Hematology Oncology · Year 2 · from Hematology Oncology
Case 1: Classical Hodgkin Lymphoma
Patient Presentation
Demographics: 24-year-old male
Chief Complaint: Painless neck mass and night sweats for 6 weeks
History of Present Illness: The patient noticed a painless lump in his left neck 6 weeks ago that has been slowly enlarging. He reports drenching night sweats requiring him to change his shirt, occurring 3-4 times per week. He has lost 15 pounds over the past 2 months without trying. He also reports generalized pruritus. He denies fever, cough, or shortness of breath. He is otherwise healthy with no significant medical history.
Physical Examination:
- Vital signs: BP 120/75, HR 78, RR 14, Temp 37.0C
- General: Thin but otherwise healthy-appearing young man
- HEENT: Left supraclavicular and cervical lymphadenopathy (4 cm, rubbery, non-tender)
- Cardiac: Regular rhythm, no murmurs
- Lungs: Clear to auscultation
- Abdomen: No hepatosplenomegaly
- Skin: Excoriations from scratching, no rash
Workup and Results
Laboratory:
- WBC: 8,500/uL with normal differential
- Hemoglobin: 11.8 g/dL (mild anemia)
- Platelets: 385,000/uL
- ESR: 65 mm/hr (elevated)
- LDH: 280 U/L (upper normal)
- Albumin: 3.2 g/dL (low)
Excisional Lymph Node Biopsy:
- Reed-Sternberg cells present
- Large cells with bilobed nuclei ("owl eyes")
- Background of lymphocytes, eosinophils, plasma cells
- Nodular sclerosis pattern with fibrous bands
Immunohistochemistry:
- CD15: Positive
- CD30: Positive
- CD20: Negative
- CD45: Negative
- EBV (EBER): Negative
Staging Workup:
- PET-CT: Avid lymphadenopathy in left neck and mediastinum (10 cm mediastinal mass)
- No disease below diaphragm
- Bone marrow: Negative
Clinical Image
Histologic section demonstrating a classic Reed-Sternberg cell with its characteristic bilobed nucleus, prominent eosinophilic nucleoli, and "owl-eye" appearance, surrounded by a reactive inflammatory infiltrate.
Diagnosis
Classical Hodgkin Lymphoma, Nodular Sclerosis Type - Stage IIB (Bulky)
Staging:
- Ann Arbor Stage II (both sides of neck = 2 regions, same side of diaphragm)
- B symptoms present (night sweats, weight loss >10%)
- Bulky disease (mediastinal mass >10 cm)
- Early-stage unfavorable
Treatment Plan
- Pre-treatment evaluation:
- Pulmonary function tests (baseline for bleomycin)
- Echocardiogram (baseline for anthracycline)
- Fertility preservation discussion (sperm banking)
- Chemotherapy:
- ABVD x 4-6 cycles (Adriamycin, Bleomycin, Vinblastine, Dacarbazine)
- OR A+AVD (brentuximab vedotin replacing bleomycin) if available
- Interim PET assessment:
- PET-CT after 2 cycles
- If PET-negative: May reduce therapy
- If PET-positive: Consider escalation
- Radiation:
- Involved-site radiation therapy after chemotherapy
- Particularly important for bulky mediastinal disease
- Response-adapted approach:
- End-of-treatment PET to confirm complete remission
- Long-term surveillance for relapse
- Prognosis:
- Early-stage unfavorable: 85-90% cure rate
- Young age and nodular sclerosis favorable features
Teaching Points
- Reed-Sternberg cells with CD15+/CD30+ and CD45- define classical Hodgkin lymphoma
- B symptoms (fever, night sweats, weight loss >10%) indicate worse prognosis
- Hodgkin lymphoma spreads contiguously through lymph node groups
- PET-CT is essential for staging and response assessment
- ABVD is standard therapy with excellent cure rates even in advanced disease
- Bleomycin pulmonary toxicity requires baseline and monitoring PFTs
- The mediastinum is commonly involved in nodular sclerosis type (most common subtype)