Hodgkin Lymphoma

Stage

Areas involved

One lymph node region or lymphoid structure

≥2 lymph node regions on the same side of the diaphragm

III

Lymph nodes on both sides of the diaphragm

Extranodal sites other than one contiguous or proximal extranodal site or bone marrow

Qualifier

Clinical features

No systemic symptoms present

Unexplained fevers >38 °C; drenching night sweats; or weight loss >10% of body weight (within 6 months prior to diagnosis)

Bulky disease (mediastinal mass larger than a third of thoracic diameter, or any nodal mass >10 cm in diameter)

Involvement of one contiguous or proximal extranodal site

The Lugano Classification also incorporates CT neck, chest, abdomen, and pelvis combined with functional imaging with ¹⁸F-fluorodeoxyglucose-PET (PET/CT) as the optimal staging modality in Hodgkin lymphoma. PET/CT upstages 13–24% of cases compared to CT only. PET/CT may however be positive in sites of infection or inflammation and careful interpretation is required.

PET/CT is highly sensitive for focal bone marrow infiltration, and non-targeted pelvic bone marrow biopsy for staging is now rarely performed. Diffuse bone marrow uptake on PET/CT usually reflects a reactive process, while focal lesions are usually due to disease. Where there is uncertainty, a bone marrow biopsy is advisable.

1.6 Prognostic Factors at Baseline

At diagnosis, cHL is sub-classified into three main prognostic categories (Box 1.1), namely, early favourable, early unfavourable, and advanced, according to the modified Ann-Arbor stage and, for early stage cHL, the presence of clinical risk factors. The treatment and outcomes are in turn influenced by the prognostic category the patient falls into. The precise definition of the risk factors differs somewhat among study groups. The German Hodgkin Study Group risk factors are widely used in early stage disease. Bulky disease has been shown to be an independent adverse prognostic marker in early stage cHL, as is extranodal extension, presence of 3 or more nodal sites (see Fig 1.1) and a raised ESR.

German Hodgkin Study Group Risk Factors for early stage cHL