What is the best course of action for a young patient with suspected Hodgkin lymphoma and no symptoms of spleen or mediastinal involvement?

Management of Young Patient with Suspected Hodgkin Lymphoma Without Spleen or Mediastinal Involvement

For a young patient with suspected Hodgkin lymphoma lacking spleen and mediastinal involvement, the treatment approach depends entirely on whether other risk factors are present—if none exist, treat as early favorable disease with 2 cycles of ABVD followed by 30 Gy involved-field radiotherapy; however, if any risk factors are identified (elevated ESR, extranodal involvement, or ≥3 lymph node areas), escalate to intermediate-stage treatment with 4 cycles of ABVD plus 30 Gy radiotherapy. 1, 2, 3

Critical Initial Risk Stratification

The absence of spleen and mediastinal involvement is favorable, but you must systematically evaluate for other risk factors that would upgrade this patient from limited to intermediate stage:

• Check ESR levels: Elevated ESR (>30 mm/h for B-stages or >50 mm/h for A-stages) is a risk factor that changes management 1
• Assess for extranodal involvement: Any extranodal disease automatically upgrades to intermediate stage regardless of Ann Arbor staging 1, 2
• Count involved lymph node areas: ≥3 lymph node areas constitutes extensive involvement and is a risk factor 1
• Document B symptoms: Fever, night sweats, or weight loss must be carefully assessed 1

Required Staging Workup Before Treatment Decision

Complete the following mandatory evaluations to finalize risk stratification:

• PET-CT scan is the gold standard for staging FDG-avid lymphomas and should be performed for accurate initial assessment 1, 3
• Contrast-enhanced CT of neck, chest, abdomen, and pelvis to confirm no other sites of involvement 1, 2
• Bone marrow biopsy is strongly recommended, especially if any B symptoms or blood count abnormalities are present 1, 2
• Laboratory tests: Complete blood count, ESR, albumin, LDH, liver and renal function, alkaline phosphatase 1, 3
• Baseline cardiac function with echocardiographic LVEF measurement before anthracycline therapy 1, 4

Treatment Algorithm Based on Final Risk Classification

If Early Favorable Disease (No Risk Factors Present)

Administer 2 cycles of ABVD followed by 30 Gy involved-field radiotherapy, which achieves overall survival exceeding 90% at 5 years 1, 3, 4

• ABVD consists of doxorubicin, bleomycin, vinblastine, and dacarbazine given every 2 weeks 3, 4
• This represents the minimum effective treatment for truly favorable disease 1, 3

If Intermediate Stage (Any Risk Factor Present)

Administer 4 cycles of ABVD followed by 30 Gy involved-field radiotherapy, achieving tumor control rates of 85-90% at 5 years 1, 2, 3, 4

• For patients under 60 years eligible for intensive treatment, consider 2 cycles of BEACOPPescalated followed by 2 cycles of ABVD and 30 Gy radiotherapy for superior freedom from treatment failure 2, 3, 4
• However, BEACOPPescalated carries significantly higher toxicity, particularly infertility risk, requiring careful counseling 4

Critical Pitfalls to Avoid

Do not assume limited stage based solely on absence of spleen/mediastinal involvement—other risk factors may be present that mandate treatment intensification 1, 2. The ESMO guidelines explicitly state that extranodal involvement, elevated ESR, or extensive nodal involvement (≥3 areas) automatically upgrade patients to intermediate stage requiring 4 cycles of chemotherapy rather than 2 1.

Do not omit baseline PET-CT—it is essential for accurate staging and provides the baseline for response assessment using Deauville criteria 1, 3. The Lugano classification established PET-CT as the gold standard for staging FDG-avid lymphomas 1.

Do not skip fertility counseling in young patients—this must occur before treatment initiation, as both ABVD and especially BEACOPP carry fertility risks 3, 4. This is particularly critical for patients under 60 who might be candidates for intensified regimens 4.

Response Assessment Strategy

• Interim PET-CT after 2-4 cycles allows treatment optimization, though response-adapted therapy is not yet standard practice 3, 4
• End-of-treatment PET-CT is necessary to confirm complete remission using Deauville criteria 2, 3
• Positive end-of-treatment PET scans indicate partial remission with high risk for early relapse 1

Long-Term Surveillance Considerations

Given the young age of this patient, long-term follow-up is essential:

• Thyroid function monitoring (TSH) at 1,2, and 5 years if neck irradiation is performed 1
• Breast cancer screening for women who receive chest irradiation at premenopausal age, especially under 25 years 1
• Cardiovascular disease surveillance due to anthracycline and radiation exposure 2, 3
• Secondary malignancy monitoring as a late effect of treatment 2, 3