My Flight Surgeon
Sr. Aviation Medical Examiner
[FONT="]This is another in the series of condition for which the FAA grants Special Issuance certificates.
As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissunace.com can assist you in preparing your records for submission.
The topic today is Lymphoma and Hodgkin’s Disease[/FONT]
[FONT="]Hodgkin's disease[/FONT][FONT="], sometimes called Hodgkin's lymphoma, is a cancer that starts in lymphatic tissue. Lymphatic tissue includes the lymph nodes and related organs that are part of the body's immune and blood-forming systems. The lymph nodes are small, bean-shaped organs found underneath the skin in the neck, underarm, and groin. They are also found in many other places in the body such as inside the chest, abdomen, and pelvis. [/FONT]
[FONT="]Lymph nodes make and store infection-fighting white blood cells, called lymphocytes. They are connected throughout the body by lymph vessels (narrow tubes similar to blood vessels). These lymph vessels carry a colorless, watery fluid (lymphatic fluid) that contains lymphocytes. Eventually the lymphatic fluid is emptied into the blood vessels in the left upper chest.[/FONT]
[FONT="]Other components of the lymphatic system include the spleen, the bone marrow, and the thymus. The spleen is an organ in the left side of the upper abdomen that is composed primarily of mature and immature lymphocytes. It removes old cells and other debris from the blood. The bone marrow is the spongy tissue inside the bones that creates new red and white blood cells including lymphocytes. The thymus is a small organ in the chest that is important in developing a special lymphocyte called a T cell.[/FONT]
[FONT="]Because lymphatic tissue is present in many parts of the body, Hodgkin's disease can start almost anywhere, but most often starts in lymph nodes in the upper part of the body. The most common sites are in the chest, neck, or under the arms. Hodgkin's disease enlarges the lymphatic tissue, which can then cause pressure on important structures. It can spread through the lymphatic vessels to other lymph nodes. This is the major way it spreads. Most Hodgkin's disease spreads to nearby lymph node sites in the body, not distant ones. It rarely gets into the blood vessels and can spread to almost any other site in the body, including the liver and lungs.[/FONT]
[FONT="]Lymph nodes enlarge for many reasaons. Although Hodgkin's disease is one cause, enlarged lymph nodes are more commonly a result of the body fighting an infection. Your doctor can help determine the cause. [/FONT]
[FONT="]Hodgkin's disease is a malignant lymphoma (cancer of lymphatic tissue). There are two kinds of lymphomas: Hodgkin's disease (named after Dr. Thomas Hodgkin who first recognized it in 1832) and non-Hodgkin's lymphomas. For information on non-Hodgkin's lymphomas see the document "Non-Hodgkin's Lymphomas". [/FONT]
[FONT="]The cancer cells in Hodgkin's disease are called Reed-Sternberg cells, after the two doctors who first described them in detail. Under a microscope they look different from cells of non-Hodgkin's lymphomas and other cancers. Most scientists now believe that Reed-Sternberg cells are a type of malignant B lymphocyte. Normal B lymphocytes are the cells that make antibodies that help fight infections. [/FONT]
[FONT="]Doctors have given names to different types and subtypes of Hodgkin's disease. The two main types are classical Hodgkin's disease (which has several subtypes) and nodular predominant Hodgkin's disease. [/FONT]
[FONT="]Classical Hodgkin's disease:[/FONT]
[FONT="]All of these types are malignant because as they grow, they may compress, invade, destroy normal tissue and spread to other tissues. There is no benign (noncancerous) form of Hodgkin's disease.[/FONT]
[FONT="]Many people with Hodgkin's disease experience no classic symptoms. Sometimes, an abnormality found on a chest X-ray done for nonspecific symptoms leads to an eventual diagnosis of Hodgkin's disease.[/FONT]
[FONT="]Because the symptoms of Hodgkin's are similar to those of other disorders, such as influenza, the disease can be difficult to diagnose. Some distinctive characteristics help diagnose Hodgkin's disease, and these include:[/FONT]
[FONT="]Other procedures that may be valuable in evaluating Hodgkin's disease include X-ray, computerized tomography (CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, bone marrow biopsy and blood tests. If the disease is predominantly in your abdomen, you may need exploratory surgery to help define the extent of the disease.[/FONT]
[FONT="]Staging Hodgkin's disease[/FONT][FONT="]
Once the diagnosis is confirmed, doctors "stage" the disease. Staging is how doctors judge the extent of the disease, which will likely affect your treatment options.[/FONT]
[FONT="]The most important factor in the treatment of Hodgkin's disease is the stage of the disease. The number and regions of lymph nodes affected and whether only one or both sides of your diaphragm are involved are also important considerations. Other factors affecting decisions about treating this disease include:[/FONT]
[FONT="]Treatment options include:[/FONT]
[FONT="]Radiation[/FONT][FONT="]
When the disease is confined to a limited area, radiation therapy is the treatment of choice. It's typical to radiate the affected nodes and the next area of nodes where the disease might progress. The length of radiation treatment varies depending on the stage of the disease. Radiation therapy may be used alone, but is commonly used in conjunction with chemotherapy. If you relapse after radiation therapy, chemotherapy becomes necessary.[/FONT]
[FONT="]Some forms of radiation therapy may increase the risk of other forms of cancer, such as breast or lung cancer. The risk of breast cancer from standard dose radiation is even higher for girls and women treated when they were younger than 30 than for other people and is generally too high for this therapy to be considered. Most children with Hodgkin's disease are treated with combination chemotherapy, but may also receive low-dose radiation therapy.[/FONT]
[FONT="]Chemotherapy[/FONT][FONT="]
When the disease progresses and involves more lymph nodes or other organs, chemotherapy is the preferred treatment. Chemotherapy uses specific drugs in combination to kill tumor cells.[/FONT]
[FONT="]A major concern with chemotherapy is the possibility of long-term side effects and complications, such as heart damage, lung damage, liver damage and secondary cancers, such as leukemia. Although these severe effects occur in only a small number of people, great effort is being put into finding equally effective regimens with less toxicity. Drug regimens have been developed that substantially diminish the likelihood of long-range, life-threatening complications, including acute leukemia in people who have received multiple courses of chemotherapy and radiation therapy.[/FONT]
[FONT="]These regimens are commonly referred to by their initials, such as:[/FONT]
[FONT="]Bone marrow transplant[/FONT][FONT="]
If the disease recurs after an initial chemotherapy-induced remission, high-dose chemotherapy and transplantation of your own (autologous) bone marrow or peripheral stem cells may lead to prolonged remission. Peripheral stem cells are bone marrow cells mobilized from the bone marrow into the bloodstream. Because high doses of chemotherapy destroy bone marrow, your own marrow or peripheral blood stem cells are collected before treatment and frozen. You'll undergo chemotherapy, and then your own cells, which have been protected from the effects of the treatment, are injected back into your body.[/FONT]
[FONT="]FAA Special Issuance[/FONT][FONT="]
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.
An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.
Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following: [/FONT]
As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissunace.com can assist you in preparing your records for submission.
The topic today is Lymphoma and Hodgkin’s Disease[/FONT]
[FONT="]Hodgkin's disease[/FONT][FONT="], sometimes called Hodgkin's lymphoma, is a cancer that starts in lymphatic tissue. Lymphatic tissue includes the lymph nodes and related organs that are part of the body's immune and blood-forming systems. The lymph nodes are small, bean-shaped organs found underneath the skin in the neck, underarm, and groin. They are also found in many other places in the body such as inside the chest, abdomen, and pelvis. [/FONT]
[FONT="]Lymph nodes make and store infection-fighting white blood cells, called lymphocytes. They are connected throughout the body by lymph vessels (narrow tubes similar to blood vessels). These lymph vessels carry a colorless, watery fluid (lymphatic fluid) that contains lymphocytes. Eventually the lymphatic fluid is emptied into the blood vessels in the left upper chest.[/FONT]
[FONT="]Other components of the lymphatic system include the spleen, the bone marrow, and the thymus. The spleen is an organ in the left side of the upper abdomen that is composed primarily of mature and immature lymphocytes. It removes old cells and other debris from the blood. The bone marrow is the spongy tissue inside the bones that creates new red and white blood cells including lymphocytes. The thymus is a small organ in the chest that is important in developing a special lymphocyte called a T cell.[/FONT]
[FONT="]Because lymphatic tissue is present in many parts of the body, Hodgkin's disease can start almost anywhere, but most often starts in lymph nodes in the upper part of the body. The most common sites are in the chest, neck, or under the arms. Hodgkin's disease enlarges the lymphatic tissue, which can then cause pressure on important structures. It can spread through the lymphatic vessels to other lymph nodes. This is the major way it spreads. Most Hodgkin's disease spreads to nearby lymph node sites in the body, not distant ones. It rarely gets into the blood vessels and can spread to almost any other site in the body, including the liver and lungs.[/FONT]
[FONT="]Lymph nodes enlarge for many reasaons. Although Hodgkin's disease is one cause, enlarged lymph nodes are more commonly a result of the body fighting an infection. Your doctor can help determine the cause. [/FONT]
[FONT="]Hodgkin's disease is a malignant lymphoma (cancer of lymphatic tissue). There are two kinds of lymphomas: Hodgkin's disease (named after Dr. Thomas Hodgkin who first recognized it in 1832) and non-Hodgkin's lymphomas. For information on non-Hodgkin's lymphomas see the document "Non-Hodgkin's Lymphomas". [/FONT]
[FONT="]The cancer cells in Hodgkin's disease are called Reed-Sternberg cells, after the two doctors who first described them in detail. Under a microscope they look different from cells of non-Hodgkin's lymphomas and other cancers. Most scientists now believe that Reed-Sternberg cells are a type of malignant B lymphocyte. Normal B lymphocytes are the cells that make antibodies that help fight infections. [/FONT]
[FONT="]Doctors have given names to different types and subtypes of Hodgkin's disease. The two main types are classical Hodgkin's disease (which has several subtypes) and nodular predominant Hodgkin's disease. [/FONT]
[FONT="]Classical Hodgkin's disease:[/FONT]
- [FONT="] Lymphocyte predominance [/FONT]
- [FONT="] Nodular sclerosis [/FONT]
- [FONT="] Mixed cellularity [/FONT]
- [FONT="] Lymphocyte depletion [/FONT]
- [FONT="] Unclassified. [/FONT]
[FONT="]All of these types are malignant because as they grow, they may compress, invade, destroy normal tissue and spread to other tissues. There is no benign (noncancerous) form of Hodgkin's disease.[/FONT]
[FONT="]Many people with Hodgkin's disease experience no classic symptoms. Sometimes, an abnormality found on a chest X-ray done for nonspecific symptoms leads to an eventual diagnosis of Hodgkin's disease.[/FONT]
[FONT="]Because the symptoms of Hodgkin's are similar to those of other disorders, such as influenza, the disease can be difficult to diagnose. Some distinctive characteristics help diagnose Hodgkin's disease, and these include:[/FONT]
- [FONT="]Orderly spread.[/FONT][FONT="] The pattern of spread is orderly, progressing from one group of lymph nodes to the next.[/FONT]
- [FONT="]Only rare "skipping."[/FONT][FONT="] The disease rarely skips over an area of lymph nodes as it spreads.[/FONT]
[FONT="]Other procedures that may be valuable in evaluating Hodgkin's disease include X-ray, computerized tomography (CT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, bone marrow biopsy and blood tests. If the disease is predominantly in your abdomen, you may need exploratory surgery to help define the extent of the disease.[/FONT]
[FONT="]Staging Hodgkin's disease[/FONT][FONT="]
Once the diagnosis is confirmed, doctors "stage" the disease. Staging is how doctors judge the extent of the disease, which will likely affect your treatment options.[/FONT]
- [FONT="]Stage I.[/FONT][FONT="] The cancer is limited to one lymph node region.[/FONT]
- [FONT="]Stage II.[/FONT][FONT="] In this stage, the cancer is in two different lymph nodes, but is limited to a section of the body either above or below the diaphragm.[/FONT]
- [FONT="]Stage III.[/FONT][FONT="] When the cancer moves to lymph nodes both above and below the diaphragm, but hasn't spread to other organs, it's considered stage III.[/FONT]
- [FONT="]Stage IV.[/FONT][FONT="] This is the most advanced stage of Hodgkin's disease. Stage IV Hodgkin's disease affects not only the lymph nodes but also other parts of your body, such as the bone marrow or your liver.[/FONT]
[FONT="]The most important factor in the treatment of Hodgkin's disease is the stage of the disease. The number and regions of lymph nodes affected and whether only one or both sides of your diaphragm are involved are also important considerations. Other factors affecting decisions about treating this disease include:[/FONT]
- [FONT="]Your age[/FONT]
- [FONT="]Your symptoms[/FONT]
- [FONT="]Whether you're pregnant[/FONT]
- [FONT="]Your overall health status[/FONT]
[FONT="]Treatment options include:[/FONT]
[FONT="]Radiation[/FONT][FONT="]
When the disease is confined to a limited area, radiation therapy is the treatment of choice. It's typical to radiate the affected nodes and the next area of nodes where the disease might progress. The length of radiation treatment varies depending on the stage of the disease. Radiation therapy may be used alone, but is commonly used in conjunction with chemotherapy. If you relapse after radiation therapy, chemotherapy becomes necessary.[/FONT]
[FONT="]Some forms of radiation therapy may increase the risk of other forms of cancer, such as breast or lung cancer. The risk of breast cancer from standard dose radiation is even higher for girls and women treated when they were younger than 30 than for other people and is generally too high for this therapy to be considered. Most children with Hodgkin's disease are treated with combination chemotherapy, but may also receive low-dose radiation therapy.[/FONT]
[FONT="]Chemotherapy[/FONT][FONT="]
When the disease progresses and involves more lymph nodes or other organs, chemotherapy is the preferred treatment. Chemotherapy uses specific drugs in combination to kill tumor cells.[/FONT]
[FONT="]A major concern with chemotherapy is the possibility of long-term side effects and complications, such as heart damage, lung damage, liver damage and secondary cancers, such as leukemia. Although these severe effects occur in only a small number of people, great effort is being put into finding equally effective regimens with less toxicity. Drug regimens have been developed that substantially diminish the likelihood of long-range, life-threatening complications, including acute leukemia in people who have received multiple courses of chemotherapy and radiation therapy.[/FONT]
[FONT="]These regimens are commonly referred to by their initials, such as:[/FONT]
- [FONT="]ABVD[/FONT][FONT="], which consists of Adriamycin (doxorubicin), bleomycin, vinblastine and dacarbazine[/FONT]
- [FONT="]BEACOPP[/FONT][FONT="], which consists of bleomycin, etoposide, Adriamycin, cyclophosphamide, Oncovin (vincristine), procarbazine and prednisone[/FONT]
- [FONT="]COPP/ABVD[/FONT][FONT="], which consists of cyclophosphamide, Oncovin, procarbazine, prednisone, Adriamycin, bleomycin, vinblastine and dacarbazine[/FONT]
- [FONT="]Stanford V[/FONT][FONT="], which consists of Adriamycin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin and prednisone[/FONT]
- [FONT="]MOPP[/FONT][FONT="], which consists of mechlorethamine, Oncovin, procarbazine and prednisone[/FONT]
[FONT="]Bone marrow transplant[/FONT][FONT="]
If the disease recurs after an initial chemotherapy-induced remission, high-dose chemotherapy and transplantation of your own (autologous) bone marrow or peripheral stem cells may lead to prolonged remission. Peripheral stem cells are bone marrow cells mobilized from the bone marrow into the bloodstream. Because high doses of chemotherapy destroy bone marrow, your own marrow or peripheral blood stem cells are collected before treatment and frozen. You'll undergo chemotherapy, and then your own cells, which have been protected from the effects of the treatment, are injected back into your body.[/FONT]
[FONT="]FAA Special Issuance[/FONT][FONT="]
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.
An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.
Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following: [/FONT]
- [FONT="]An Authorization granted by the FAA; and[/FONT]
- [FONT="]An update of the status of the disease from the last FAA medical examination and any testing deemed necessary by the treating physician.[/FONT]
- [FONT="]There has been any recurrence or disease progression.[/FONT]
