Hodgkin Lymphoma

See Lymphomas — Overview for the Hodgkin vs non-Hodgkin comparison table.

Localised or disseminated malignant proliferation of B-cells of the lymphoreticular system, usually with contiguous spread to other sites. Presents with painless lymphadenopathy, fever, night sweats, and weight loss.

Demographics: rare before age 10; most common between 15–40 years, with a second peak over 60. Males > females (~1.2:1).

Risk factors: family history (same-sex siblings of an affected patient have a 10-fold higher risk); phenytoin; radiation/chemotherapy; infection (EBV, HIV); rheumatoid arthritis, coeliac disease, Sjögren syndrome, SLE; post-transplant or other immunosuppression; congenital immunodeficiency disorders.

Pattern: malaise + fever/night sweats + pruritus.

Subtypes: classical Hodgkin lymphoma is ~95% of cases — nodular sclerosis, mixed cellularity, lymphocyte-rich, lymphocyte-depleted. Nodular lymphocyte-predominant Hodgkin lymphoma (NLP-HL) is now reclassified as a non-Hodgkin B-cell lymphoma.

History

Painless cervical/axillary lymphadenopathy. Pain may occur in diseased areas right after drinking alcohol (mechanism unknown). Intense itch. Fever, night sweats, weight loss (>10% in 6 months) — “B symptoms,” which carry prognostic significance. Splenomegaly is often present; hepatomegaly is unusual.

Investigations

• Lymph node biopsy — diagnostic (Reed-Sternberg cells); excisional/core biopsy preferred, fine-needle aspiration is often inadequate.
• CXR may show mediastinal lymphadenopathy.
• FBC + differential, ESR, LDH — non-diagnostic but supportive; lymphocytopenia is an adverse prognostic factor.
• FDG-PET/CT of chest, abdomen, and pelvis — imaging of choice for staging (Ann Arbor); bone marrow biopsy only if PET/CT unavailable or findings would change management.

Management

Treatment is risk-stratified by stage and prognostic factors:

• Early-stage, favourable (I–IIA) — short-course chemotherapy (typically 2 cycles ABVD: doxorubicin, bleomycin, vinblastine, dacarbazine) + involved-field radiotherapy.
• Limited-stage, unfavourable features (bulky mediastinal disease, raised ESR, extranodal extension) — longer chemotherapy course (4–6 cycles) + higher-dose radiotherapy.
• Advanced-stage (IIB–IV) — risk-stratified by the International Prognostic Score; ABVD is standard for most patients.
• Refractory/relapsed disease (up to ~30% relapse after initial remission) — high-dose chemotherapy + autologous stem cell transplant is standard; if that fails, brentuximab vedotin (anti-CD30 antibody-drug conjugate), PD-1 blockade (nivolumab, pembrolizumab), or non-myeloablative allogeneic transplant.

Prognosis: overall cure rate ~80%. 5-year overall survival is ~90% for stage I–IIA, falling to ~60% for stage IV disease.

Follow-up: once in remission, patients are typically followed for 5 years to confirm no relapse.