Diagnostic Evaluation for Hodgkin Lymphoma
The diagnostic workup for Hodgkin lymphoma requires excisional or core-needle lymph node biopsy with mandatory immunohistochemistry, baseline PET-CT for staging, comprehensive laboratory evaluation including viral screening, and pre-treatment cardiac and pulmonary assessment—bone marrow biopsy is no longer needed when PET-CT is performed. 1
Tissue Acquisition and Pathologic Diagnosis
Biopsy Requirements
- Excisional lymph node biopsy is the gold standard, providing adequate tissue for morphology, immunohistochemistry, flow cytometry, and molecular studies 2, 1
- Core-needle biopsy is acceptable only when excisional biopsy is not feasible and an expert hematopathologist confirms adequacy 2, 1
- Fine-needle aspiration is insufficient for initial diagnosis and should not be used except in rare circumstances with expert hematopathology review 2, 1
- Store additional paraffin-embedded, fresh-frozen tissue, or cell suspensions for future research when possible 2
Mandatory Immunohistochemistry Panel
A standardized panel must include: CD3, CD15, CD20, CD30, CD45, CD79a, and PAX5 1, 3
Classical Hodgkin lymphoma (95% of cases) demonstrates:
- CD30-positive and CD15-positive Hodgkin-Reed-Sternberg cells 4, 1
- Negative for CD45 and CD3 1
- CD20 expression in fewer than 40% of cases 1
Nodular lymphocyte-predominant Hodgkin lymphoma (5% of cases) shows:
Clinical Assessment
History and Symptom Documentation
Record the following B-symptoms (each impacts staging):
- Unexplained fever >38°C (>101°F) 4, 1
- Drenching night sweats 4, 1
- Unexplained weight loss >10% of body mass over 6 months 2, 4, 1
Additional symptoms to document:
Physical Examination
Perform thorough examination of all lymphoid regions, spleen, and liver for palpable involvement 2, 1
Imaging Studies
Mandatory Imaging
- Posteroanterior and lateral chest X-ray to evaluate mediastinal mass size 4, 1
- Contrast-enhanced CT of neck, chest, abdomen, and pelvis for anatomic staging 2, 4, 1
- Baseline whole-body PET-CT (skull base to mid-thigh) within one month before therapy initiation 4, 1
Critical point: PET-CT has replaced bone marrow biopsy for detecting marrow involvement due to its high sensitivity 4, 1. Bone marrow biopsy should only be performed if PET-CT is unavailable 4, 1.
Laboratory Evaluation
Mandatory Blood Tests
- Complete blood count with differential and platelet count 4, 1
- Erythrocyte sedimentation rate (ESR) 4, 1
- Comprehensive metabolic panel including:
Mandatory Viral Screening
Screen for hepatitis B, hepatitis C, and HIV prior to therapy initiation 4, 1. This is compulsory because treatment may reactivate latent infections or require modification in HIV-positive patients 4.
Pre-Treatment Functional Assessment
Cardiac Evaluation
- Baseline electrocardiography (ECG) 4, 1
- Echocardiography to assess cardiac function before anthracycline-based chemotherapy 4, 1
Pulmonary Evaluation
- Pulmonary function testing must be completed before treatment, particularly before bleomycin administration 4, 1
Reproductive Counseling
For all patients of reproductive age:
- Discuss fertility preservation options before treatment 4, 1
- Offer sperm banking for males 4, 1
- Offer oocyte collection or ovarian tissue cryopreservation for females 4, 1
- Mandatory serum pregnancy test in females of reproductive age 4, 1
This is critical because chemotherapy and abdominal radiotherapy can cause permanent infertility 4.
Risk Stratification
After completing the diagnostic workup, classify patients using the Ann Arbor staging system into limited, intermediate, or advanced stages according to EORTC/LYSA or GHSG criteria 4, 1. This classification, combined with prognostic factors (bulky disease, ESR, number of nodal sites), determines treatment intensity 4.