Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Airway, vena caval or spinal compression
Stridor, orthopnoea, facial swelling, venous congestion, tamponade, focal neurology or sphincter dysfunction from bulky nodal disease requires immediate anatomical stabilisation before routine staging.
Action: Use ABCDE assessment, keep a patient with mediastinal compression in the tolerated position, involve anaesthesia, respiratory, oncology and surgery urgently, obtain tissue before corticosteroids when safely possible, and use emergency radiotherapy, systemic treatment, stenting or decompression according to anatomy and pathology certainty.
Synopsis
Recognise Hodgkin lymphoma, obtain adequate tissue before steroids, stage with PET-CT and deliver response-adapted curative treatment while reducing pulmonary, cardiac, fertility and second-cancer harm.
Painless cervical or supraclavicular lymphadenopathy, mediastinal mass, pruritus and B symptoms are typical; alcohol-induced node pain is memorable but uncommon and non-diagnostic.
Reference-standard diagnosis is an excision or adequate core biopsy showing architecture, Reed–Sternberg morphology and the appropriate immunophenotype; fine-needle aspiration is inadequate.
Avoid corticosteroids before biopsy unless life-saving because lymphoma can melt rapidly and leave non-diagnostic tissue.
Key red flags
Stridor, severe orthopnoea, superior vena cava obstruction, pericardial compromise or inability to lie flat makes sedation and supine biopsy hazardous and needs senior airway planning.
Mediastinal compression
Cough, chest pressure, facial swelling, orthopnoea, stridor or inability to lie flat requires urgent anatomical and anaesthetic assessment.
Investigation priorities
01
Reference standard: excision biopsyFirst stepReference standard
Preserve nodal architecture and enough tissue for confident subtype and differential diagnosis.
02
First-line staging: FDG PET-CTFirst line
Map nodal, splenic, marrow and extranodal disease and establish a metabolic baseline.
Management branches
Persistent nodeObtain architecture before steroids
Unexplained lymphadenopathy or mediastinal mass persists or progresses.
Assess compression, infection, HIV and alternative cancer and obtain FBC, ESR, organ and viral baseline.
Arrange excision biopsy or multiple large cores with specialist tissue handling before corticosteroids when safe.
Key medicines
ABVDGive doxorubicin 25 mg/m², bleomycin 10,000 IU/m², vinblastine 6 mg/m² and dacarbazine 375 mg/m² intravenously on days 1 and 15 of each 28-day cycle for the protocol-defined number of cycles.
Brentuximab vedotin with AVDGive brentuximab vedotin 1.2 mg/kg IV, maximum 120 mg, on days 1 and 15 of a 28-day cycle with protocol doxorubicin 25 mg/m², vinblastine 6 mg/m² and dacarbazine 375 mg/m² for six cycles.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.