Diagnostic Workup for Hodgkin Lymphoma
The recommended workup for suspected Hodgkin lymphoma must include an excisional lymph node biopsy (or core needle biopsy if diagnostic), followed by comprehensive staging with PET-CT, laboratory tests, and assessment for B symptoms to guide appropriate treatment and improve survival outcomes. 1
Initial Diagnostic Steps
Biopsy:
- Excisional lymph node biopsy is preferred
- Core needle biopsy may be adequate if diagnostic
- Fine-needle aspiration alone is insufficient except in rare circumstances when combined with immunohistochemistry and evaluated by an expert hematopathologist 1
Immunohistochemistry:
- For Classical Hodgkin Lymphoma (CHL): CD3, CD15, CD20, CD30, CD45, CD79a, and PAX5
- Reed-Sternberg cells typically express CD30 in all patients and CD15 in most patients; usually negative for CD3 and CD45 1
- Nodular Lymphocyte-Predominant Hodgkin Lymphoma (NLPHL): characterized by lymphocyte-predominant cells expressing CD20 and CD45 but lacking CD15 and CD30 1
Comprehensive Staging Workup
Clinical Assessment
- Detailed history focusing on:
- B symptoms (fever >38°C, drenching night sweats, weight loss >10% over 6 months)
- Other associated symptoms: alcohol intolerance, pruritus, fatigue 1
- Physical examination of all lymphoid regions, spleen, and liver 1
Imaging Studies
- Mandatory:
- Chest X-ray
- Contrast-enhanced CT scan of neck, chest, and abdomen
- Whole-body PET scan (baseline) - skull base to mid-thigh or vertex to feet in selected cases 1
Laboratory Tests
Required blood work:
- Complete blood count with differential and platelets
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Lactate dehydrogenase (LDH)
- Alkaline phosphatase (AP)
- Liver enzymes
- Albumin
- Renal function tests 1
Mandatory screening:
- Hepatitis B (HBV)
- Hepatitis C (HCV)
- HIV 1
Bone Marrow Assessment
- Bone marrow biopsy is no longer indicated in patients undergoing PET-CT evaluation due to the high sensitivity of PET-CT for bone marrow involvement 1
- Bone marrow biopsy must be performed only if PET-CT is not available 1
Pre-Treatment Evaluations
Cardiac assessment:
- ECG
- Echocardiography 1
Pulmonary function tests 1
Reproductive counseling:
- Sperm banking, oocyte collection, or ovarian tissue cryopreservation should be offered to patients of reproductive age 1
Additional assessments:
- Serum pregnancy test for females of reproductive age
- ENT specialist consultation including fiberoptic nasolaryngoscopy (if PET-CT not available) 1
Staging Classification
- Staging follows the Ann Arbor classification with consideration of defined clinical risk factors
- Patients are allocated to three categories: limited, intermediate, and advanced stages 1
Common Pitfalls to Avoid
Inadequate biopsy: Relying solely on fine-needle aspiration without expert hematopathologist review can lead to misdiagnosis
Omitting PET-CT: PET-CT is essential for accurate staging and subsequent treatment planning
Unnecessary bone marrow biopsy: When PET-CT is performed, bone marrow biopsy adds little additional information
Neglecting reproductive counseling: Treatment can cause permanent fertility damage, so this discussion must occur before starting therapy
Incomplete viral screening: HBV, HCV, and HIV screening is mandatory as these infections can complicate treatment
By following this comprehensive diagnostic approach, clinicians can accurately diagnose and stage Hodgkin lymphoma, which is critical for selecting appropriate therapy and optimizing outcomes, with cure rates now exceeding 80% in most patients 2.