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Follow-up care after treatment of Hodgkin's lymphoma

Follow-up examinations

All follow-up visits should include a clinical history and clinical examination with special attention to lymph node status and examination of the heart, lungs, and abdomen. Areas originally involved by lymphoma and irradiated organs/areas should be focused on for recurrence and side effects after treatment. Blood tests should be performed at each follow-up visit and should include hematological tests with differential counts of leukocytes, SR, LDH, TSH, and free T4 in patients who have been irradiated to the neck and/or upper mediastinum, liver and kidney function tests (especially after irradiation to the kidney regions or other nephrotoxic therapy).

Follow-up with chest imaging should be done with X-ray or CT, but MRI should be considered if frequent follow-up is necessary, especially in children and adolescents to reduce radiation exposure.

Follow-up of the abdomen and pelvis for slim patients should be done with imaging using ultrasound of the liver, spleen, and retroperitoneum instead of CT. Multiple CT scans give a significant amount of radiation over time, therefore MRI as an alternative to CT should be considered. MRI should be considered routine for children and adolescents.

The follow-up schedules given below are only guidelines and apply as long as the patient is in remission. For curative treatment of Hodgkin and non-Hodgkin's lymphoma, response is evaluated at least once during chemotherapy as well as after chemotherapy and additional radiation therapy. For palliative chemotherapy, the follow-up schedule is customized, likewise for untreated patients under observation.

The goal of treatment is to cure the disease after first-line therapy and also, for most patients, after recurrence therapy. Blood examination should include the tests mentioned above. A clinical examination should be peformed at all follow-up visits.

  • The first follow-up visit is 1–2 months after completed therapy to evaluate whether the patient is in full remission. The examination should include imaging and bone marrow examination if findings were present before treatment.
  • The first two years after completing treatment will involve follow-up visits every 3 months. Only a chest X-ray is performed after three months. X-ray or chest CT or ultrasound of the abdomen/pelvis is taken after 6, 12, and 24 months. Chest X-ray is taken only at follow-up visits where CT is not performed.  
  • 3 years: Follow-up visit every 4 months. Chest X-ray after 28 and 32 months, X-ray or chest CT and CT or ultrasound of abdomen/pelvis after 36 months. 
  • 3–5 years: biannual follow-up visits with chest X-ray and annual imaging  (ultrasound or CT) of the abdomen/pelvis. 
  • Further annual checks should be carried out with the patient's primary care doctor with guidelines for what the visits should include, for example, thyroid function tests (TSH and free T4) in patients who have received radiation therapy to the neck.
  • For certain patients, especially those who have completed radiation therapy, it is recommended the patient is examined after 10 years with a heart and lung function examination and mammography where appropriate.

Follow-up after high-dose treatment with autologous stem cell support (HDT with SCS)

For recurrence after HDT with SCS, there is rarely a curative treatment option except for rare localized recurrences which can be controlled by radiotherapy. Many patients with recurrence after such treatment for Hodgkin's can, however, live long (many years) with a good quality of life after the recurrence is confirmed. Complications and side effects after completed treatments must be confirmed and registered. Physiotherapy for symptoms from muscle and bone is often of help. Psychological problems can occur long after treatment is finished. Some patients must be rehabilitated to less heavy or demanding jobs.  

Upon discharge after HDT with SCS, the patient is informed of the applicable vaccination program. Full reimmunization (three doses) of tetanus, diphtheria, and whooping cough are recommended after 12 months.   

The intervals between visits are the same as those given for different lymphoma types.

What patients often struggle with

  • Fatigue. This patient group may struggle with fatigue long after treatment is over. This may last for months, maybe years.  Many Hodgkin's patients are relatively young and are in education when they receive the diagnosis. It has been shown that many struggle with resuming their studies later due to difficulties in consentrating and memory problems. Some needs to restart their education. It is importantto evaluate the degree of fatigue in patients treated for lymphoma. Many patients have experienced that there is too little discussion and not enough knowledge shared. It is also important to exclude depression since treatment is very different.
  • Fertility, which is an increasing problem with age and amount/type of treatment. For those who have utilized sperm banking, assisted fertilization may be necessary.
  • Psychological and socioeconomic problems. Many patients benefit from counseling with a social worker or psychiatric nurse. 
  • Dry mouth, tooth decay, and gum diseases are often present after irradiation to the oral cavity. With sufficient documentation from a dentist stating dental care is required as a result of irradiation, the patient can apply for reimbursement from the national health service. 
  • Hypothyroidism after irradiation to the neck is observed in > 50% of patients long after follow-up. 
  • Myalgias and strain injuries are sometimes observed after irradiation to the muscles. These patients often benefit from physiotherapy in the form of heat, massage, and exercises.  

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