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.
- Baseline staging uses FDG PET-CT; it usually removes the need for routine bone-marrow biopsy in classical Hodgkin lymphoma.
- Record Ann Arbor stage, bulky disease, B symptoms and early-stage favourable or unfavourable factors; treatment is curative and risk adapted rather than stage number alone.
- Early favourable classical disease often receives two ABVD cycles followed by 20 Gy involved-site radiotherapy; other early groups use more chemotherapy or 30 Gy according to BSH protocol and PET response.
- Advanced disease uses PET-adapted chemotherapy; after a negative interim PET, bleomycin is commonly omitted from later ABVD-derived cycles to reduce pulmonary toxicity.
- NICE supports brentuximab vedotin with doxorubicin, vinblastine and dacarbazine for untreated stage III or IV CD30-positive adult Hodgkin lymphoma.
- Interim PET is interpreted with the Deauville five-point scale and must be timed and acted on through the same protocol; inflammation can produce false positivity.
- Discuss sperm, oocyte or embryo preservation before gonadotoxic treatment whenever delay is safe, and provide long-term cardiac, thyroid, breast, lung and second-cancer follow-up based on exposure.
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.
New weakness, sensory level, radicular pain or bladder or bowel dysfunction suggests malignant spinal cord compression and requires urgent MRI and dexamethasone through the MSCC pathway.
Rapid clinical decline, high LDH, lysis chemistry or an atypical extranodal pattern should prompt review for non-Hodgkin lymphoma, infection or transformation rather than assumption of ordinary classical Hodgkin lymphoma.
Fever during treatment is neutropenic sepsis until assessed; bleomycin-associated cough or hypoxaemia requires immediate drug review and pulmonary investigation.
Cough, chest pressure, facial swelling, orthopnoea, stridor or inability to lie flat requires urgent anatomical and anaesthetic assessment.
Investigation priorities
Preserve nodal architecture and enough tissue for confident subtype and differential diagnosis.
Map nodal, splenic, marrow and extranodal disease and establish a metabolic baseline.
Management branches
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.
- Review integrated pathology, then stage confirmed disease with PET-CT and classify early risk or advanced disease.