Hodgkin Lymphoma

Hodgkin Lymphoma (HL) – Summary for Oncology Pharmacist

Definition

A malignant lymphoma characterized by the presence of Reed–Sternberg cells (large, binucleated B cells, CD30+ and CD15+), typically arising from germinal center B-cells.

Epidemiology

• Bimodal age distribution: peaks at 15–35 and >55 years
• Slight male predominance
• High cure rate (>85%) with modern therapies

Subtypes (WHO Classification)

1. Classical Hodgkin Lymphoma (cHL) (95%):
   • Nodular sclerosis (most common)
   • Mixed cellularity
   • Lymphocyte-rich
   • Lymphocyte-depleted
2. Nodular lymphocyte-predominant HL (NLPHL) (CD20+, CD30–, CD15–)

Clinical Features

• Painless lymphadenopathy (often cervical, mediastinal)
• B symptoms: fever, night sweats, weight loss
• Alcohol-induced pain at lymph nodes (rare, but specific)
• Fatigue, pruritus, splenomegaly

Diagnosis

• Excisional lymph node biopsy (not FNA)
• Histology: Reed–Sternberg cells in an inflammatory background
• Immunohistochemistry: CD30+, CD15+, PAX5+, CD20 variable
• PET-CT for staging and response assessment
• Bone marrow biopsy if advanced stage or cytopenias

Staging (Ann Arbor System)

• Stage I–IV based on nodal/extranodal spread
• A = no B symptoms, B = presence of B symptoms
• Bulky disease = mass >10 cm or mediastinal mass >1/3 thoracic diameter

Treatment Regimens

First-line:

• ABVD: doxorubicin, bleomycin, vinblastine, dacarbazine
  • Given every 28 days x 4–6 cycles
• A+AVD (brentuximab + doxorubicin, vinblastine, dacarbazine) – for advanced-stage, especially CD30+
• BEACOPP: escalated in high-risk patients (more toxic)

Radiation therapy:

• Often used in early-stage or bulky disease
• Involved-site radiation (ISRT)

Relapsed/Refractory HL

• Salvage chemo (e.g., ICE, DHAP, GDP) followed by autologous stem cell transplant (ASCT)
• Brentuximab vedotin (anti-CD30 ADC)
• Checkpoint inhibitors: nivolumab, pembrolizumab (especially post-ASCT)

Key Toxicities to Monitor

• Doxorubicin → cardiotoxicity
• Bleomycin → pulmonary toxicity (monitor DLCO, avoid in older adults or lung disease)
• Vinblastine → neuropathy, constipation
• Brentuximab vedotin → neuropathy, neutropenia
• Myelosuppression, secondary malignancies

Monitoring

• CBC, renal/hepatic panels
• Pulmonary function (bleomycin)
• Ejection fraction (doxorubicin)
• Interim PET-CT after 2 cycles (Deauville score)
• Long-term: secondary malignancy, infertility, hypothyroidism (after neck radiation), cardiopulmonary toxicity

Prognosis

• Highly curable with frontline therapy
• Early-stage: >90% cure rate
• Advanced-stage: ~70–80%
• Poor prognostic markers: B symptoms, bulky disease, high ESR, extranodal involvement

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