Can a young adult with a previously normal contrast computed tomography (CT) scan of the pelvis and abdomen develop high-grade Hodgkin's lymphoma (HL) with lymphadenopathy on opposite sides of the body, specifically in the groin and ear nodes?

Can High-Grade Hodgkin Lymphoma Develop This Rapidly with Bilateral Lymphadenopathy?

Yes, high-grade Hodgkin lymphoma (HL) can absolutely develop within a few months following a normal CT scan, and bilateral lymphadenopathy on opposite sides of the body (groin and ear nodes) is entirely consistent with HL presentation. 1

Why This Presentation is Compatible with HL

Rapid Disease Progression

• HL can progress rapidly, particularly aggressive subtypes, and a normal CT scan from a few months ago does not exclude current disease 2, 3, 4
• The disease doubling time for aggressive lymphomas can be measured in weeks, making interval development between scans entirely plausible 2
• High-grade or aggressive HL variants (such as lymphocyte-depleted subtype) can emerge and progress within 2-3 months 1, 4

Bilateral Non-Contiguous Lymphadenopathy Pattern

• HL commonly presents with lymphadenopathy on both sides of the body, which would be classified as Stage III disease (lymph node regions on both sides of the diaphragm) 1
• The Ann Arbor staging system specifically accounts for bilateral involvement, and this pattern occurs frequently in HL 1
• Involvement of peripheral nodes (groin/inguinal) combined with head/neck nodes (ear/preauricular or postauricular) represents a typical distribution pattern for disseminated HL 1

Limitations of Prior CT Imaging

• CT scans have significant limitations in detecting early lymphomatous involvement, with sensitivity as low as 36-58% for occult disease 1, 5
• Lymph nodes must typically exceed 1.5 cm in long axis or 1.0 cm in short axis to be considered abnormal on CT 1, 6
• Microscopic lymphomatous involvement can be present in normal-sized nodes, which would not be detected on contrast CT 1, 5
• The prior CT of pelvis and abdomen would not have included the head/neck region where the ear node is located 1

Critical Next Steps for Diagnosis

Immediate Tissue Diagnosis Required

• Excisional biopsy is the gold standard and strongly recommended over core needle biopsy to preserve nodal architecture necessary for HL diagnosis 1, 6
• Core needle biopsy may be adequate if diagnostic, but excisional biopsy is preferred 1
• Fine needle aspiration alone is insufficient for HL diagnosis except in unusual circumstances when combined with immunohistochemistry 1

Essential Staging Workup

• PET/CT scan from skull base to mid-thigh is now the gold standard for staging FDG-avid lymphomas including HL, with sensitivity of 82-96% and specificity of 95-98% 1, 5
• PET/CT is superior to CT alone for detecting both nodal and extranodal involvement, changing staging in 10-30% of patients 1
• Contrast-enhanced diagnostic CT should include all areas identified as abnormal on PET/CT at minimum 1

Mandatory Laboratory Assessment

• Complete blood count with differential, erythrocyte sedimentation rate (ESR), comprehensive metabolic panel, lactate dehydrogenase (LDH), and liver function tests 1
• Careful assessment for B symptoms (unexplained fever >38°C, drenching night sweats, weight loss >10% within 6 months) is critical for staging and prognosis 1, 6
• HIV and hepatitis B/C testing is encouraged 1

Common Pitfalls to Avoid

• Do not rely on the negative CT from months ago to exclude current disease - HL can develop rapidly and CT has poor sensitivity for early disease 5, 2
• Do not assume bilateral involvement indicates metastatic carcinoma rather than lymphoma - this is a classic HL presentation pattern 1
• Do not proceed with FNA alone - this will likely be inadequate for definitive HL diagnosis and will delay appropriate treatment 1
• Do not order only regional imaging - comprehensive staging with PET/CT from skull base to mid-thigh is essential for treatment planning 1