Hodgkin Lymphoma in Children
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Direct answer
Hodgkin lymphoma in a child is an indolent, painless, rubbery cervical or supraclavicular mass that announces itself earlier than most childhood cancers and, treated with modern risk-adapted chemo(radio)therapy, is curable in the great majority. The Reed-Sternberg cell — a binucleate CD15- and CD30-positive giant cell — defines it histologically, and the disease spreads predictably to contiguous node groups, which is why the Ann Arbor staging system, not the Murphy system used for non-Hodgkin lymphoma, applies. Fever above 38 degrees for three consecutive days, drenching night sweats and more than 10 per cent weight loss over six months are the B symptoms that upstage every patient.
What you must remember
- Bimodal age curve with an adolescent-young adult peak (15–34 years) and a second peak after 55; in developing countries younger children with mixed-cellularity histology and EBV association are seen more often.
- Histological subtypes: nodular sclerosis is commonest overall in adolescents; lymphocyte-predominant has the best outlook; lymphocyte-depleted the worst.
- Reed-Sternberg cells mark CD15 and CD30 positive; the cellular background of reactive lymphocytes and eosinophils is what actually determines prognosis.
- Presentation: painless cervical/supraclavicular adenopathy; mediastinal mass; the classic sign of pain at the lymph node site after alcohol intake is famous but rare.
- B symptoms: unexplained fever over 38°C for three or more consecutive days, drenching night sweats, or loss of more than 10 per cent body weight over six months.
- Staging is Ann Arbor I–IV with A/B suffix; the spleen, and contiguous spread, matter — stage II means two node regions on the same side of the diaphragm, stage III both sides, stage IV extranodal dissemination.
- A mediastinal mass more than one-third of the transthoracic diameter on an upright film flags superior mediastinal widening with airway and anaesthetic risk.
- Modern therapy is risk-adapted combination chemotherapy (regimens of the OEPA/COPDAC or ABVD families) with response-adapted, volume-reduced radiotherapy; over 90 per cent of localised and the majority of advanced-stage children survive.
- Late effects shape follow-up: second cancers including breast carcinoma after chest radiotherapy, anthracycline cardiomyopathy, infertility and hypothyroidism after neck irradiation.
A typical exam case
A fourteen-year-old notices a lump above the left clavicle for six weeks — non-tender, rubbery, 3 cm, freely mobile. There is a month of evening fever and drenching night sweats. Step one is the chest radiograph before anything invasive: a widened mediastinum changes the approach entirely, both for staging and because a supine biopsy under general anaesthesia in a child with a large mediastinal mass can obstruct the airway. Step two is excision biopsy of the accessible peripheral node — the node itself, not a fine-needle aspirate, because architecture is the diagnosis in Hodgkin lymphoma. Step three is staging with contrast CT (PET-CT where available), plus counts, ESR and an echocardiogram ahead of anthracyclines.
Suppose the biopsy shows nodular sclerosis with Reed-Sternberg cells, and imaging shows disease confined to the cervical and mediastinal nodes without B symptoms: Ann Arbor stage IIA. Treatment is a short course of risk-adapted chemotherapy with or without involved-field radiotherapy, and the expected cure rate is well over 90 per cent. The examinable nuance is what happens fifteen years later — breast screening after chest radiotherapy in girls, cardiac surveillance after doxorubicin, thyroid function after neck fields, and fertility counselling before gonadotoxic cycles.
How the exam frames it
Mostly through contrasts. A painless rubbery node with contiguous spread and B symptoms versus a rapidly enlarging extranodal abdominal mass (non-Hodgkin); Ann Arbor versus Murphy staging as a matching question; CD15/CD30 versus CD20 and lymphoblastic markers; and the staging vignette that turns on the spleen or on nodes crossing the diaphragm. A favourite one-best-answer asks which child needs urgent airway assessment before biopsy — the one with a mediastinal mass and positional stridor. Candidates lose marks by suggesting staging laparotomy (historical, abandoned) or fine-needle aspiration cytology as adequate — the reactive cellular background, visible only on histology, grades the disease.
Frequently asked questions
Which staging system is used for Hodgkin lymphoma and why?
The Ann Arbor system (I–IV with A or B suffix), because Hodgkin lymphoma spreads contiguously from one lymph node region to the next, unlike the haematogenous pattern of non-Hodgkin lymphoma staged by the Murphy criteria.
What are B symptoms and how do they alter staging?
Unexplained fever above 38°C on consecutive days, drenching night sweats and loss of more than 10 per cent body weight over six months; their presence adds the B suffix and worsens prognosis.
Which immunohistochemical markers define the Reed-Sternberg cell?
CD15 and CD30 positivity; the classic owl-eye binucleate appearance is supported by these markers; CD45 is typically negative.
Why is excision biopsy preferred over fine-needle aspiration in suspected Hodgkin lymphoma?
Diagnosis depends on nodal architecture — the mixed reactive background of lymphocytes, eosinophils and plasma cells around Reed-Sternberg cells determines subtype and prognosis, and this is lost on cytology.
What late effects must be monitored after treatment of childhood Hodgkin lymphoma?
Second malignancies (especially breast cancer after chest radiotherapy in girls), anthracycline cardiomyopathy, post-irradiation hypothyroidism and infertility.