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ESSENTIALS OF DIAGNOSIS

  • Often painless lymphadenopathy.

  • Constitutional symptoms may or may not be present.

  • Pathologic diagnosis by lymph node biopsy.

GENERAL CONSIDERATIONS

Hodgkin lymphoma is characterized by lymph node biopsy showing Reed-Sternberg cells in an appropriate reactive cellular background (eFigure 13–34). The malignant cell is derived from B lymphocytes of germinal center origin.

eFigure 13–34.

Hodgkin lymphoma, mixed cellularity, showing multinucleated Reed-Sternberg cells in a background of cells that include lymphocytes, plasma cells, eosinophils, histiocytes, and mononuclear Reed-Sternberg cells. (Reproduced, with permission, from Chandrasoma P, Taylor CR. Concise Pathology, 3rd ed. Originally published by Appleton & Lange. Copyright © 1998 by The McGraw-Hill Companies, Inc.)

CLINICAL FINDINGS

There is a bimodal age distribution, with one peak in the 20s and a second over age 50 years. Most patients seek medical attention because of a painless mass, commonly in the neck. Others may seek medical attention because of constitutional symptoms such as fever, weight loss, or drenching night sweats, or because of generalized pruritus. An unusual symptom of Hodgkin lymphoma is pain in an involved lymph node following alcohol ingestion.

An important feature of Hodgkin lymphoma is its tendency to arise within single lymph node areas and spread in an orderly fashion to contiguous areas of lymph nodes. Late in the course of the disease, vascular invasion leads to widespread hematogenous dissemination.

Hodgkin lymphoma is divided into two subtypes: classic Hodgkin (nodular sclerosis, mixed cellularity, lymphocyte rich, and lymphocyte depleted) and non-classic Hodgkin (nodular lymphocyte predominant). Hodgkin lymphoma should be distinguished pathologically from other malignant lymphomas and may occasionally be confused with reactive lymph nodes seen in infectious mononucleosis, cat-scratch disease, or drug reactions (eg, phenytoin).

Patients undergo a staging evaluation to determine the extent of disease, including serum chemistries, whole-body PET/CT scan, and bone marrow biopsy. The staging nomenclature (Ann Arbor) is as follows: stage I, one lymph node region involved; stage II, involvement of two or more lymph node regions on one side of the diaphragm; stage III, lymph node regions involved on both sides of the diaphragm; and stage IV, disseminated disease with extranodal involvement. Disease staging is further categorized as "A" if patients lack constitutional symptoms or as "B" if patients have 10% weight loss over 6 months, fever, or drenching night sweats (or some combination thereof).

TREATMENT

Chemotherapy is the mainstay of treatment for Hodgkin lymphoma and ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) remains the standard first-line regimen. Even though other regimens such as escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) may improve response rates and reduce the need for consolidative radiotherapy, they are usually associated with increased toxicity and lack a definitive overall survival advantage. Low-risk patients are those with stage I or ...

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