Delayed But Not Defeated: A Case of Hodgkin Lymphoma Treated After a Two-Year Delay

   

Abdulaziz Wannas Abd^1,2*, Fatimah Hashim Mohammed² and Boshra Abd Alhaleem Alhoushi²

Citation: Abd AW, Mohammed FH, Alhoushi BAA. Delayed but Not Defeated: A Case of Hodgkin Lymphoma Treated After a Two-Year Delay. Adv Clin Med Res. 6(2):1-05.

Received: October 15, 2025  | Published: October 28, 2025

Copyright^© 2025 Genesis Pub by Abd AW. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are properly credited.

DOI: https://doi.org/10.52793/ACMR.2025.6(3)-107

Abstract

This is a reported case of classical Hodgkin’s lymphoma (mixed cellularity type) in an otherwise healthy nine- year-old male who diagnosed after one-month history of swelling of the right neck and supraclavicular region without other symptoms and left the for very long period more than two years without professional medical treatment. An ultrasound of the neck detected many enlarged lymph nodes in the right supraclavicular area, and a chest X-ray showed mild mediastinal dilatation. Subsequent other investigation of the neck, chest and abdomen with cervical lymph node biopsy confirmed the diagnosis of Hodgkin lymphoma after reviewed by two histopathologists. The treatment protocol includes 7 cycles of ABVD (Adriamycin, Bleomycin, Vinblastine and Decarbazine) with 14 doses of radiotherapy with shows full recovery by FDG PET\CT scan. The treatment delay in this patient, is related to the family neglect, seem to have no significant influence on response to the chemotherapy treatment and not affect the short-term survival. The less aggressiveness of such tumor may be the important parameter.

Keywords

Hodgkin lymphoma; Delayed treatment.

Introduction

Until the recently, Hodgkin lymphoma was known as Hodgkin's disease. The eponym honors the British physician Thomas Hodgkin, who published the first description of the disease in 1832.Hodgkin lymphoma affects nearly 8000-9000 new patients in the United States each year [1,2]. The disease has a bimodal distribution with an increased incidence in young adults as well as in patients 55 years and older. There are no clearly defined risk factors for the development of this disease and the cause of HL remains unknown. Factors shown to be associated with HL include familial factors, viral exposures and immune suppression. Same sex siblings of patients with HL have a 10-fold higher risk for developing the disease and a monozygotic twin of a patient with HL has a significantly increased risk of developing HL when compared to a dizygotic twin sibling of a patient with HL. Factors for Hodgkin lymphoma include infection with infectious mononucleosis and a history of the disease in the family. Risk factors for common types of non-Hodgkin lymphomas include autoimmune diseases, human immune deficiency virus  infection T-Lymphotropic virus and immune suppressive therapy [3,4,5]. Hodgkin lymphoma is one of the most curable malignancies of childhood and adolescence. The treatment of pediatric Hodgkin lymphoma is based on the experience of adult Hodgkin lymphoma treatment regimens. In general, the treatment of Hodgkin lymphoma is tailored to the subtype, staging, and response to therapy, and, as such, an accurate histopathological diagnosis is required. Hodgkin lymphoma can be cured with radiation therapy and/or chemotherapy. Combined-modality therapy, including radiation and chemotherapy, is the preferred approach for most pediatric patients. Because most pediatric patients with Hodgkin lymphoma are successfully treated, an important consideration in the treatment approach of children and adolescents is the selection of a treatment regimen, particularly in reference to the anticipated late toxicities associated with cancer-directed therapy. Late toxicities vary substantially according to the treatment modality used. Most modern pediatric treatment strategies focus on reducing late effects of therapy while maintaining excellent cure rates with risk-adapted chemotherapy alone or response-adjusted combined-modality regimens [6]. Clinical trials incorporating radiation-sparing therapy protocols for pediatric Hodgkin lymphoma have recently been implemented. Preliminary data suggest that a subset of patients with good response to therapy may have good outcomes without radiation therapy. PET scanning is becoming an important modality to guide involved-field radiation therapy in adult Hodgkin lymphoma, and its role in guiding involved-field radiation therapy in pediatrics is being explored [7]. For early or favorable disease (stage IA or IIA with < 3 nodal sites, and some IIIA without bulky disease) standard treatment includes 2-4 chemotherapy cycles of ABVE, OEPA, or VAMP plus low-dose, involved-field radiation of 15-30 Gy or 6 chemotherapy cycles of COPP alternating with ABVD and no irradiation. 2-4 cycles of the adult regimen ABVD are also comparable in terms of survival and cumulative doses of chemotherapy. Other regimens are feasible, effective, and safe but expose patients to unnecessary doses of chemotherapy [8].

Case Scenario

A 9 years old male who presented with right cervical and right supra clavicular swelling for one-month durations. The patient family denied any family history of fever, weight loss and night sweating. Physical examination revealed hard fixed mass attached to underlying structure of 3x3 cm in supra cavicular area and 3x2 cm in the right cervical region with initial chest radiography shows mild hilar lymphadenopathy and respiratory examination revealed fair air entry and normal heart sound. The rest of the examination was otherwise within normal limits. Laboratory investigations showed normal complete blood count with differential, hepatic and renal function tests; slightly elevation of lactate dehydrogenase (LDH), normal serum electrolytes and marked elevation of C-reactive protein and ESR (92,114 respectively). An ultrasound exam of the neck shows the presence of enlarged lymph nodes in the right supraclavicular side of the neck, with destructed unclear hilum that were consistent with a lymphoproliferative disease. Bone marrow aspirate and biopsy was done with negative result for any malignant infiltrate. Abdominal US shows mild focal splenic infiltrate. The disease was assigned as stage III according to Ann Arbor staging classification.

Supraclavicular lymph node biopsy and immunohistochemically study was reviewed by two pathologists made the diagnosis of classical Hodgkin’s lymphoma (mixed cellularity subtype) by finding the diagnostic Reed-Sternberg cells and CD30 positive. After diagnosis the patient left for more than two years and (32 months) without treatment and refuse any intervention or chemotherapy and family neglect and the prefer alternative and complementary medicine. During this period the family notice no change in size with slight progression of lymph node so they decided to return back for medical treatment. The treatment protocol includes 7 cycles of ABVD (Adriamycin, Bleomycin, Vinblastine and Decarbazine) with 14 doses of radiotherapy with shows full recovery by FDG PET\CT scan. The patient has remained disease-free for the past four years and is considered fully cured. This case highlights that complete remission and cure are still possible, even after a prolonged period of treatment delay and neglect.

Discussion

Delayed treatment of cancer for any causes represent is the major health condition lead to decreased survival rates in children with cancer that lives in developing countries and this depend on the nature of tumor availability of chemotherapy and presence of special  health care facility .[9]Similar study with median delay of four months versus more than 2 years in this case study carry no specific correlation between delay in diagnosis and age, B-symptoms, stage of disease, recurrent disease or death of disease and carry minimal difference in  overall survival advanced disease (stages IIB-IV) [10].  This also depend on multiple regimens uses as an attempt to improve efficacy of the treatment. The ABVD chemotherapy regimen was then developed and also showed significant clinical activity with potentially less toxicity in compares with other protocol [11,12]. Most of the family attributed the causes of swelling to the infection and they wait resolve spontaneously and avoid chemotherapy treatment. The large amounts of information on previous illnesses, including infections, are routinely collected by medical practitioners working in primary care. Although these data, which are principally collected with the aim of documenting and monitoring patient care, have been used in a limited way in a number of etiological studies [13]. The diagnosis of this case was confirmed by two histopathologist similar to initial diagnosis of any case Hodgkin Lymphoma can be made by a biopsy, so there is no doubt about the diagnosis that give adequate excuse for the family to escape from the treatment [14]. Any child with cancer needs parental consent in our country before start treatment. Though the most common form of child maltreatment, neglect can prove among the hardest to diagnose, and intervention is equally difficult. In considering neglect of a child's medical needs, a number of factors play important roles. Diagnosis should be motivated foremost by the intent of providing the best ongoing care for the patient, supplying what the child has not been able to receive from the caregiver. Characteristics peculiar to the patient, the parents, the pathologic condition, its possible treatments, and the mutual understanding between the child's caregivers and the treating professionals all help determine why the therapeutic relationship has failed and which interventions will be most effective. Religious and cultural considerations may lead a family to refuse medical treatments, occasionally to the child's detriment. The caregivers' wishes must be taken into account, but legal precedent has affirmed that the patient's welfare remains the paramount concern. Sorting through the opinions and providing clarity can be a challenge. Finally, good medical care can help prevent medical neglect in many cases. Clear communication and empathy remain hallmarks of good medical practice. Delay in cancer treatment has been a topic of numerous studies [15]. Despite the efforts represented by these studies, patients continue to neglect seeking timely treatment and suffer significant consequences for this neglect [16]. Late diagnosis and treatment of children with cancer had a serious and life treating effect in the future of their life. The survival chance of child with cancer in Low- and Middle-income countries, is still a major problem and is less than 30%, whereas 80% in developed countries in which the variation might be related to delay in diagnosis [17]. A patient who receives a delayed cancer diagnosis due to their doctor’s negligence may have the right to seek compensation for financial and personal losses through a medical malpractice claim. The tumor neglect phenomenon is of broad interest to the field of plastic and reconstructive surgery. Given the complex patient factors that contribute to the extreme state of disease progress upon presentation, all cases required extensive extirpative efforts with complex and challenging reconstructive solutions. Diagnosing of cancer early on is crucial in helping treat it. If cancer patients receive a formal diagnosis early on, they’ll have a considerably higher survival rate and more easily treat the cancer before it has the chance to spread to other parts of the body. Conversely, if doctors detect and diagnose cancer too late, patients will have a much harder time treating the cancer and making a recovery. An early diagnosis is particularly vital for treating cancers that become exponentially more deadly as they progress, such as breast and colorectal cancer.

Conclusion

The treatment delay in this patient, is related to the family neglect, seem to have no significant influence on response to the chemotherapy treatment and not affect the short-term survival. The less aggressiveness of such tumor may be the important parameter. Even advanced disease with classical Hodgkin lymphoma can be treated successfully. after initial delayed whether family or doctors related but still early diagnosis, careful staging and risk group identification of Hodgkin's lymphoma represent the optimal management of this disease. Although delays in diagnosis of cancer among children were relatively low as compared to other studies, the prevalence of delay in diagnosis of cancer among children remains prevalent in the study area. Rural residence, absence of health insurance, no referral and absence of comorbid were significant factors associated with delay in diagnosis of childhood cancer especially in Hodgkin lymphoma.

Conflict of interest: None

Funding: None

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