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Hodgkin lymphoma

Last updated: May 30, 2021

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Hodgkin lymphoma (HL) is a malignant lymphoma that is typically of B-cell origin. The incidence of HL has a bimodal age distribution, with peaks in the 3rd and 6th–8th decades of life. The WHO classifies HL into two types: classical HL (CHL) and nodular lymphocyte-predominant HL (NLPHL). CHL is further divided into four subtypes, which are nodular sclerosis (most common), mixed cellularity, lymphocyte-depleted, and lymphocyte-rich CHL. Risk factors for developing HL include a history of infectious mononucleosis caused by the Epstein-Barr virus (EBV) and immunodeficiency (e.g., HIV infection). HL typically presents with painless cervical lymphadenopathy, fever, night sweats, and involuntary weight loss. Pel-Ebstein fevers (cyclical fever with periods of both high and normal temperature) and alcohol-induced pain at affected lymph nodes are less common but specific for HL. Suspicious lymph nodes are excised and definitive diagnosis is made via histological analysis, which characteristically reveals pathognomonic Reed‑Sternberg cells (malignant B-cells). The modified Ann Arbor classification (Cotswold staging system) is used to stage HL based on both the localization of the lymphoma with respect to the diaphragm and on the presence of systemic symptoms. Treatment is typically initiated with curative intent. In early stages, treatment is generally limited to involved-field radiation and chemotherapy. In later stages, when local radiation is often unsuccessful or not feasible due to tumor spread, polychemotherapy is the mainstay of treatment.

  • Incidence
    • 2–3/100 000 per year [1]
    • Subtype variance with age (see “Pathology” below)
      • Young adults: nodular sclerosing HL
      • Elderly adults: mixed-cellularity HL
  • Age: bimodal distribution [2]
    • 1st peak: 25–30 years
    • 2nd peak: 50–70 years
  • Sex: > [2]
    • Male predominance, especially in pediatric cases
    • Exception: = in nodular sclerosing HL (most common type)

Epidemiological data refers to the US, unless otherwise specified.

The exact causes are unknown, but several risk factors have been associated with HL. [3][4]

Lugano classification (based on the Cotswolds modified Ann Arbor system) [6][7][8]
Stage Description
I Involvement of 1 lymph node area (IN), or 1 extranodal (IE) focus
II Confined to one side of the diaphragm: Involvement of ≥ 2 (IIN) lymph node areas or extranodal foci (IIE)
III On both sides of the diaphragm: Involvement of ≥ 2 (IIIN) lymph node areas or extranodal foci (IIIE)
IV Disseminated spread into one or more extralymphatic organs independent of lymph node involvement

Additional modifiers

  • Primarily involved tissue: nodal (N) or extranodal (E)
  • Symptoms
  • Bulky disease (X)

Staging is based on the number of affected nodes, the presence or absence of B symptoms, and whether or not the disease is present on both sides of the diaphragm.

Diagnosis of HL is primarily based on medical history and clinical features (B symptoms, localization of lymph node involvement) and is confirmed with lymph node biopsy.

Blood tests

Histology

Reed-Sternberg cells are bi(2)nucleate with CD15/CD30 positivity. To recall the cell markers, remember that 2 x 15 = 30.

Imaging

Histological classification of Hodgkin lymphoma (WHO)
Classification Subtype Characteristics Prognosis Pathology
Classical Hodgkin lymphoma (95%) Nodular sclerosing classical HL (NSHL)
  • Most common subtype (> 60%)
  • Localization: mostly mediastinal and cervical
  • Good
Mixed-cellularity classical HL (MCHL)
  • Commonly found in immunocompromised patients (e.g., HIV-positive individuals)
  • Localization: mostly abdominal and splenic
  • Good (but slightly worse than NSHL)
Lymphocyte-rich classical HL (LRHL)
  • Rare
  • Localization: mostly cervical and axillary
  • Very good
Lymphocyte-depleted classical HL (LDHL)
  • Very rare (< 1%)
  • Commonly found in immunocompromised patients
  • Localization: mostly below the diaphragm
  • Poor
Lymphocyte predominant Hodgkin lymphoma (5%) Nodular lymphocyte predominant HL (NLPHL)
  • Rare (5%)
  • Localization: mostly neck, axillary, and inguinal [9]
  • Very good (but slightly worse than LRHL)

Hodgkin vs Non-Hodgkin lymphoma

Feature Hodgkin lymphoma Non-Hodgkin lymphoma
Age distribution
  • Increases with age (peak > 50 years)
Etiology
Lymph node involvement
  • Lymph node groups localized above the diaphragm
  • Contiguous spread
  • Extranodal involvement rare
  • Multiple lymph node groups
  • Noncontiguous spread
  • Extranodal involvement common
Histology

Prognosis

  • Good
  • Worse .

Differential diagnoses of lymphadenopathy

Examining lymph nodes can yield important diagnostic clues. Generalized lymphadenopathy is usually a sign of systemic illness, such as HIV, mycobacterial infection (e.g., tuberculosis), infectious mononucleosis, systemic lupus erythematodes, or serum sickness. Signs of malignancy include rapid growth, painlessness, hardness/coarseness, and being fixed to underlying or surrounding tissue. Most often, though, there is no discernible cause or pathology.

Feature Normal Infection Malignancy
Size
  • < 1 cm
  • > 1 cm
  • > 1 cm
Consistency
  • Soft
  • Hard (various malignancies)
  • Rubbery (typical of lymphoma)
Tender/nontender
  • Nontender
  • Tender
  • Nontender
Fixation
  • Freely movable
  • May be fixed or freely movable
  • Fixed to the underlying tissue

Differential diagnosis of B symptoms

Differential diagnosis of granulomatous disease

The differential diagnoses listed here are not exhaustive.

Independent of stage, treatment is typically initiated with curative intent.

  • Good prognosis
  • Prognosis is largely determined by disease stage (i.e., lower stage has a better prognosis)
  • ∼ 10–20% of patients will develop secondary malignancies (especially lung cancer; related to radiation therapy and chemotherapy) [11]
  • Unfavorable factors for Hodgkin lymphoma (relevant when selecting a treatment regimen)
  • International Prognostic Score (IPS): evaluation of prognosis in patients with advanced disease (for each factor present, the patient receives one point)
    • IPS factors
    • IPS categories: Based on the calculated IPS, patients can be categorized as follows:
      • Good prognosis (IPS 0–1)
      • Fair prognosis (IPS 2–3)
      • Poor prognosis (IPS 4–7)
  1. Ansell SM. Hodgkin lymphoma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol. 2016; 91 (4): p.434-442. doi: 10.1002/ajh.24272 . | Open in Read by QxMD
  2. Asif S, Raza S. Long-term time trends in incidence, survival and mortality of Hodgkin lymphoma in the United States: A surveillance, epidemiology, and end results (SEER) database study 1975-2015.. Journal of Clinical Oncology. 2019; 37 (15_suppl): p.e19014-e19014. doi: 10.1200/jco.2019.37.15_suppl.e19014 . | Open in Read by QxMD
  3. Hodgkin lymphoma risk factors. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/hodgkin-lymphoma/risk-factors. Updated: February 8, 2017. Accessed: February 8, 2017.
  4. Ansell SM. Hodgkin lymphoma: 2018 update on diagnosis, risk-stratification, and management. Am J Hematol. 2018; 93 (5): p.704-715. doi: 10.1002/ajh.25071 . | Open in Read by QxMD
  5. Mauch PM, Kalish LA, Kadin M, Coleman CN, Osteen R, Hellman S. Patterns of presentation of Hodgkin disease. Implications for etiology and pathogenesis. Cancer. 1993; 71 (6): p.2062-2071. doi: 10.1002/1097-0142(19930315)71:6<2062::aid-cncr2820710622>3.0.co;2-0 . | Open in Read by QxMD
  6. Mauch PM, Canellos GP, Arnold S Freedman AS, Rosmarin AG. Staging and Prognosis of Hodgkin Lymphoma. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/staging-and-prognosis-of-hodgkin-lymphoma.Last updated: February 21, 2017. Accessed: August 4, 2017.
  7. T A Lister, D Crowther, S B Sutcliffe, E Glatstein, G P Canellos, R C Young, S A Rosenberg, C A Coltman, M Tubiana. Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin's disease: Cotswolds meeting.. Journal of Clinical Oncology. 1989; 7 (11): p.1630-1636. doi: 10.1200/jco.1989.7.11.1630 . | Open in Read by QxMD
  8. Lugano Classification for Hodgkin and Non-Hodgkin Lymphoma. https://www.ncbi.nlm.nih.gov/books/NBK66057/table/CDR0000062707__1075/. Updated: January 20, 2021. Accessed: February 14, 2021.
  9. Porwit A, McCullough JJ, Erber WN. Blood and Bone Marrow Pathology. Churchill Livingstone ; 2011
  10. Friedman DL. Hodgkin Lymphoma. Elsevier ; 2016 : p. 429-441
  11. Paul Lorigan, John Radford, Anthony Howell, Nick Thatcher. Lung cancer after treatment for Hodgkin's lymphoma: a systematic review. Lancet Oncol. 2005; 6 (10): p.773-779. doi: 10.1016/s1470-2045(05)70387-9 . | Open in Read by QxMD
  12. Smolewski P, Robak T, Krykowski E, et al. Prognostic factors in Hodgkin's disease: multivariate analysis of 327 patients from a single institution.. Clin Cancer Res. 2000; 6 (3): p.1150-60.
  13. Liu R, Cao J, Gao X, et al. Overall survival of cancer patients with serum lactate dehydrogenase greater than 1000 IU/L. Tumor Biology. 2016; 37 (10): p.14083-14088. doi: 10.1007/s13277-016-5228-2 . | Open in Read by QxMD