What is the recommended workup for a patient with a history of Hodgkin's (Hodgkin lymphoma) lymphoma presenting with an enlarged lymph node in the left groin?

Workup for a Patient with History of Hodgkin's Lymphoma and Enlarged Left Groin Lymph Node

A comprehensive diagnostic workup for a patient with a history of Hodgkin's lymphoma presenting with an enlarged lymph node in the left groin should include a complete blood count, biochemistry panel, CT scan of the neck, thorax, abdomen, and pelvis, and a whole-body FDG-PET/CT scan, with biopsy of the enlarged lymph node being strongly recommended to confirm recurrence. 1

Initial Evaluation

Clinical Assessment

• Assess for systemic symptoms (B symptoms):
  • Unexplained weight loss >10% of baseline in the past 6 months
  • Recurrent unexplained fever >38°C
  • Recurrent night sweats 1

Laboratory Tests

• Complete blood count
• Erythrocyte sedimentation rate (ESR)
• Serum albumin
• Serum LDH
• Liver and renal function tests
• Hepatitis B, C, and HIV serology 1

Imaging Studies

Required Imaging

1. CT scan of neck, thorax, abdomen, and pelvis with contrast 1

   • Essential for determining the extent of disease
   • Allows assessment of other nodal regions and potential extranodal involvement

2. Whole-body FDG-PET/CT scan 1, 2

   • Highly recommended for suspected recurrence
   • Superior to CT alone for detecting viable tumor tissue
   • Serves as baseline for future response assessment
   • Has become integral to lymphoma management with sensitivity of 84% and specificity of 90% 1, 2

3. Standard chest X-ray

   • To calculate mass-to-thorax diameter ratio if mediastinal involvement is present 1

Tissue Diagnosis

Biopsy

• Excisional biopsy of the enlarged groin lymph node is strongly recommended 1
  • Provides sufficient material for fresh frozen and formalin-fixed samples
  • Essential to confirm recurrence and rule out second malignancies
  • Should be performed before initiating any treatment 1

Bone Marrow Assessment

• Bone marrow biopsy should be performed if:
  • B symptoms are present
  • Advanced stage disease is suspected
  • Blood count abnormalities are present 1

Additional Evaluations

Cardiac Assessment

• Bidimensional ultrasound evaluation of left ventricular ejection fraction
  • Particularly important if previous treatment included cardiotoxic agents 1

Reproductive Counseling

• Should be offered to patients of fertile age 1

Thyroid Function

• Assessment of thyroid function (FT3, FT4, TSH) if previous neck irradiation or if neck irradiation is anticipated 1

Risk Stratification

After confirming recurrence, patients should be stratified into risk groups based on:

1. Time to relapse:

   • Primary refractory disease (progression during treatment or within 3 months)
   • Early relapse (3-12 months after end of first-line therapy)
   • Late relapse (>12 months) 1

2. Clinical stage at relapse 1

3. Response to previous treatment 1

Follow-up Protocol

For patients in complete remission after treatment:

• Physical examination and blood count every 3-4 months for the first 2 years
• Every 6 months for the next 3 years
• Annually for at least 10 years after treatment 1
• CT scans every 6 months for 2 years, then annually up to 5 years 1

Important Considerations

• FDG-PET is crucial for distinguishing between active disease and post-treatment changes 2
• False positive PET results can occur due to inflammation, infection, or granulomatous disease 1
• Biopsy remains the gold standard for confirming recurrence, especially in cases with isolated lymphadenopathy 1
• Early detection of recurrence significantly impacts treatment outcomes and survival 3

By following this structured approach, clinicians can efficiently diagnose recurrent Hodgkin's lymphoma and determine the appropriate management strategy based on the extent and timing of recurrence.