What is the treatment approach for Hodgkin’s and Non-Hodgkin’s lymphoma in the neck lymph nodes?

Treatment of Hodgkin's and Non-Hodgkin's Lymphoma in the Neck Lymph Nodes

For Hodgkin's lymphoma involving neck nodes, treatment depends on stage: limited-stage disease requires 2-3 cycles of ABVD chemotherapy followed by 30 Gy involved-site radiotherapy, intermediate-stage requires 4 cycles of ABVD plus 30 Gy radiotherapy, and advanced-stage requires 6 cycles of ABVD or BEACOPPescalated chemotherapy alone. 1 For Non-Hodgkin's lymphoma, 6-8 cycles of R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) every 21 days is the standard treatment for CD20-positive large B-cell lymphoma. 1, 2, 3

Diagnostic Requirements Before Treatment

Obtain an excisional lymph node biopsy from the neck to establish diagnosis—fine needle aspiration is inadequate except in emergency situations or patients unsuitable for curative therapy. 1, 2 The biopsy must provide sufficient tissue for immunohistochemistry, specifically CD20 staining for Non-Hodgkin's lymphoma and identification of Reed-Sternberg cells for classical Hodgkin's lymphoma. 1

Complete staging workup must include:

• Contrast-enhanced CT scan of neck, chest, and abdomen 1, 2
• PET-CT baseline scan if available (preferred over CT alone) 1, 2
• Complete blood count, ESR, LDH, and comprehensive chemistry 1, 2
• Mandatory screening for hepatitis B, hepatitis C, and HIV before initiating treatment 1, 2
• Bone marrow biopsy only if PET-CT is unavailable 1
• Cardiac and pulmonary function tests before starting chemotherapy 1

Treatment Algorithm for Hodgkin's Lymphoma

Stage IA Nodular Lymphocyte-Predominant Hodgkin's Lymphoma (NLPHL) Without Risk Factors

Treat with involved-site radiotherapy (ISRT) at 30 Gy alone—no chemotherapy required. 1, 2 This is the only scenario where radiotherapy alone is standard treatment. 1

Limited-Stage Classical Hodgkin's Lymphoma

Administer 2-3 cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) followed by 30 Gy ISRT to the neck and involved regions. 1, 2 Combined-modality treatment produces superior tumor control compared to radiotherapy alone. 1

Perform interim PET-CT after 2 cycles of ABVD:

• If PET-negative: complete planned ABVD and radiotherapy 1
• If PET-positive: switch to 2 cycles of BEACOPPescalated before ISRT 1

Intermediate-Stage Classical Hodgkin's Lymphoma

Deliver 4 cycles of ABVD followed by 30 Gy ISRT as standard treatment. 1, 2 For patients under 60 years eligible for intensive treatment, consider 2 cycles of BEACOPPescalated followed by 2 cycles of ABVD and 30 Gy radiotherapy. 1

Critical caveat: In patients over 60 years, limit bleomycin to maximum 2 cycles due to increased pulmonary toxicity risk. 1

Advanced-Stage Classical Hodgkin's Lymphoma

Treat with 6 cycles of ABVD or 4-6 cycles of BEACOPPescalated chemotherapy alone—radiotherapy is reserved only for residual disease after chemotherapy. 1, 2

PET-guided treatment modifications:

• After 2 cycles of ABVD, if interim PET is negative, consider omitting bleomycin in cycles 3-6, especially in elderly patients or those at increased lung toxicity risk 1
• If interim PET is positive after 2 cycles of ABVD, switch to BEACOPPescalated 1
• For BEACOPPescalated: PET-negative patients after 2 cycles need only 2 more cycles, while PET-positive patients require 4 more cycles 1

Treatment Algorithm for Non-Hodgkin's Lymphoma

CD20-Positive Large B-Cell Lymphoma

Administer 6-8 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) every 21 days as standard treatment for all stages. 1, 2, 3 Rituximab must be given with each cycle as it significantly improves outcomes in CD20-positive disease. 1, 3

Alternative dosing: Consider shortening the interval to 14 days with growth factor support, though 21-day intervals remain standard. 1

Critical premedication requirements per FDA labeling:

• Premedicate before each rituximab infusion to prevent severe infusion reactions 3
• Monitor patients closely during infusion—approximately 80% of fatal infusion reactions occur with the first dose 3
• Screen for hepatitis B before treatment and monitor during therapy, as reactivation can cause fulminant hepatitis and death 3

Avoid dose reductions for hematological toxicity—instead use prophylactic growth factors for febrile neutropenia in patients treated with curative intent. 1

CD20-Positive NLPHL (Other Stages)

Treat identically to classical Hodgkin's lymphoma based on stage, or consider R-CHOP which has shown promising results in retrospective studies. 1, 2 The addition of rituximab is logical given consistent CD20 expression on malignant cells. 1

T-Cell Lymphoma

Use CHOP without rituximab as standard treatment, since T-cell lymphomas do not express CD20. 1

Consolidative Radiotherapy Considerations

For Non-Hodgkin's lymphoma, consolidation radiotherapy to sites of bulky disease has not proven benefit and is not routinely recommended. 1 This contrasts sharply with Hodgkin's lymphoma where radiotherapy is integral to combined-modality approaches. 1

For Hodgkin's lymphoma, ISRT is preferred over involved-field radiotherapy (IFRT) after chemotherapy in limited and intermediate stages. 1 ISRT delivers radiation to smaller volumes, reducing long-term toxicity while maintaining efficacy. 1

Response Evaluation During Treatment

Perform interim PET-CT after 2-4 cycles of chemotherapy to guide treatment modifications. 1, 2 For Hodgkin's lymphoma specifically, interim PET after 2 cycles of ABVD is mandatory regardless of stage. 1

Repeat initially pathological bone marrow or imaging at end of treatment to confirm remission status. 1 Patients with incomplete response should be evaluated immediately for salvage regimens. 1

Treatment of Relapsed/Refractory Disease

High-dose chemotherapy followed by autologous stem cell transplantation is standard of care for relapsed/refractory Hodgkin's lymphoma. 1, 2 Use salvage regimens like DHAP, IGEV, or ICE before transplantation. 2

For patients failing autologous stem cell transplantation:

• Brentuximab vedotin is FDA-approved and represents the next treatment option 1, 2
• Nivolumab and pembrolizumab (anti-PD-1 antibodies) are FDA and EMA approved for patients with disease recurrence after high-dose chemotherapy, autologous stem cell transplantation, and brentuximab vedotin therapy 1, 2
• Allogeneic stem cell transplantation should be considered in young, chemosensitive patients in good condition after careful risk-benefit evaluation 1

Post-Treatment Surveillance

Follow patients with history and physical examination, complete blood count, ESR, and chemistry every 3 months for 6 months, then every 6 months until year 4, then annually. 1, 2

Obtain CT scan once to confirm remission status, then follow clinically—routine surveillance scans are not indicated unless clinical symptoms develop. 1, 2 This represents a significant shift from older practices that recommended routine imaging.

Monitor thyroid function (TSH) annually if the neck was irradiated, as hypothyroidism is a common late complication. 1, 2

Expected Outcomes

With modern treatment strategies, 80-90% of Hodgkin's lymphoma patients achieve permanent remission and can be considered cured. 1, 2 Prognosis for Non-Hodgkin's lymphoma varies based on International Prognostic Index (IPI) score, with R-CHOP providing significant improvement in outcomes for B-cell lymphomas compared to historical CHOP alone. 1, 2