Management of Hodgkin Lymphoma with Severe Pancytopenia and Visceral Involvement
The immediate next step is to perform a bone marrow biopsy to determine if the pancytopenia is due to marrow involvement by Hodgkin lymphoma versus treatment-related toxicity, followed by completion of staging with FDG-PET scan, while simultaneously initiating supportive care with transfusions and monitoring for infection. 1, 2
Immediate Diagnostic Priorities
Complete the Staging Workup
Bone marrow biopsy is mandatory given the severe pancytopenia (Hb 7, ANC 1100, platelets 38,000) and abnormal hemogram, as recommended by multiple guidelines for patients with systemic symptoms or abnormal blood counts 1. This will determine whether the cytopenias are due to marrow infiltration by lymphoma versus other causes.
FDG-PET scan from skull base to mid-thigh should be performed immediately for accurate staging and baseline assessment, as it is critical for response evaluation and will clarify the extent of disease, particularly the hepatosplenic nodules 2, 3, 4, 5. The CT already shows hepatosplenomegaly with multiple hypodense nodules suggesting Stage IV disease, but PET will confirm metabolic activity.
Obtain complete laboratory work-up including ESR, LDH, albumin, liver and renal function tests, which are essential for risk stratification and calculating the International Prognostic Score (IPS) 1.
Critical Supportive Care Measures
Monitor complete blood counts daily to track progression of pancytopenia, particularly the ANC and platelet count 2. With ANC of 1100/µL (borderline), the patient is at high risk for neutropenic complications.
Assess immediately for active infection given the pancytopenia and splenomegaly—obtain blood cultures and consider empiric broad-spectrum antibiotics if ANC falls below 1.0 × 10⁹/L or if clinical deterioration occurs 2.
Transfuse packed red blood cells for the severe anemia (Hb 7 g/dL) to improve oxygen delivery and quality of life, targeting Hb >8 g/dL in this elderly patient with comorbidities.
Platelet transfusion threshold should be 10,000/µL prophylactically, or 50,000/µL if any bleeding or before invasive procedures like bone marrow biopsy.
Risk Stratification and Staging
Disease Stage Assessment
Based on the clinical presentation, this patient likely has Stage IV Hodgkin lymphoma (hepatosplenic involvement with nodules) with B symptoms (if present—this should be documented) 6, 4, 5. The absence of lymph nodes on CT neck/chest is unusual but does not exclude advanced disease given the visceral involvement 6.
Cardiac and Pulmonary Function Testing
Obtain echocardiogram or MUGA scan and pulmonary function tests before initiating chemotherapy, as this is essential given the planned use of doxorubicin (cardiotoxic) and bleomycin (pulmonary toxic) in ABVD regimen 1, 2, 3. This is particularly critical given the patient's pre-existing COPD and emphysema.
Left ventricular ejection fraction assessment is recommended to identify patients at increased risk of treatment-related cardiac complications 1, 2.
Thyroid Function
- Document baseline thyroid function as the patient has known hypothyroidism, which will need optimization before chemotherapy and monitoring during treatment 1.
Treatment Planning Considerations
Advanced-Stage Disease Management
For this 65-year-old patient with likely Stage IV disease and multiple comorbidities:
ABVD chemotherapy (6 cycles) is the standard first-line treatment for advanced-stage Hodgkin lymphoma in patients >60 years 1, 4, 5. However, the severe baseline pancytopenia and comorbidities (COPD, CLD) make this patient extremely high-risk for treatment-related mortality.
Escalated BEACOPP is NOT recommended for this patient given age >60 years and significant comorbidities 1. The guidelines explicitly state that for patients >60 years, escalated BEACOPP should only be considered if IPS ≥4, and even then, a modified approach is preferred 1.
Critical Pitfall to Avoid
- Do NOT initiate chemotherapy based solely on the axillary lymph node biopsy without completing staging and addressing the pancytopenia etiology 2. Starting treatment with severe baseline cytopenias significantly increases treatment-related mortality, particularly infection risk and bleeding complications.
Dose Modifications and Growth Factor Support
Filgrastim (G-CSF) support will be essential during chemotherapy given the baseline neutropenia (ANC 1100) 7. The FDA label supports filgrastim use in patients with lymphoma undergoing chemotherapy to reduce duration of neutropenia 7.
Consider dose-reduced ABVD initially (e.g., 75% dose) given the severe baseline pancytopenia, low body weight (45 kg), and multiple comorbidities, with escalation based on tolerance.
Multidisciplinary Consultation
Hematology-oncology consultation is mandatory for treatment planning given the complex presentation with severe cytopenias and multiple comorbidities.
Pulmonology consultation should be obtained given the COPD/emphysema before initiating bleomycin-containing regimens, as bleomycin is contraindicated in severe pulmonary disease.
Cardiology evaluation may be needed given the small vessel ischemic changes in the brain and planned use of anthracyclines.
Prognosis and Treatment Timing
Once staging is complete and the etiology of pancytopenia is determined:
If bone marrow shows lymphoma involvement, this confirms Stage IV disease and the pancytopenia is disease-related. Treatment should begin promptly after supportive care optimization, as delay worsens outcomes 2, 4, 5.
If bone marrow is negative for lymphoma, alternative causes of pancytopenia (hypersplenism from massive splenomegaly, chronic liver disease, medication effects) should be investigated before initiating chemotherapy.
The 5-year overall survival for advanced-stage Hodgkin lymphoma is approximately 81%, but this patient's age, comorbidities, and baseline cytopenias place him at significantly higher risk for treatment-related complications and mortality 6, 4.