Diagnosis and Staging of Hodgkin Lymphoma

Tissue Acquisition

Excisional lymph‑node biopsy is the gold‑standard method, providing sufficient fresh‑frozen and formalin‑fixed tissue for definitive diagnosis. 1
Core‑needle biopsy may be acceptable when an expert hematopathologist determines that the sample is adequate for diagnosis. 3
Fine‑needle aspiration alone is insufficient for diagnosis, except in rare situations where immunohistochemistry is performed and the specimen is reviewed by an expert hematopathologist. 3

A mandatory immunohistochemistry panel (CD3, CD15, CD20, CD30, CD45, CD79a, PAX5) must be applied to all suspected Hodgkin lymphoma specimens. 3
In classical Hodgkin lymphoma (≈95 % of cases), Hodgkin‑Reed‑Sternberg cells are uniformly CD30‑positive and most are CD15‑positive; they lack CD45 and CD3 expression. 1
CD20 expression is seen in fewer than 40 % of classical Hodgkin lymphoma cases. 3
In nodular lymphocyte‑predominant Hodgkin lymphoma (≈5 % of cases), LP cells are CD20‑positive, CD45‑positive, and negative for CD15 and CD30. 1

A postero‑anterior and lateral chest X‑ray is required to evaluate large mediastinal masses. 1
Contrast‑enhanced CT of the neck, chest, abdomen, and pelvis is recommended for anatomic staging. 1
A baseline whole‑body PET‑CT (skull base to mid‑thigh) must be performed within one month before initiating therapy to define disease extent. 1

Complete blood count with differential and platelet count is required. 3
Erythrocyte sedimentation rate (ESR) should be measured. 6
Blood chemistry including lactate dehydrogenase, alkaline phosphatase, liver enzymes, albumin, and C‑reactive protein is mandatory. 6
Mandatory viral screening for hepatitis B, hepatitis C, and HIV prior to therapy. 1

Document B‑symptoms: unexplained fever > 38 °C, drenching night sweats, and weight loss > 10 % over six months. 6
Record additional symptoms such as alcohol intolerance, pruritus, fatigue, and performance status. 3
Perform a thorough physical examination of all lymphoid regions, spleen, and liver. 3

Bone‑marrow biopsy is not required when a PET‑CT has been performed, because PET‑CT has high sensitivity for marrow involvement. 1
Bone‑marrow biopsy should be reserved for cases where PET‑CT is unavailable. 1

Baseline electrocardiography and echocardiography are required to assess cardiac function before therapy. 6
Pulmonary function testing must be completed prior to treatment initiation. 6
Reproductive counseling, including discussion of sperm banking, oocyte collection, or ovarian tissue cryopreservation, is advised for patients of reproductive age. 6
Serum pregnancy testing is mandatory in female patients of reproductive age before starting therapy. 4

After staging, patients are classified by the Ann Arbor system into limited, intermediate, or advanced stages, using EORTC/LYSA or GHSG criteria. 1