Hodgkin Lymphoma Diagnosis and Staging

July 13, 2024

This page was reviewed under our medical and editorial policy by Alex Herrera, M.D., associate professor, division of lymphoma, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope® Cancer Center Duarte

If Hodgkin lymphoma is suspected, a range of tests may be used to help guide a diagnosis. While a biopsy is the only diagnostic tool that may confirm Hodgkin lymphoma, imaging tests, lab tests and other procedural tests all play an important part in providing a clear picture of the disease to the care team. This information helps doctors determine the cancer’s stage, type and subtype in order to plan the appropriate treatment.

How Is Hodgkin Lymphoma Diagnosed?

To diagnose Hodgkin lymphoma, the care team takes into account a person’s age, overall health, symptoms, the type of cancer suspected and any prior test results.

Physical Exam and Medical History

The diagnostic process typically begins with a physical exam and a thorough medical history to identify any risk factors. The doctor may examine the lymph nodes and other organs in the lymph system, like the liver or the spleen.

Biopsy

If cancer is suspected after a physical exam, the next step is a biopsy of the affected area. Doctors remove a portion of lymph tissue in order to test it for cancer. This is the only way to confirm Hodgkin lymphoma, but doctors need a large enough tissue sample to test. Sometimes, it may take more than one biopsy to get a big enough sample.

Excisional or Incisional Biopsy

Biopsies may either be excisional (the whole lymph node is removed) or incisional (a portion of a larger tumor or lymph node is removed).

Doctors may remove this tissue through a minor surgery called mediastinoscopy, where they insert a tube with a sharp tool on the end into the chest to collect an affected lymph node or lymph tissue. A camera and light on the tube allow doctors to guide it. They may use an ultrasound or a computed tomography (CT) scan to help them locate the affected area and remove the tissue.

Needle Biopsy

Needle biopsies are not often used to diagnose Hodgkin lymphoma, but doctors may do a needle biopsy to rule out swollen lymph nodes caused by infection or the spread of cancer from another organ. If the affected area is deep under the skin, doctors may use a CT scan to help them guide the needle to the area.

After a needle biopsy, an excisional or incisional biopsy may be recommended to diagnose lymphoma.

Needle biopsies may also be used to check changes in lymph nodes, such as swelling, after Hodgkin lymphoma has already been diagnosed.

Bone Marrow Aspiration and Biopsy

Doctors may do this type of biopsy to get a sample of bone marrow fluid and bone tissue. Often, doctors may get the information they need through a combination scan of a positron emission tomography (PET) scan and a CT scan called a PET/CT, so bone marrow aspiration and biopsies do not happen often in relation to Hodgkin lymphoma.

Testing the Tissue Sample

A pathologist — a doctor who specializes in looking at tissue samples — will look at the tissue from the biopsy under a microscope. Sometimes, the pathologist may diagnose Hodgkin lymphoma just by looking at the sample, and other times a test called immunohistochemistry is needed to look for certain proteins on the cells. This test may help pathologists diagnose the specific type of Hodgkin lymphoma as well.

Additional Tests

Many tests may follow an initial biopsy or biopsies. These tests help the care team stage the cancer, or figure out how much it has progressed or spread. They also may help diagnose the specific type of Hodgkin lymphoma, confirm how well treatment is working and help monitor the effect of treatment on other areas of the body, such as the heart and lungs.

Imaging tests, such as those listed below, might be used to get a clearer picture of how Hodgkin lymphoma is affecting the body.

X-ray: Doctors may use an X-ray to see if enlarged lymph nodes are in the chest. 

CT scan: This scan combines X-ray images, providing doctors a detailed image of enlarged lymph nodes throughout the body.

PET scan: In these scans, a sugar substance with low radioactivity is injected into a vein. This substance highlights high-energy cells, such as cancer cells. This test tends to produce more information about the whole body than a CT scan. It helps doctors more closely identify where cancer is, track the effect of treatment and even evaluate areas after treatment to see if cancer is still present.

Magnetic resonance imaging (MRI): This test, which shows images of soft tissues in the body, is only used for Hodgkin lymphoma if doctors think the brain or spinal cord might be affected.

Other tests, such as those listed below, might be performed to provide doctors more information about the cancer’s location and effects, or to see how chemotherapy treatment may have impacted parts of the body.

Complete blood count (CBC): A CBC is a blood test that provides counts of red blood cells, white blood cells and platelets, which may provide doctors information on how cancer is affecting these cells.

Erythrocyte sedimentation rate (ESR): An ESR test measures the amount of inflammation in the body, which might be due to cancer.

Pulmonary function test (PFT): This test might be performed to check how well the lungs are working after chemotherapy drugs were used to treat Hodgkin lymphoma.

Echocardiogram: This procedure is a heart ultrasound, and might be performed to see how the heart is working after chemotherapy drugs were used to treat Hodgkin lymphoma.

Since Hodgkin lymphoma may have an effect on many parts of the body, doctors might do a variety of additional tests, like kidney function tests, depending on personal factors in each patient.

Hodgkin Lymphoma Stages

After Hodgkin lymphoma is diagnosed, the care team will focus on figuring out how much the cancer has spread or progressed and what characteristics it has. This is called staging. The staging system for Hodgkin lymphoma, known as the Lugano classification, involves four stages, with additional letters providing further description for each stage, if appropriate. Assigning a stage to the cancer enables the care team to quickly understand information about a patient’s condition.

Stage 1 Hodgkin Lymphoma

Cancer cells are in one lymph node or one group of lymph nodes near one another.

Stage 2 Hodgkin Lymphoma

Cancer cells are in two lymph node areas above or both below the diaphragm. The diaphragm is a muscle beneath the lungs that is used to designate the line between the chest and abdomen in Hodgkin lymphoma staging.

Stage 3 Hodgkin Lymphoma

Cancer cells are in at least one lymph node area above the diaphragm and at least one below the diaphragm. The area below the diaphragm with cancer cells may be a lymph node area or it may be the spleen.

Stage 4 Hodgkin Lymphoma

Cancer cells have been found in at least one organ outside of the lymphatic system. Most commonly, Hodgkin lymphoma spreads to the lungs, liver or bone marrow in Stage 4.

Additional Lymphoma Stage Descriptions

Any of the Hodgkin lymphoma stages may have a letter added to it for a more detailed description.

A: No B symptoms are present. B symptoms include unexplained fever, extreme night sweats or unexpected weight loss of 10% body weight or more within six months. B symptoms may suggest a more advanced cancer.

B: This means at least one of the B symptoms is present.

E: Cancerous cells have been found in an organ or tissue outside of the lymphatic system.

S: Cancerous cells have been found in the spleen.

X: Also called bulky disease, this means there is a tumor in the chest at least one-third as wide as the chest, or at least 10 centimeters wide in another area of the body. Bulky disease is treated differently than non-bulky Hodgkin lymphoma.

For example, if there is a tumor over one-third the width of the chest in Stage 2 Hodgkin lymphoma, it would be written as stage 2X. Or, a person with B symptoms in Stage 1 would have Stage 1B Hodgkin lymphoma.

Recurrent Hodgkin Lymphoma

Hodgkin lymphoma that returns after being in remission is called recurrent or resistant. This may happen shortly after treatment ends or years later. Testing and treatment planning largely mirror those of the initial diagnosis, allowing the care team to determine where the cancer has returned and how it is growing.

Hodgkin Lymphoma Types

Types of Hodgkin lymphoma vary in how they grow, spread and affect the rest of the body.

Classical Hodgkin Lymphoma (cHL)

The most common form of Hodgkin lymphoma, which is now known has classic HL, has a certain type of large cancerous cell called Reed-Sternberg cells in B lymphocytes.

The four subtypes of cHL are listed below.

Nodular sclerosis classical Hodgkin lymphoma (NSCHL): Starting in the neck and chest, NSCHL tends to affect mostly teens and young adults. This is the most common subtype. In addition to Reed-Sternberg cells and normal lymphocytes, lymph nodes often have scar tissue as well.

Mixed cellularity classical Hodgkin lymphoma (MCCHL): Most commonly seen in men and people with HIV, MCCHL is the second most common subtype. It tends to affect the upper part of the body.

Lymphocyte-rich classical Hodgkin lymphoma: This subtype has many normal-looking lymphocytes in addition to some Reed-Sternberg cells. It is uncommon and tends to only affect the upper part of the body.

Lymphocyte-depleted classical Hodgkin lymphoma: This subtype is rare but aggressive. Seen predominantly in older people and people with HIV, it tends to be found in the middle of the body: the abdomen, spleen and liver. It may also be found in bone marrow.

Nodular Lymphocyte-Predominant Hodgkin Lymphoma (NLPHL)

This type of Hodgkin lymphoma tends to grow slowly, and it has slightly different cancerous cells than the classical Reed-Sternberg cells found in cHL. NLPHL often starts in lymph nodes in the neck and underarm, and it is more common in men than women. Treatment plans are different for NLPHL because it grows differently than cHL.

References
References
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