What causes the local signs and symptoms of Hodgkin disease-related lymphadenopathy?

Local Signs and Symptoms of Hodgkin Disease-Related Lymphadenopathy

The local signs and symptoms of Hodgkin disease-related lymphadenopathy primarily result from direct tumor infiltration of lymph nodes and surrounding tissues, causing mechanical compression and obstruction of adjacent structures. 1

Pathophysiology of Lymphadenopathy in Hodgkin Lymphoma

Hodgkin lymphoma (HL) typically manifests as painless, firm, and enlarged lymph nodes that progressively increase in size. The specific mechanisms responsible for local symptoms include:

• Direct tumor infiltration: Reed-Sternberg cells and associated inflammatory cells infiltrate lymph nodes, causing enlargement 1
• Mechanical compression: Enlarged nodes compress adjacent structures, leading to various symptoms depending on location 1
• Obstruction of lymphatic drainage: This is particularly important in mediastinal disease, which can lead to pleural effusions 1

Common Presentations Based on Anatomical Location

Cervical Lymphadenopathy (Most Common)

• More than 60% of patients with Hodgkin lymphoma initially present with enlarged cervical lymph nodes 2
• Typically painless, firm, and non-tender masses
• May cause dysphagia or voice changes if significantly enlarged

Mediastinal Lymphadenopathy

• Can cause:
  • Cough
  • Chest pain
  • Dyspnea (from compression of airways)
  • Superior vena cava syndrome (facial swelling, distended neck veins)
  • Pleural effusions (from obstruction of lymphatic drainage) 1

Abdominal/Retroperitoneal Lymphadenopathy

• May result in:
  • Abdominal pain
  • Early satiety
  • Bowel or urinary obstruction
  • Lower extremity edema (from compression of iliac vessels)

Distinguishing Features of Hodgkin Lymphoma Nodes

• Size: Often larger than 2 cm 3
• Consistency: Firm to hard texture
• Mobility: Initially mobile, becoming fixed as disease progresses
• Tenderness: Usually non-tender (unlike infectious lymphadenitis)
• Matting: Advanced disease may show matted or fused nodes 3

Systemic vs. Local Symptoms

It's important to distinguish between local symptoms (caused by direct effects of lymphadenopathy) and systemic "B symptoms" that result from cytokine release:

• Local symptoms: Directly related to mass effect and compression
• B symptoms: Fever >38°C, drenching night sweats, weight loss >10% within 6 months 1

Diagnostic Approach for Suspected Hodgkin Lymphoma

When lymphadenopathy raises suspicion for Hodgkin lymphoma:

1. Excisional biopsy is the gold standard for diagnosis 2

   • Core needle biopsy may be inadequate for proper classification 2
   • Identification of Reed-Sternberg cells is essential 1

2. Imaging studies:

   • PET-CT is recommended for accurate staging, improving staging accuracy by 10-30% compared to CT alone 2

Key Pitfalls to Avoid

• Misdiagnosis: Don't confuse HL with other causes of lymphadenopathy (infection, other lymphomas)
• Inadequate biopsy: Fine-needle aspiration is insufficient; excisional biopsy is required 2
• Premature steroid administration: Avoid corticosteroids before diagnosis as they can mask histologic features 3
• Overlooking supraclavicular nodes: These have a high malignancy risk and should prompt immediate investigation 2

In summary, the local manifestations of Hodgkin lymphoma-related lymphadenopathy stem primarily from the direct effects of tumor infiltration causing lymph node enlargement and subsequent compression of adjacent structures, with symptoms varying based on the anatomical location of the affected nodes.