeted therapy is an active area of cancer research. New targeted therapy drugs are being studied in clinical trials.
Side effects of chemotheraphy
Chemotherapy can cause unpleasant side effects, although many can be treated or prevented and most will pass once the patient’s treatment stops. It’s difficult to predict what side effects you’ll get.
Here’s a list of many of the common side effects:
Tiredness
Tiredness (fatigue) is one of the most common side effects of chemotherapy. Many people having treatment feel generally tired a lot of the time very easily during everyday tasks. To reduce the tiredness is essential to:
• get plenty of rest;
• avoid doing tasks or activities that you don’t feel up to
• do light exercise, such as walking or yoga, if the patient is able to – this can boost energy levels;
Feeling sick and vomiting
Many people having chemotherapy will have periods where they feel sick or vomit. The care team can give you anti-sickness medication to reduce or prevent this.
This is available as:
• tablets or capsules;
• injections or a drip into a vein;
• suppositories – capsules you put into your bottom;
• a skin patch;
Side effects of anti-sickness medicines include constipation,indigestion, problems sleeping and headaches.
Hair loss
Hair loss is a common side effect of chemotherapy, although it doesn’t happen to everyone If you a patient lose hair, it usually starts within a few weeks of the first treatment session. If a patient lose lots of hair this typically happens within a month or two.
It’s most common to lose hair from the head but can also lose it from other parts of your body, including your arms, legs and face. The hair loss is almost always temporary. The hair should start to grow back soon after your treatment has finished; but sometimes the hair that grows back is a slightly different colour or it may be curlier or straighter than it used to be.
Preventing hair loss
It may be possible to reduce the chances of hair loss by wearing a cold cap while having chemotherapy. A cold cap looks similar to a bicycle helmet and is designed to cool your scalp during a treatment session. This reduces blood flow to the scalp, reducing the amount of medicine that reaches it.
Infections
Chemotherapy can reduce the body’s ability to fight infection. This makes a patient more likely to pick up infections that could make seriously ill.
It’s a good idea to take precautions to protect yourself against infection. For example:
• wash your hands regularly with soap and water – particularly after going to the toilet and before preparing food and eating
• try to avoid close contact with people who have an infection – such as chickenpox or flu
• have the annual flu jab
A course of antibiotics may sometimes be prescribed to reduce your risk of developing an infection.
Anaemia
Chemotherapy lowers the amount of red blood cells, which carry oxygen around the body. If the patient’s red blood cell count drops too low, anaemia will be developed.
Symptoms of anaemia include:
• tiredness and lack of energy – this tends to be more severe than the general fatigue associated with chemotherapy
• shortness of breath
• noticeable heartbeats (heart palpitations)
• a pale complexion
Preventing anaemia
Including a high amount of iron in your diet can help reduce your risk of anaemia, as iron helps the body make red blood cells.
Foods high in iron include:
• meat – particularly liver
• beans and nuts
• dried fruit – such as dried apricots
• wholegrains – such as brown rice
• fortified breakfast cereals
• dark-green leafy vegetables – such as watercress and curly kale
Bruising and bleeding
Chemotherapy can reduce the number of cells called platelets in the blood. These help stop severe bleeding when you cut or injure yourself.
If you have a low number of platelets, the patient may have:
• skin that bruises easily;
• severe nosebleeds;
• bleeding gums;
Sore mouth
Sometimes chemotherapy can make the lining of the mouth sore and irritated. This is known as mucositis.
Symptoms tend to develop a few days after treatment starts and include:
• the inside of the mouth feeling sore;
• mouth ulcers, which can become infected;
• discomfort when eating, drinking and/or talking;
• a dry mouth;
• reduced sense of taste
• bad breath
Mucositis usually clears up a few weeks after chemotherapy finishes.
Loss of appetite
A patient may lose their appetite while having chemotherapy, but they should try to drink plenty of fluids and eat what theay can.
It may help to:
• eat smaller meals more often instead of three large meals a day
• eat healthy snacks regularly
• eat light meals on the day of your treatment
• sip drinks slowly through a straw, rather than drinking them straight from a glass
Skin and nail changes
Some chemotherapy medicines can cause temporary changes to your skin.
For example, it may become:
• dry;
• slightly discoloured (this may be patchy);
• more sensitive to sunlight;
• red and sore;
• itchy;
Chemotherapy can also make a patient’s nails become brittle or flaky, and white lines may develop across them. This should go back to normal after the treatment has finished.Using moisturiser on the nails may help and nail varnish (but not quick-drying varnish or false nails) can be used to cover the nails during treatment if wanted.
Memory and concentation problems
Some people have problems with their short-term memory, concentration and attention span during chemotherapy. The patient may find that routine tasks take much longer than usual. It’s unclear why this happens, but the symptoms usually improve once treatment is finished. Things such as using lists, post-it notes, calendars and mobile phone for reminders can help. Doing some mental exercises, eating well, and getting enough rest may also be useful.
Sleep problems
Some people having chemotherapy have difficulty falling asleep, or wake up in the middle of the night and can’t get back to sleep. This is known as insomnia.
Diarrhoea and constipation
A patient may have diarrhoea or constipation a few days after you begin chemotherapy.
Emotional issues
Having chemotherapy can be a frustrating, stressful and traumatic experience. It’s natural to feel anxious and to wonder if your treatment will be successful. Stress and anxiety can also increase your risk of getting depression.

Fertility issues
A possible long-term effect of chemotherapy and radiation therapy, especially in younger patients, is reduced or lost fertility. For example, some chemo drugs can affect a male’s ability to make sperm, which might be temporary or permanent. If the patient is old enough and is going to get chemo drugs that can affect fertility, sperm banking should be considered before chemo is started.
Likewise, women may stop having menstrual periods with chemotherapy. This may or may not return to normal. Radiation to the lower abdomen can cause infertility unless the ovaries are surgically moved outside the radiation field beforehand. Moving the ovaries does not affect cure rates because Hodgkin lymphoma almost never spreads to the ovaries.

Heart disease and strokes
People who have had radiation to the chest have a higher risk of heart disease and heart attacks. This has become less of a problem with more modern radiation techniques, but it’s important to do what you can to help lower your risk, such as not smoking, staying at a healthy weight, being active, and eating a healthy diet. Some chemo drugs such as doxorubicin (Adriamycin) can also cause heart damage. The doctor might want to check your heart function for several years after your treatment.
Radiation to the neck increases the chance of stroke because it can damage the blood vessels in the neck that supply the brain. Smoking and high blood pressure also increase the risk of stroke. Once again, it’s important to avoid smoking. It’s also important to have regular check-ups with your doctor and to get treated if you have high blood pressure.
Lung damage
The chemo drug bleomycin can damage the lungs, as can radiation therapy to the chest. This can lead to problems such as shortness of breath, which might not show up until years after treatment. Smoking can also seriously damage the lungs, so it’s important that people who have had these treatments do not smoke.
The steroid medication is given intravenously, usually at the same time as your chemotherapy. Common side effects of steroid medication include:
• increased appetite, which can lead to weight gain
• indigestion
• problems sleeping
• feeling agitated
The side effects of steroid medication usually start to improve once treatment finishes.
Side effects of radiation
Radiotherapy can cause side effects, although many of these can be treated or prevented and most will pass once treatment stops.
It’s difficult to predict what side effects a patient get; it varies from person to person and depends on things such as the part of your body being treated and the type of radiotherapy you have. The main side effects are simiilar to che chemotheraphy, but it’s unlikely that a patient will have all of the mentioned above.
Symptoms
The most common symptom of Hodgkin lymphoma is a swelling in the neck, armpit or groin. The swelling is usually painless, although some people find that it aches.
The swelling is caused by an excess of affected lymphocytes (white blood cells) collecting in a lymph node (also called lymph glands). Lymph nodes are pea-sized lumps of tissue found throughout the body. They contain white blood cells that help to fight infection.
However, it’s highly unlikely that you have Hodgkin lymphoma if you have swollen lymph nodes, as these glands often swell as a response to infection.
Some people with Hodgkin lymphoma also have other more general symptoms. These can include:
• night sweats
• unintentional weight loss
• a high temperature (fever)
• a persistent cough or feeling of breathlessness
• persistent itching of the skin all over the body
Other symptoms will depend on where in the body the enlarged lymph glands are. For example, if the abdomen (tummy) is affected, a person may have abdominal pain or indigestion.
A few people with lymphoma have abnormal cells in their bone marrow when they’re diagnosed. This may lead to:
• persistent tiredness or fatigue;
• an increased risk of infections;
• excessive bleeding – such as nosebleeds, heavy periods and spots of blood under the skin;

In some cases, people with Hodgkin lymphoma experience pain in their lymph glands when they drink alcohol.
Risk factors
A risk factor is anything that affects the chance of getting a disease such as cancer. Most cancers are the result of many risk factors, however sometimes Hodgkin lymphoma develops in people who don’t have any of the risk factors described below.
Hodgkin lymphoma affects men slightly more often than women. It is most common in younger adults (mid-teens through the 30s) and in people age 55 and older.
The following are risk factors for Hodgkin lymphoma. Most of the known risk factors are not modifiable; this means that they can’t be changed.

1) Epstein-Barr virus infection/mononucleosis
People who have had infectious mononucleosis, an infection caused by the Epstein-Barr virus (EBV), have an increased risk of Hodgkin lymphoma. Although the risk is higher than for people who have not had mono, the overall risk is still very small.
The exact role of EBV in the development of Hodgkin lymphoma is not clear. Many people are infected with EBV, but very few develop Hodgkin lymphoma. Parts of the virus are found in Reed-Sternberg cells in about 1 out of 3 people with Hodgkin lymphoma. But most people with Hodgkin lymphoma have no signs of EBV in their cancer cells.
2) Age
People can be diagnosed with Hodgkin lymphoma at any age, but it is most common in early adulthood (especially in a person’s 20s) and in late adulthood (after age 55).
3) Gender
Hodgkin lyphoma occurs slightly more often in males than in females.
4) Geography
Hodgkin lymphoma is most common in the United States, Canada, and Europe, and is least common in African and Asian countries.
5) Family history
Brothers and sisters of young people with this disease have a higher risk for Hodgkin lymphoma. The risk is very high for an identical twin of a person with Hodgkin lymphoma. But a family link is still uncommon – most people with Hodgkin lymphoma do not have a family history of it.
It’s not clear why family history might increase risk. It might be because family members have similar childhood exposures to certain infections (such as Epstein-Barr virus), because they share inherited gene changes that make them more likely to get Hodgkin lymphoma, or some combination of these factors.
6) Socioeconomic status
The risk of Hodgkin disease is greater in people with a higher socioeconomic background. The reason for this is not clear. One theory is that children from more affluent families might be exposed to some type of infection (such as Epstein-Barr virus) later in life than children from less affluent families, which might somehow increase their risk.
7) HIV infection
The risk of Hodgkin disease is increased in people infected with HIV, the virus that causes AIDS.
For some people, Hodgkin lymphoma may never go away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to help control it for as long as possible and to help relieve symptoms. Learning to live with Hodgkin lymphoma that does not go away can be difficult and very stressful.
Even if you’ve completed treatment, doctors will still want to watch the patient closely. It’s very important to go to all the follow-up appointments, as Hodgkin lymphoma can sometimes come back even many years after treatment.
Some treatment side effects might last a long time or might not even show up until years after you have finished. The doctor visits are a good time to ask questions and talk about any changes or problems you notice or concerns you have

Exams and tests
During follow-up visits, the doctor will ask about symptoms, do physical exams, and may order blood tests or imaging tests such as CT scans or chest x-rays. Doctor visits and tests are usually recommended every few months for the first several years after treatment. Gradually, the length of time between visits can be increased, but even after 5 years they should be done at least yearly.
People whose Hodgkin lymphoma doesn’t go away completely with treatment will have a follow-up schedule that is based on their specific situation.

Keeping health insurance and copies of your medical records
Even after treatment, it’s very important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.
At some point after your treatment, you might find yourself seeing a new doctor who doesn’t know about your medical history. It’s important to keep copies of your medical records to give your new doctor the details of your diagnosis and treatment.
Dietary supplements
So far, no dietary supplements (including vitamins, minerals, and herbal products) have been shown to clearly help lower the risk of Hodgkin lymphoma progressing or coming back. This doesn’t mean that no supplements will help, but it’s important to know that none have been proven to do so.
Dietary supplements are not regulated like medicines in the United States – they do not have to be proven effective (or even safe) before being sold, although there are limits on what they’re allowed to claim they can do. If you’re thinking about taking any type of nutritional supplement, talk to your health care team. They can help you decide which ones you can use safely while avoiding those that might be harmful.
If Hodgkin lymphoma does come back at some point, your treatment options will depend on where the lymphoma is, what treatments you’ve had before, how long it’s been since treatment, and your current health and preferences.
Special concerns in childhood Hodgkin lymphoma survivors
Just as the treatment of childhood Hodgkin lymphoma requires a very specialised approach, so does follow-up and monitoring for late effects of treatment. Careful follow-up after treatment is very important. The earlier problems are found, the more likely it is they can be treated effectively.
Along with physical side effects (including those listed above), survivors of childhood lymphoma may have emotional or psychological issues. They also may have some problems with normal functioning and school work. These can often be addressed with support and encouragement. Doctors and other members of the health care team can also often recommend special support programs and services to help children after treatment.
To help increase awareness of late effects and improve follow-up care for childhood cancer survivors throughout their lives, the Children’s Oncology Group (COG) has developed long-term follow-up guidelines for survivors of childhood cancers. These guidelines can help you know what to watch for, what types of health screening should be done, and how late effects may be treated.
Patient’s case study on Hodgink’s lymphoma

Patient Characteristics
• 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.

Examination

Subjective:
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 hospitalizsed 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)
Objective:
• 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.
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.

Intervention
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 1 – 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.

Co-interventions:
• Chemotherapy, radiation, proper diet, and psychological counseling.
Outcomes
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.
Discussion
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.

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