Initial evaluation and diagnosis of classical Hodgkin lymphoma in adults
- Peter M Mauch, MD
Peter M Mauch, MD
- Professor of Radiation Oncology
- Harvard Medical School
- Ann S LaCasce, MD
Ann S LaCasce, MD
- Assistant Professor of Medicine
- Harvard Medical School
Hodgkin lymphoma (HL, formerly called Hodgkin's disease) is a group of cancers characterized by Reed-Sternberg cells in an appropriate reactive cellular background. An important clinical feature is its tendency to arise within lymph node areas and to 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.
The initial evaluation of the patient with suspected HL is designed to provide information for diagnosis, prognosis, staging, and the selection of treatment. The components of this evaluation are reviewed here. The epidemiology, pathologic features, and staging of HL are discussed separately. (See "Staging and prognosis of Hodgkin lymphoma" and "Epidemiology, pathologic features, and diagnosis of classical Hodgkin lymphoma" and "Overview of the treatment of classical Hodgkin lymphoma in adults".)
Hodgkin lymphoma (HL) has a bimodal age distribution with one peak in the 20s and 30s, and a second peak over the age of 50. It accounts for approximately 10 percent of all lymphomas in economically advanced countries. The epidemiology of HL is discussed in more detail separately. (See "Epidemiology, pathologic features, and diagnosis of classical Hodgkin lymphoma".)
Typical presentation and disease tempo — The majority of patients with classical Hodgkin lymphoma (HL) present with overt disease, most often as an asymptomatic enlarged lymph node or a mass on chest radiograph. However, the presenting symptoms and signs may be relatively nonspecific and more compatible with infection than malignant disease. Occult presentation of HL is unusual, but the incidence of clinically occult disease has been an important influence in the development of therapeutic strategies.
The disease tempo at presentation is variable. B symptoms (fever, night sweats) are present over weeks to months, though other symptoms such as fatigue or lymphadenopathy may be present over many months. Mediastinal masses can be quite large before resulting in discomfort or respiratory symptoms, suggesting that this is not a rapidly growing tumor. In patients being followed after treatment, evidence of recurrence can be seen on imaging within three to six months, but it may be longer before there is clinical evidence of disease.
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- CLINICAL PRESENTATION
- Typical presentation and disease tempo
- Asymptomatic lymphadenopathy
- Mediastinal mass
- Systemic symptoms
- - B symptoms
- - Pruritus
- Other nonspecific symptoms and paraneoplastic syndromes
- - Intraabdominal disease
- - Cholestatic liver disease
- - Alcohol-induced pain
- - Skin lesions
- - Neurologic syndromes
- - Nephrotic syndrome
- - Other
- PATTERNS OF DISEASE PRESENTATION
- Variation by histology
- DIAGNOSTIC EVALUATION
- History and physical examination
- Tissue biopsy
- PRETREATMENT EVALUATION
- Laboratory studies
- Imaging studies
- Cardiac function
- Pulmonary function
- Fertility counseling
- INFORMATION FOR PATIENTS