Hodgkin Lymphoma Staging and Treatment

Staging Classification

The Lugano classification defines Stage IV disease as involving "additional noncontiguous extralymphatic involvement," which includes an abdominal wall mass in Hodgkin lymphoma, automatically placing the patient in Stage IV regardless of nodal involvement patterns 1, 2, 3
Stage IV encompasses any additional noncontiguous extralymphatic involvement, which includes organs such as liver, bone marrow, lung parenchyma, or in this case, the abdominal wall 1, 2, 3
The "E" designation for extranodal disease is only relevant for limited disease (Stage IE or IIE with direct extension from an adjacent node) and is not applicable to patients with advanced-stage disease like this case 1, 2, 3

Advanced-stage Hodgkin lymphoma (Stage IV) is treated with chemotherapy alone, with radiotherapy confined only to patients having large residual masses after chemotherapy 4, 5, 6
Patients up to 60 years old receive either 6-8 cycles of ABVD (depending on remission status after 4 cycles) or 8 cycles of BEACOPPescalated, followed by localized radiation with 30 Gy only to residual lymphoma >1.5 cm 4, 5
BEACOPPescalated leads to superior freedom from treatment failure and overall survival rates compared to ABVD but is associated with increased toxicity requiring G-CSF support 4
Patients older than 60 years should receive 6-8 cycles of ABVD followed by localized radiation with 30 Gy to residual lymphoma >1.5 cm, as BEACOPP should not be used in elderly patients due to increased toxicity 4
Radiotherapy might be omitted in patients with residual lymphoma and a negative FDG-PET after completion of chemotherapy, though this approach requires validation 4

Extranodal disease is specifically listed as an unfavorable risk factor in the German Hodgkin Study Group (GHSG) classification system 4, 5, 6
The International Prognostic Score (IPS) for advanced Hodgkin lymphoma includes 7 adverse factors, each reducing survival rates by 7-8% per year: age ≥45 years, male gender, stage IV disease, albumin <4 g/dL, hemoglobin <10.5 g/dL, leukocytosis (WBC >15,000/mm³), and lymphocytopenia (<8% of WBC or <600/mm³) 7
This patient automatically has at least one IPS factor (Stage IV disease), and additional factors should be assessed to determine overall prognosis 7