Case Studies "Clinical

Hodgkin's Lymphorna in, an'Elite Endurance Athlete,

2 1 YORCK OLAF SCHUMACHER', KLAUS' MUSER , BARBARA HIRSCHBERGER , KAI ROECKER',:

HANS HERRMANN DICKHUTH', and TORBEN POTTGIESSER'

2 'Department of Sports Medicine, University of Freiburg,Freiburg,GERMANY; and Department of Oncology,, Hospital of the FederalArmed 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 world

and mainly affects older individuals. However, certain types of malignancies such as testicular

treated for cancer. The aim of the present case report was, therefore, to illustrate this issue with a complete physiolog-

cancer or lymphomas are more frequently observed in

younger, persons. Cancer kills slowly; the malignant cells

ical profile of a world-class endurance athlete who was diagnosed with advanced-stage Hodgkin's lymph6ma. CASE REPORT
At the time of diagnosis, the studied athlete was 22 yr old and had practiced the sport of cycling since the age of 12. His training load in the year before the diagnosis averaged 20-25 h'wk-1. He had placed within the top 10 at world championships of his cycling discipline in the same year. The athlete gave informed written consent for the publication of his data.

drain the organism of resources and impair organ functions,

and one of the most apparent features of advanced stages is

the cachexia of the affected patients. From this point, it can

be reasoned that cancer might impair sporting performance to a large degree. Athletes are affected by malignancies, and there are many examples of high-performance sportsmen being diagnosed with cancer.

However, there are no reports on the physical performance

of 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. 0195-9131/08/4003-040110 MEDICINE & SCIENCE IN SPORTS & EXERCISFO Copyright 0 2008 by the American College of Sports Medicine DOI: I0.1249/mss.0b013e31815d8e8a

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

exams and physiological testing in regular intervals. The

testing comprised a physical examination, echocardiography (2D technique, Powervision 7000, Toshiba, Japan), routine laboratory examinations, blood volume measurements (optimized CO-rebreathing method (9)), lung function tests (Jaeger Master Screen Body, Viasys Healthcare,

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

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(Pmax) and power output at lactate threshold (LT) and at LT + 1 mM net lactate increase (LT+I) (8) (SRM cycle ergometer, SRM, Jilich Germany, test protocol: start with 80 or 100 W, increase by 20 W every 3 min until volitional exhaustion). Physical examination on one of these occasions in autumn 2006 revealed prominent retroauricular and supraclavicular lymphnodes. Biopsy and histological analysis of one of the nodes led to the diagnosis of Hodgkin's disease (nodular sclerosing type). Staging found the disease spread to the parotid gland, the spleen, and mediastinal and paraaortic lymph nodes; thus it was classified as III A (S) (Ann Arbor classification). At the time of diagnosis, the athlete was without any physical complaints or impaired performance. He did not present any constitutional symptoms such as -weight loss, night sweats, fever, or fatigue. He described his physical shape to be very good, underlined by good recent racing results. The athlete was immediately admitted to an oncology ward and treated with six courses of an escalated BEACOPP chemotherapy scheme for a period of 5 months. The escalated BEACOPP scheme is a combination of bleomycin, etoposide, Adriamycin, cyclophosphamide, vincristin, procarbazide, and prednisolone. Every course of treatment was administered for 4 d with a 22-d recovery period. In addition to the chemotherapy, the patient received various drugs to treat the side effects of the therapy (pantozole, metoclopramide, antibiotics, G-CSF, darbepoietin (150 Ag every 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 treated surgically, the athlete tried to maintain a certain level of physical activity. His weekly amount of endurance-type training during the time of chemotherapy ranged between 0 and 10 h, depending on his subjective condition. The training was mainly performed on an indoor cycle or as "nordic walking" at low intensities. After the fifth cycle, and despite supportive intermittent treatment with darbepoietin, the hemoglobin concentration of the athlete had dropped to 8.6 g.dL-l, and he received two units of packed red cells. With the completion of the sixth BEACOPP cycle, all medication was successively stopped. The athlete rapidly recovered and gradually resumed his normal training, reaching a training load of 20 h.wk-1 within 6 wk. Selected anthropometrical, physiological, and laboratory data of the athlete before, immediately after, and 2 months after chemotherapy are presented in Table I and Figure 1. The corresponding data from exercise tests are depicted in Figure 2. DISCUSSION We present physiological data of a 22-yr-old elite endurance athlete before, during, and after chemotherapy

TABLE 1. Anthropometrical and physiological data of a 22-yr-old elite endurance athlete

with advanced Hodgkin's lymphoma before, immediately after, and 2 months after six courses of escalated.BEACOPP chemotherapy. 3 wk Immediately 2 months before after after Diagnosis Chemotherapy Chemotherapy Weight (kg) 73 Height (cm) 181 1 Power output at LT (W'kg- ) 2.95 Power output at LT + 1 iWkg-1) 4.17 1 Maximal power output (W.kg- ) 4.9 Heart volume (ml) 1011 Heart volume/body weight (mL.kg- 1) 13.8 Left ventricular end diastolic 59 diameter (EDD) (mm) Septum thickness (ST) (mm) 11 Posterior wall thickness (PWT) (mm) 11 Left ventricular length (TL4) (mm) 95 Forced expiratory volume (FEV.) (L) 5.6 Total lung capacity TLC (L) 7.4
Residual volume (RV) (L) 1.6

71.5 181 1.74 2.45 4.0 1004 14 59 9 9 101 -

73.6 181 3.16 4.18 5.2 935 12.7 54 9 10 95 4.5 7.8

2.0

Vital capacity (VC) (L) Resistance (R) (kPa x s-L-)

5.75 0.25

5.7 0.16

for advanced Hodgkin's lymphoma. To our knowledge, there is no body of literature on the issue of performance and cancer therapy in highly trained athletes. The only other report evaluating performance and physiology in an elite athlete before and after chemotherapy cannot fully be compared with our case, because the available physiological data on the subject were limited, were not obtained in close timely relation to the diagnosis and therapy, and were presented with several methodological flaws (2,6,10). The first feature of the present case is the total absence of symptoms and the fact that the athlete was reported to be in very good physical shape at the time of diagnosis, despite the advanced stage of malignancy. Although the lack of symptoms is frequently observed in untrained individuals affected by cancer, it can reasonably be speculated that a malignancy might affect the body's performance capacity simply by the fact of draining resources for its growth. All laboratory and blood volume data were within the normal range before the diagnosis. The aerobic performance of the athlete 3 wk before the diagnosis in the first exercise test (Fig. 2, test A) was very high. A power output of 4.17 W'kg-I at LT + 1 places him within the range of performance of professional road cyclists (4.6 0.3 W.kg-1, same test protocol (12)). It has to be noted that the athlete reported not to have exercised until exhaustion in this first test; this is illustrated by his heart rate and his peak lactate, which did not reach the maximal values found in the other tests. However, this fact does not affect power output at LT and LT + 1, but it certainly affects Pmax. Therefore, this parameter should be interpreted with caution. Not surprisingly, the aerobic performance of the athlete was found to be markedly decreased immediately after completion of chemotherapy (-42%). Performance at LT + 1 is a marker for aerobic performance capacity and correlates with maximal oxygen uptake (.O2 . ax). The main determinants of VO2 m,aX are the oxygen uptake in the lung; the

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satory mechanism, the decrease in blood volume is accompanied by a higher heart rate at similar workloads (exercise test B). The decrease of hemoglobin mass is of a similar magnitude to the decrease of aerobic performance. It is of note that this drop of hemoglobin mass occurred despite the supportive therapy with darbepoietin and packed red cells. It can reasonably be speculated that without this treatment, the decrease in hemoglobin mass would have been even more important. On the pulmonary side, no difference in lung function before and after 2 months after

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

oxygen transport, mediated by the total hemoglobin mass in the red blood cells and the cardiac output; and, lastly, the oxygen delivery and metabolism in the enzymatic systems of the muscle (1). There is evidence that in the healthy individual, the oxygen transport is the main limitation for 9O2max. Our case provides illustration for this issue. Compared with the exercise test before chemotherapy, hemoglobin mass (and, thus, the oxygen transport) is the compartment that is the most affected (-37%) compared with the unchanged heart volume. As an expected compen181614' 12E 10E 100875E (n

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

LYMPHOMA IN AN ENDURANCE ATHLETE

Medicine &Science in Sports & Exercise& 403

chemotherapy other than a slightly reduced FEVI was noted, probably because of the reduced performance of the respiratory muscles. However, the FEVI was still well within the normal range. Furthermore, it is known that in the healthy individual, the lung is not performance limiting. The muscle metabolism as the third component of potential V/O limitation cannot be fully evaluated through the 2 . available data. The lactate'kinetics of the exercise tests suggest that these systems have not been affected to a large degree by either the malignancy or its therapy. In fact, one would expect higher or lower overall lactate levels or a different shape of the lactate curve, such as those observed in myopathic diseases (5,7,11), if significant chemotherapyor malignancy-related damage to the relevant enzymatic systems of the energy metabolism were present. The fact that the peak lactate is higher in the exercise tests after chemotherapy (tests B and C) can be explained by motivational issues related to the completion of cancer therapy. These findings are surprising because chemotherapy and its cytotoxic effects have a large impact on the organism. Bleomycin is known to affect the lungs and to cause pulmonary fibrosis. Other major side effects of the escalated BEACOPP scheme that might affect athletic performance aside from their general cytotoxic action include muscle weakness and cardiotoxicity (Adriamycin), myelosuppression (cyclophosfamide), neuromuscular disturbance, and bronchospasm (vincristin). REFERENCES
1. Bassett DR Jr., Howley ET. Limiting factors for maximum oxygen uptake and determinants of endurance performance. Med Sci Sports Fxerc. 2000;32(l):70-84. 2. Coyle EF. Improved muscular efficiency displayed as Tour de France champion matures. JAppl Physiol.2005;98(6):2191-6. 3. Dimeo F, Fetscher S, Lange W, Mertelsmann R, Keul J. Effects of aerobic exercise on the physical performance and incidence of treatment-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 of patients with hematological malignancies during chemotherapy.
Support Care Cancer. 2003; 1 (10):623-8.

After 2 months, all investigated components had recovered, and the aerobic performance of the athlete was almost at the prechemotherapy level. The'slightly smaller cardiac dimensions after 2 months might be explained by the variability of measurement of 2D echocardiography. Apparently, several weeks of training, together with discontinuation of the cytotoxic treatment, were enough to restore physical performance and, especially, hemoglobin mass, which seems to be a major component of aerobic capacity in the present case. In this context, no iron was given, and no dietary supplements other than occasional multivitamins were taken by the athlete during the studied period. It can be speculated that the fast recovery is probably attributable to the high initial training status of the athlete and to the fact that he maintained a relatively large amount of endurance training throughout his chemotherapy. These facts are in line with findings from interventional training studies that demonstrated that an aerobic exercise program adjacent to chemotherapy reduced the treatment-related loss of physical performance in patients with hematological malignancies and improved the recovery of several organ systems, including the red blood cell line (3,4). In summary, this case illustrates that 1) advanced malignancies can be present in elite athletes without significantly affecting performance, and 2) full physical performance can be regained within a short time, even after highly aggressive systemic chemotherapy.

7. Mousson B, Collombet JM, Dumoulin R, et al. An abnormal exercise test response revealing a respiratory chain complex III deficiency. 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 by means 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 J Appl Physiol. 2005;95:486-95.
10. Schumacher YO, Vogt S, Roecker K, Schmid A, Coyle EF.

Scientific considerations for physiological evaluations of elite

athletes. J Appl Physiol. 2005;99(4):1630-1.

5. Lindholm H, Lofberg M, Somer H, Naveri H, Sovijarvi A. Abnormal blood lactate accumulation after exercise in patients with multiple mitochondrial DNA deletions and minor muscular symptoms. Clin Physiol Funct Imaging. 2004;24(2):109-15. 6. Maitin DT, Quod MJ, Gore CJ, Coyle EF. Has Armstrong's cycle efficiency improved? JAppl Physiol.2005;99(4): 1628-9.

11. Vissing J, Galbo H, Haller RG. Exercise fuel mobilization in mitochondrial myopathy: a metabolic dilemma. Ann Neurol. 1996;40(4):655-62. 12. Vogt S, Heinrich L, Schumacher YO, et al. Power output during stage racing in professional road cycling. Med Sci Sports Exerc. 2006;38(l):147-51.

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TITLE: Hodgkins Lymphoma in an Elite Endurance Athlete SOURCE: Med Sci Sports Exercise 40 no3 Mr 2008 The magazine publisher is the copyright holder of this article and it is reproduced with permission. Further reproduction of this article in violation of the copyright is prohibited.