A 41-year-old man had a history of fever and night sweats for 6 weeks. He lost 2 kg in weight. 

He recently coughed and had sputum, but his fever was not relieved after taking antibiotics. 

He smokes 10 cigarettes per day and drinks 16 units of alcohol per week. 

On examination, he is pale and looks unwell. There is no palpable lymphadenopathy or splenomegaly. 

Hemoglobin (Hb) 87 g/L 

Mean corpuscular volume (MCV) 81 fL 

Platelets 310 X 109/L 

Erythrocyte sedimentation rate (ESR) 91 mm/h 

Urea and electrolytes Normal 

Immunoglobulins Normal 

White blood cells (WBC) 9.1 X 109/L (differential normal) 

Bilirubin 61 mmol/L (NR 5–17 mmol/L) 

Aspartate aminotransferase (AST) 137 U/L (NR 5–40 U/L) 

Alkaline phosphatase 250 U/L (NR 35–130 U/L) 

Gamma-glutamyl transferase (GGT) 215 U/L (NR 10–48 U/L) 

Albumin 34 g/L (NR 35–50 g/L) 

Q5. How should he be treated? 

A1. The chest x-ray shows a large mediastinal mass, compatible with lymph node enlargement. 

A2. Abdominal CT scan shows an enlargement of the retroperitoneal lymph nodes between the junction of the renal vessels and the bifurcation of the aorta. 

A3. The liver biopsy shows infiltration of the liver by large multinucleated cells which have the appearance of Reed–Sternberg cells. 

Bone marrow trephine biopsy shows an abnormal area at one end of the core biopsy which also shows the involvement of Hodgkin's disease at high power. 

The cells were confirmed to be CD30 positive. 

A4. Stage IV B mixed cellularity Hodgkin’s lymphoma (HL). 

The advent of fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning has improved the management of HL because it can accurately locate the lesion tissues that will ablate after successful treatment. 

Hodgkin lymphoma (HL) – fluorodeoxyglucose–positron emission tomography (FDG–PET) scans. (a) Pre-treatment. (b) Post-treatment. 

A5. Localized Hodgkin’s disease (e.g., Stages I and IA) respond well to radiotherapy. 

However, systemic symptoms, involving the tissues above and below the diaphragm (stage III) and involving outside the lymphoreticular system (e.g., into the liver, marrow, lung, central the nervous system, skin – Stage IV) should be treated with combination chemotherapy. 

appropriate regimes are chlorambucil, vinblastine, procarbazine, prednisolone (ChlVPP) and adriamycin, BCNU, vinblastine, dacarbazine (ABVD). 

The failure of the response assessed by the PET scan indicates the possibility of intensifying chemotherapy. 

Side effects of compound chemotherapy include bone marrow suppression, hair loss, susceptibility to infection, and infertility. 

There is an increased risk of acute myeloid leukemia in lymphoma patients who have received combination chemotherapy, particularly if they have also received radiotherapy. 

The figures below show gastric involvement and pyloric obstruction by high-grade non-Hodgkin’s lymphoma; barium flow and symptoms were both improved by radiotherapy. 

The following are adverse prognostic features at diagnosis: 

- Albumin <40 g/L 

- Hemoglobin concentration <105 g/L 

- Male sex 

- Age 45 or older 

- Stage IV disease according to Ann Arbor classification 

- Leukocytosis (WBC >15 X 109/L) 

- Lymphopenia (lymphocyte count <0.6 X 109/L)