What are the typical clinical features of Hodgkin's lymphoma?

Clinical Features of Hodgkin Lymphoma

The most common clinical presentation of Hodgkin lymphoma is painless, enlarged cervical or supraclavicular lymph nodes, with over 60% of patients initially presenting with this manifestation. 1, 2

Common Clinical Manifestations

Lymphadenopathy

• Cervical and supraclavicular lymph nodes are most commonly affected (>60% of cases)
• Mediastinal lymph node involvement is also frequent
• Lymphadenopathy is typically painless and firm
• Disease usually spreads in a contiguous pattern through the lymphatic system 1, 3

Systemic Symptoms

• B symptoms occur in approximately 35% of patients 1, 2:
  • Unexplained fever >38°C
  • Drenching night sweats
  • Weight loss >10% of body weight within 6 months of diagnosis
• Other systemic symptoms may include:
  • Alcohol-induced pain at sites of disease
  • Pruritus (itching)
  • Fatigue
  • Reduced performance status 1

Less Common Manifestations

• Sub-diaphragmatic presentations (less common)
• Bone marrow involvement (uncommon)
• Hepatic involvement (usually with concurrent splenic disease)
• Splenic involvement (typically with systemic symptoms)
• Extranodal presentations (quite rare) 3

Disease Distribution by Age

• Bimodal age distribution:
  • First peak in young adults (third decade of life)
  • Second peak after age 55 1, 2

Histopathological Features

Hodgkin lymphoma is divided into two major subtypes:

1. Classical Hodgkin Lymphoma (95% of cases):

   • Characterized by Reed-Sternberg cells (CD15+/CD30+/CD20-)
   • Subtypes include:
     • Nodular sclerosis
     • Mixed cellularity
     • Lymphocyte-depleted
     • Lymphocyte-rich 1, 2

2. Nodular Lymphocyte-Predominant Hodgkin Lymphoma (5% of cases):

   • Characterized by "popcorn cells" or L&H cells (CD15-/CD30-/CD20+) 1, 2

Diagnostic Approach

• Definitive diagnosis requires an excisional lymph node biopsy
• Core needle biopsy may be adequate if diagnostic
• Fine-needle aspiration alone is insufficient for diagnosis
• Immunohistochemistry is essential for proper classification 1

Staging Workup

• Physical examination of all lymph node regions
• Laboratory tests: CBC, ESR, comprehensive metabolic panel, LDH, LFTs
• Imaging: PET/CT scan (skull base to mid-thigh)
• Bone marrow biopsy if there are cytopenias and negative PET 1

Risk Assessment

Risk factors for poor prognosis include:

• Large mediastinal mass (>1/3 of chest diameter)
• Extranodal disease
• Elevated ESR (>50 with B symptoms; >30 without B symptoms)
• Three or more involved lymph node areas 1

Clinical Pitfalls to Avoid

• Failing to perform adequate biopsy (FNA alone is insufficient)
• Missing the characteristic bimodal age distribution when considering differential diagnosis
• Overlooking B symptoms during history taking
• Not recognizing that Hodgkin lymphoma typically spreads contiguously through lymphatic tissue before involving distant organs 1, 3

With modern treatment approaches, Hodgkin lymphoma is highly curable with 5-year survival rates exceeding 80%, and early-stage disease having even better outcomes (>95% 5-year overall survival) 2.