"Clinical Case Studies

Hodgkin's Lymphorna in, an'EliteEndurance Athlete,

YORCK OLAF SCHUMACHER', KLAUS' MUSER1, BARBARA HIRSCHBERGER2 , KAI ROECKER',:

HANS HERRMANN DICKHUTH', and TORBEN POTTGIESSER'

'Department of Sports Medicine, University of Freiburg, Freiburg, GERMANY; and 2Department of Oncology,,

Hospital of the Federal Armed Forces, Ulm, GERMANY

ABSTRACT

SCHUMACHER, Y. 0., K. MUSER, B. HIRSCHBERGER, K. ROECKER, H. H. DICKHUTH, and T. POTTGIESSER. Hodgkin's

Lymphoma in an Elite Endurance Athlete. Med. Sci. Sports Exerc., Vol. 40, No. 3, pp. 401-404, 2008. Cancer is a life-threatening

condition. We describe the case of a 22-yr-old world-class endurance athlete who presented with mild local lymphadenopathy but

without any systemic complaints or impaired performance. He was subsequently diagnosed with stage III A (S) Hodgkin's lymphoma.

A complete physiological workup before the diagnosis revealed high aerobic capacity. Immediately after six courses of escalated

BEACOPP chemotherapy in an identical test setting, aerobic capacity was markedly reduced (-42%), mainly because of a decrease in

total hemoglobin mass (-37%), despite maintaining a certain amount of endurance training. Other potentially performance-limiting

systems such as heart, lung, or aerobic metabolism did not show any signs of impairment. Two months after chemotherapy, the athlete

had recovered his hemoglobin mass, and his aerobic performance was almost back to pretherapy levels. This case illustrates that

advanced malignancies can be present in elite athletes 'vithout affecting performance, and that aerobic capacity can be regained within a

short time after systemic chemotherapy. Key Words: CANCER, PERFORMANCE, CHEMOTHERAPY, BLOOD VOLUME,

EXERCISE TEST

ancer is a major cause of death in the Western worldand mainly affects older individuals. However,certain types of malignancies such as testicular

cancer or lymphomas are more frequently observed inyounger, persons. Cancer kills slowly; the malignant cellsdrain the organism of resources and impair organ functions,and one of the most apparent features of advanced stages isthe cachexia of the affected patients. From this point, it canbe reasoned that cancer might impair sporting performanceto a large degree. Athletes are affected by malignancies, andthere are many examples of high-performance sportsmenbeing diagnosed with cancer.

However, there are no reports on the physical performanceof elite athletes before, during, and after being diagnosed and

Address for correspondence: Yorck Olaf Schumacher, M.D., Abtlg.

Sportmedizin, Medizinische Universitfitsk]inik Freiburg, Hugstetter Str.

55, 79106-Freiburg, Germany; E-mail: olaf@msml.ukl.uni-freiburg.de.Submitted for publication August 2007.Accepted for publication October 2007.

0195-9131/08/4003-040110MEDICINE & SCIENCE IN SPORTS & EXERCISFOCopyright 0 2008 by the American College of Sports Medicine

DOI: I0.1249/mss.0b013e31815d8e8a

treated for cancer. The aim of the present case report was,therefore, to illustrate this issue with a complete physiolog-ical profile of a world-class endurance athlete who wasdiagnosed with advanced-stage Hodgkin's lymph6ma.

CASE REPORT

At the time of diagnosis, the studied athlete was 22 yr oldand had practiced the sport of cycling since the age of 12.His training load in the year before the diagnosis averaged20-25 h'wk-1. He had placed within the top 10 at worldchampionships of his cycling discipline in the same year.

The athlete gave informed written consent for the publica-tion of his data.

Since the age of 16, the athlete had been a member of theGerman national cycling team and had undergone medical

exams and physiological testing in regular intervals. Thetesting comprised a physical examination, echocardiogra-phy (2D technique, Powervision 7000, Toshiba, Japan),routine laboratory examinations, blood volume measure-ments (optimized CO-rebreathing method (9)), lung func-tion tests (Jaeger Master Screen Body, Viasys Healthcare,

Hoechberg, Germany), and a standardized incrementalcycling test with determination of maximal power output

401

(Pmax) and power output at lactate threshold (LT) and atLT + 1 mM net lactate increase (LT+I) (8) (SRM cycleergometer, SRM, Jilich Germany, test protocol: start with80 or 100 W, increase by 20 W every 3 min until volitionalexhaustion). Physical examination on one of these occa-sions in autumn 2006 revealed prominent retroauricular andsupraclavicular lymphnodes. Biopsy and histological anal-ysis of one of the nodes led to the diagnosis of Hodgkin'sdisease (nodular sclerosing type). Staging found the diseasespread to the parotid gland, the spleen, and mediastinal andparaaortic lymph nodes; thus it was classified as III A (S)(Ann Arbor classification).

At the time of diagnosis, the athlete was without anyphysical complaints or impaired performance. He did notpresent any constitutional symptoms such as -weight loss,night sweats, fever, or fatigue. He described his physicalshape to be very good, underlined by good recent racingresults.

The athlete was immediately admitted to an oncologyward and treated with six courses of an escalated BEA-COPP chemotherapy scheme for a period of 5 months. Theescalated BEACOPP scheme is a combination of bleomy-cin, etoposide, Adriamycin, cyclophosphamide, vincristin,procarbazide, and prednisolone. Every course of treatmentwas administered for 4 d with a 22-d recovery period. Inaddition to the chemotherapy, the patient received variousdrugs to treat the side effects of the therapy (pantozole,metoclopramide, antibiotics, G-CSF, darbepoietin (150 Agevery 2 wk for 12 wk during the six BEACOPP courses)).

The chemotherapy was well tolerated by the athlete, and,despite the occurrence of side effects such as nausea,vomiting, fatigue, and a local abscess, which was treatedsurgically, the athlete tried to maintain a certain level ofphysical activity. His weekly amount of endurance-typetraining during the time of chemotherapy ranged between 0and 10 h, depending on his subjective condition. Thetraining was mainly performed on an indoor cycle or as"nordic walking" at low intensities.

After the fifth cycle, and despite supportive intermittenttreatment with darbepoietin, the hemoglobin concentrationof the athlete had dropped to 8.6 g.dL-l, and he receivedtwo units of packed red cells.

With the completion of the sixth BEACOPP cycle, allmedication was successively stopped. The athlete rapidlyrecovered and gradually resumed his normal training,reaching a training load of 20 h.wk-1 within 6 wk.

Selected anthropometrical, physiological, and laboratorydata of the athlete before, immediately after, and 2 monthsafter chemotherapy are presented in Table I and Figure 1.The corresponding data from exercise tests are depicted inFigure 2.

DISCUSSION

We present physiological data of a 22-yr-old eliteendurance athlete before, during, and after chemotherapy

TABLE 1. Anthropometrical and physiological data of a 22-yr-old elite endurance athletewith advanced Hodgkin's lymphoma before, immediately after, and 2 months after sixcourses of escalated.BEACOPP chemotherapy.

3 wk Immediately 2 monthsbefore after after

Diagnosis Chemotherapy Chemotherapy

Weight (kg) 73 71.5 73.6Height (cm) 181 181 181Power output at LT (W'kg- 1) 2.95 1.74 3.16Power output at LT + 1 iWkg-1) 4.17 2.45 4.18Maximal power output (W.kg- 1) 4.9 4.0 5.2Heart volume (ml) 1011 1004 935Heart volume/body weight (mL.kg- 1) 13.8 14 12.7Left ventricular end diastolic 59 59 54

diameter (EDD) (mm)Septum thickness (ST) (mm) 11 9 9Posterior wall thickness (PWT) (mm) 11 9 10Left ventricular length (TL4) (mm) 95 101 95Forced expiratory volume (FEV.) (L) 5.6 - 4.5Total lung capacity TLC (L) 7.4 - 7.8Residual volume (RV) (L) 1.6 - 2.0Vital capacity (VC) (L) 5.75 - 5.7Resistance (R) (kPa x s-L-) 0.25 - 0.16

for advanced Hodgkin's lymphoma. To our knowledge,there is no body of literature on the issue of performanceand cancer therapy in highly trained athletes. The only otherreport evaluating performance and physiology in an eliteathlete before and after chemotherapy cannot fully becompared with our case, because the available physiologicaldata on the subject were limited, were not obtained in closetimely relation to the diagnosis and therapy, and werepresented with several methodological flaws (2,6,10).

The first feature of the present case is the total absence ofsymptoms and the fact that the athlete was reported to be invery good physical shape at the time of diagnosis, despitethe advanced stage of malignancy. Although the lack ofsymptoms is frequently observed in untrained individualsaffected by cancer, it can reasonably be speculated that amalignancy might affect the body's performance capacitysimply by the fact of draining resources for its growth. Alllaboratory and blood volume data were within the normalrange before the diagnosis.

The aerobic performance of the athlete 3 wk before thediagnosis in the first exercise test (Fig. 2, test A) was veryhigh. A power output of 4.17 W'kg-I at LT + 1 places himwithin the range of performance of professional roadcyclists (4.6 ± 0.3 W.kg-1, same test protocol (12)). It hasto be noted that the athlete reported not to have exerciseduntil exhaustion in this first test; this is illustrated by hisheart rate and his peak lactate, which did not reach themaximal values found in the other tests. However, this factdoes not affect power output at LT and LT + 1, but itcertainly affects Pmax. Therefore, this parameter should beinterpreted with caution.

Not surprisingly, the aerobic performance of the athletewas found to be markedly decreased immediately after com-pletion of chemotherapy (-42%). Performance at LT + 1 isa marker for aerobic performance capacity and correlateswith maximal oxygen uptake (.O2 .ax). The main determi-nants of VO2m,aX are the oxygen uptake in the lung; the

402 Official Journal of the American College of Sports Medicine htt p://www.acsm-msse.org

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C,/FIGURE 1-Timeline of the diagnostic and therapeutic interventions in a 22-yr-old elite endurance athlete with stage III Hodgkin's lymphoma(horizontal axis). Hemoglobin mass (3; left vertical axis) and hemoglobin concentration (*; right vertical axis).

oxygen transport, mediated by the total hemoglobin mass inthe red blood cells and the cardiac output; and, lastly, theoxygen delivery and metabolism in the enzymatic systemsof the muscle (1). There is evidence that in the healthyindividual, the oxygen transport is the main limitation for9O2max. Our case provides illustration for this issue.Compared with the exercise test before chemotherapy,hemoglobin mass (and, thus, the oxygen transport) is thecompartment that is the most affected (-37%) comparedwith the unchanged heart volume. As an expected compen-

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satory mechanism, the decrease in blood volume isaccompanied by a higher heart rate at similar workloads(exercise test B). The decrease of hemoglobin mass is of asimilar magnitude to the decrease of aerobic performance. Itis of note that this drop of hemoglobin mass occurreddespite the supportive therapy with darbepoietin and packedred cells. It can reasonably be speculated that without thistreatment, the decrease in hemoglobin mass would havebeen even more important. On the pulmonary side, nodifference in lung function before and after 2 months after

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200 240 280 320 360 400

Power (W)

FIGURE 2-Exercise test results in an incremental cycling test of a 22-yr-old elite endurance athlete with advanced Hodgkin's lymphoma before the

diagnosis (A), immediately after (B), and 2 months after (C) six courses of escalated BEACOPP chemotherapy. The horizontal axis illustrates the

workload; the vertical axis illustrates heart rate and lactate concentration. The lower curves represent lactate concentration; the upper curves depictheart rate.

Medicine & Science in Sports & Exercise& 403LYMPHOMA IN AN ENDURANCE ATHLETE

chemotherapy other than a slightly reduced FEVI wasnoted, probably because of the reduced performance of therespiratory muscles. However, the FEVI was still wellwithin the normal range. Furthermore, it is known that inthe healthy individual, the lung is not performance limiting.The muscle metabolism as the third component of potentialV/O2 . limitation cannot be fully evaluated through theavailable data. The lactate'kinetics of the exercise testssuggest that these systems have not been affected to a largedegree by either the malignancy or its therapy. In fact, onewould expect higher or lower overall lactate levels or adifferent shape of the lactate curve, such as those observedin myopathic diseases (5,7,11), if significant chemotherapy-or malignancy-related damage to the relevant enzymaticsystems of the energy metabolism were present. The factthat the peak lactate is higher in the exercise tests afterchemotherapy (tests B and C) can be explained by motiva-tional issues related to the completion of cancer therapy.

These findings are surprising because chemotherapy andits cytotoxic effects have a large impact on the organism.Bleomycin is known to affect the lungs and to causepulmonary fibrosis. Other major side effects of the escalatedBEACOPP scheme that might affect athletic performanceaside from their general cytotoxic action include muscleweakness and cardiotoxicity (Adriamycin), myelosuppres-sion (cyclophosfamide), neuromuscular disturbance, andbronchospasm (vincristin).

REFERENCES

1. Bassett DR Jr., Howley ET. Limiting factors for maximumoxygen uptake and determinants of endurance performance. MedSci Sports Fxerc. 2000;32(l):70-84.

2. Coyle EF. Improved muscular efficiency displayed as Tour deFrance champion matures. JAppl Physiol. 2005;98(6):2191-6.

3. Dimeo F, Fetscher S, Lange W, Mertelsmann R, Keul J. Effects ofaerobic exercise on the physical performance and incidence oftreatment-related complications after high-dose chemotherapy.Blood. 1997;90(9):3390-4.

4. Dimeo F, Schwartz S, Fietz T, Wanjura T, Boning D, Thiel E.Effects of endurance training on the physical performance ofpatients with hematological malignancies during chemotherapy.Support Care Cancer. 2003; 1 (10):623-8.

5. Lindholm H, Lofberg M, Somer H, Naveri H, Sovijarvi A.Abnormal blood lactate accumulation after exercise in patientswith multiple mitochondrial DNA deletions and minor muscularsymptoms. Clin Physiol Funct Imaging. 2004;24(2):109-15.

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After 2 months, all investigated components had recov-ered, and the aerobic performance of the athlete was almostat the prechemotherapy level. The'slightly smaller cardiacdimensions after 2 months might be explained by thevariability of measurement of 2D echocardiography.

Apparently, several weeks of training, together withdiscontinuation of the cytotoxic treatment, were enough torestore physical performance and, especially, hemoglobinmass, which seems to be a major component of aerobiccapacity in the present case. In this context, no iron wasgiven, and no dietary supplements other than occasionalmultivitamins were taken by the athlete during the studiedperiod. It can be speculated that the fast recovery is probablyattributable to the high initial training status of the athlete andto the fact that he maintained a relatively large amount ofendurance training throughout his chemotherapy. These factsare in line with findings from interventional training studiesthat demonstrated that an aerobic exercise program adjacentto chemotherapy reduced the treatment-related loss ofphysical performance in patients with hematological malig-nancies and improved the recovery of several organ systems,including the red blood cell line (3,4).

In summary, this case illustrates that 1) advancedmalignancies can be present in elite athletes withoutsignificantly affecting performance, and 2) full physicalperformance can be regained within a short time, even afterhighly aggressive systemic chemotherapy.

7. Mousson B, Collombet JM, Dumoulin R, et al. An abnormalexercise test response revealing a respiratory chain complex IIIdeficiency. Acta Neurol Scand. 1995;91(6):488-93.

8. Roecker K, Schotte 0, Niess AM, Horstmann T, Dickhuth HH.Predicting competition performance in long-distance running bymeans of a treadmill test. Med Sci Sports Exerc. 1998;30(10):1552-7.

9. Schmidt W, Prommer N. The optimised CO-rebreathing method:a new tool to determine total haemoglobin mass routinely. Eur JAppl Physiol. 2005;95:486-95.

10. Schumacher YO, Vogt S, Roecker K, Schmid A, Coyle EF.Scientific considerations for physiological evaluations of eliteathletes. J Appl Physiol. 2005;99(4):1630-1.

11. Vissing J, Galbo H, Haller RG. Exercise fuel mobilization inmitochondrial myopathy: a metabolic dilemma. Ann Neurol.1996;40(4):655-62.

12. Vogt S, Heinrich L, Schumacher YO, et al. Power output duringstage racing in professional road cycling. Med Sci Sports Exerc.2006;38(l):147-51.

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TITLE: Hodgkin’s Lymphoma in an Elite Endurance AthleteSOURCE: Med Sci Sports Exercise 40 no3 Mr 2008

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