Clinical Practice Guideline
Developed for the
Aerospace Medical Association
by their constituent organization
Overview: Hodgkin’s Disease (HD) is a neoplasm of lymphoid tissue defined histopathologically by the malignant Reed-Sternberg cell. Four histologic types (lymphocyte predominant, nodular sclerosis, mixed cellularity, and lymphocyte depletion) are distinguished on the basis of the appearance and relative proportions of Reed-Sternberg cells, lymphocytes, and fibrosis. The anatomic extent of disease and, to a lesser degree, the histologic subtype are the primary factors determining the presenting features, prognosis, and optimal therapy of HD.
incidence of HD in the
Several large studies have demonstrated a three-fold increased risk for HD with a prior history of serologically confirmed infectious mononucleosis (in particular elevated titers of Epstein-Barr virus). An increased risk for HD among siblings and close relatives supports a genetic basis for increased susceptibility.
of HD is classified using the four-stage
Treatment for HD may involve radiotherapy, chemotherapy, or both. Radiotherapy is usually delivered in the mantle region (cervical, supraclavicular, infraclavicular, axillary, mediastinal, and hilar nodes), the para-aortic/splenic region, and the pelvic region. Chemotherapy regimes consist of MOPP (nitrogen mustard, vincristine, procarbazine, and prednisone) or ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). Recently, bone marrow transplantation has been used as therapy for refractory HD with limited success.
Prognosis varies depending primarily on stage of disease and histologic subtype. For limited-stage disease (Stages I or II), the cure rate after treatment is 85% to 90%. For advanced disease (III or IV) the cure rate ranges from 65% to 85%. Histologic subtypes lymphocyte predominance and nodular sclerosis usually carry a better prognosis than mixed cellularity, which in turn has a better prognosis than lymphocyte depletion. Age greater than 40 years , B systemic symptoms, and extensive tumor burden are other factors that have been repeatedly documented as poor prognostic factors. Relapse after successful treatment occurs in 25% to 40% and greater than 90% of the relapses occur within 2 to 4 years.
Aeromedical Concerns: The risk for sudden incapacitation is minimal as disease involvement of the CNS or heart is rare. Although the most common presentation of HD is a superficial nontender mass, initial manifestations may include hemoptysis (intrathoracic involvement) or neurologic symptoms from spinal cord compression. The greatest concern is for the potentially rapid (weeks to months) degradation in mental and physical status when the HD and/or treatment protocol is aggressive. Damage to the cardiopulmonary, neurologic, endocrine, and reticuloendothelial systems may occur as a result of the disease or therapy.
Treatment and Aeromedical Disposition: Initial presentation, as a minimum, should include CBC, CXR, ECG, PFT, and Hematology/Oncology consultation. The diagnosis will be reviewed by appropriate consultation, such as the AFIP or major cancer center. Additional evaluation should be based on radio-/chemotherapeutic courses given, adequate staging and prognosis. The aviator should be without major symptoms or medication / complication / sequelae that would affect aeromedical safety.
Experience: The USAF aircrew waiver file lists eleven members with HD in remission and nine received waivers (8 of the 9 received FCII waiver). Although these numbers are small, the possibility of returning to flying status after effective treatment of HD is good. Medical certification is not granted during active disease. Generally medical certification is not granted for one year after chemotherapy/radiotherapy treatment. Normally, in civil aviation medical certification is not granted for Stage III or IV disease. Yearly current status evaluations are required for at least 5 yr. after treatment. The way the FAA has its current pathology coding system Hodgkin’s and Non-Hodgkin’s Lymphoma are counted together. As of November 2005 the FAA has granted 121 Firstclass, 96 Secondclass, and 249 Thirdclass medical certificates
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Foon KA, Fisher RI. Lymphoma. Beutler E, Lichtman MA, Coller BS, Kipps TJ (eds). Williams Hematology. 1995; 5:1076-96.
Hartge P, Devesa SS, Fraumeni JF. Hodgkin’s and Non-Hodgkin’s Lymphomas. Cancer 1994; 19-20:423-53.
August 2, 2006