Hodgkin Lymphoma Staging with Abdominal Wall Mass
A patient with Hodgkin lymphoma and an abdominal wall mass indicating extranodal disease is classified as Stage IV (advanced stage), as this represents additional noncontiguous extralymphatic involvement. 1
Staging Classification
The Lugano classification clearly defines Stage IV disease as involving "additional noncontiguous extralymphatic involvement." 1 An abdominal wall mass in Hodgkin lymphoma represents extranodal disease that is noncontiguous with nodal structures, automatically placing the patient in Stage IV regardless of nodal involvement patterns. 1
Key Staging Principles
The "E" designation for extranodal disease is only relevant for limited disease (Stage IE or IIE with direct extension from an adjacent node) and is not applicable to patients with advanced-stage disease like this case. 1
Stage IV encompasses any additional noncontiguous extralymphatic involvement, which includes organs such as liver, bone marrow, lung parenchyma, or in this case, the abdominal wall. 1
This patient should be classified in the advanced-stage treatment group (Stage III-IV), which fundamentally changes the therapeutic approach from combined modality therapy to primarily systemic chemotherapy. 1
Treatment Implications
Advanced-stage Hodgkin lymphoma (Stage IV) is treated with chemotherapy alone, with radiotherapy confined only to patients having large residual masses after chemotherapy. 1
Standard Treatment Approach
Patients up to 60 years old receive either 6-8 cycles of ABVD (depending on remission status after 4 cycles) or 8 cycles of BEACOPPescalated, followed by localized radiation with 30 Gy only to residual lymphoma >1.5 cm. 1
BEACOPPescalated leads to superior freedom from treatment failure and overall survival rates compared to ABVD but is associated with increased toxicity requiring G-CSF support. 1
Patients older than 60 years should receive 6-8 cycles of ABVD followed by localized radiation with 30 Gy to residual lymphoma >1.5 cm, as BEACOPP should not be used in elderly patients due to increased toxicity. 1
Radiotherapy might be omitted in patients with residual lymphoma and a negative FDG-PET after completion of chemotherapy, though this approach requires validation. 1
Risk Stratification Considerations
Extranodal disease is specifically listed as an unfavorable risk factor in the German Hodgkin Study Group (GHSG) classification system. 1 While this patient already has Stage IV disease, the presence of extranodal involvement may influence prognostic scoring:
The International Prognostic Score (IPS) for advanced Hodgkin lymphoma includes 7 adverse factors, each reducing survival rates by 7-8% per year: age ≥45 years, male gender, stage IV disease, albumin <4 g/dL, hemoglobin <10.5 g/dL, leukocytosis (WBC >15,000/mm³), and lymphocytopenia (<8% of WBC or <600/mm³). 1
This patient automatically has at least one IPS factor (Stage IV disease), and additional factors should be assessed to determine overall prognosis. 1
Critical Staging Pitfall
Do not confuse this with Stage IIE disease. Stage IIE would only apply if there were limited extranodal disease with direct extension from an adjacent nodal group on the same side of the diaphragm. 1 An abdominal wall mass represents noncontiguous extralymphatic involvement, which by definition is Stage IV. 1