About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Hallmark: Reed-Sternberg cells (large binucleated "owl-eye" cells) on lymph node biopsy — CD15+, CD30+
- Bimodal age distribution: peaks at 20-30 years and >60 years. Painless cervical lymphadenopathy is the commonest presentation
- B symptoms (fever, night sweats, >10% weight loss) are present in ~30% and indicate poorer prognosis
- Staging: Ann Arbor system (I-IV) with PET-CT — essential for guiding treatment. FDG-PET is central to response assessment
- Treatment: early-stage favourable = 2 cycles ABVD + radiotherapy. Advanced = 6 cycles ABVD or escalated BEACOPP. Overall cure rate >85%
Overview
Hodgkin lymphoma (HL) is a B-cell lymphoid malignancy defined by the presence of neoplastic Reed-Sternberg (RS) cells within a reactive inflammatory background. There are two main types: classical HL (~95%, subdivided into nodular sclerosis, mixed cellularity, lymphocyte-rich, and lymphocyte-depleted) and nodular lymphocyte-predominant HL (~5%). Classical HL characteristically spreads contiguously between adjacent lymph node groups, unlike non-Hodgkin lymphoma which tends to spread non-contiguously. EBV is associated with approximately 40% of cases.
Epidemiology
HL has a bimodal age distribution with the first peak in young adults (20-30 years) and a second peak in the elderly (>60 years). It accounts for approximately 2,000 cases per year in the UK. Nodular sclerosis is the commonest subtype in young adults. Risk factors include EBV infection (increased risk after infectious mononucleosis), family history, and immunosuppression (HIV). It is one of the most curable cancers — overall 5-year survival exceeds 85%.
Clinical Features
Symptoms
Painless, non-tender lymphadenopathy — most commonly cervical/supraclavicular (60-70%)
B symptoms: fever (often Pel-Ebstein cyclical pattern), drenching night sweats, weight loss >10% in 6 months
Pruritus — often severe and generalised (not a B symptom but characteristic)
Alcohol-induced lymph node pain (rare but classic exam feature)
Fatigue and malaise
Cough, breathlessness (mediastinal lymphadenopathy — especially nodular sclerosis)
Signs
Firm, rubbery, non-tender lymphadenopathy — cervical > mediastinal > axillary
Mediastinal mass (bulky disease — >1/3 thoracic diameter on CXR)
Hepatosplenomegaly (advanced disease)
SVC obstruction (if massive mediastinal disease)
Investigations
First-line
Excisional lymph node biopsyESSENTIAL for diagnosis — core needle biopsy may be insufficient. Shows Reed-Sternberg cells (CD15+, CD30+, CD20-) within reactive background
FBCMay show normocytic anaemia, lymphopenia, eosinophilia, or raised ESR
LDH, ESR, albuminPrognostic markers. Raised ESR and LDH, low albumin = poorer prognosis
Second-line
PET-CT (whole body)The GOLD STANDARD for staging and response assessment. HL is intensely FDG-avid. Ann Arbor staging (I-IV): I = single node group, II = ≥2 same side of diaphragm, III = both sides, IV = extranodal involvement
Bone marrow biopsyNo longer routinely required if PET-CT is performed (PET-CT is more sensitive for marrow involvement)
Hepatitis B/C, HIVScreen before immunochemotherapy
Specialist
Interim PET-CT (after 2 cycles)Negative interim PET = excellent prognosis. Used to guide treatment adaptation (de-escalation or intensification)
Fertility assessmentDiscuss fertility preservation BEFORE starting treatment — sperm banking, oocyte cryopreservation
Pulmonary function testsBaseline DLCO before bleomycin-containing regimens (bleomycin lung toxicity)
Management
BSH/NICE Guidelines + NCCN HL Guidelines1
Early-stage favourable (IA/IIA, no bulk, ESR <50)
- 2 cycles ABVD + involved-field radiotherapy (20-30 Gy)
- PET-adapted: if PET-negative after 2 cycles, some protocols omit radiotherapy
2
Early-stage unfavourable or advanced (IIB-IV)
- 6 cycles ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) is standard
- Escalated BEACOPP may be used for advanced disease with high IPS score — higher cure rate but more toxicity
- PET-adapted: negative interim PET → de-escalate to AVD (drop bleomycin). Positive interim PET → escalate or switch therapy
3
Relapsed/refractory disease
- Salvage chemotherapy (DHAP, ICE, or GDP) followed by autologous stem cell transplant (ASCT)
- Brentuximab vedotin (anti-CD30 ADC) — post-ASCT consolidation or for relapse after ASCT
- Checkpoint inhibitors: nivolumab, pembrolizumab — for relapsed/refractory HL after ASCT and brentuximab
4
Long-term follow-up
- Monitor for late effects: secondary cancers (breast cancer after mediastinal RT — screening advised), cardiovascular disease, thyroid dysfunction, pulmonary fibrosis (bleomycin), infertility
- Survivorship care plan essential — many patients are young and will live decades
Complications
- Secondary malignancies: Breast cancer (especially women irradiated to mediastinum <30 years), lung cancer, AML/MDS — greatest long-term risk
- Cardiovascular disease: Accelerated atherosclerosis and cardiomyopathy from anthracyclines and RT
- Bleomycin pulmonary toxicity: Pneumonitis → pulmonary fibrosis. Monitor DLCO; stop if declining
- Infertility: Particularly with escalated BEACOPP. Fertility preservation counselling mandatory
- Thyroid dysfunction: Hypothyroidism after neck/mediastinal RT — lifelong TFT monitoring
UKMLA Exam Tips
- 1Reed-Sternberg cells ("owl-eye" binucleated giant cells) = Hodgkin lymphoma. CD15+, CD30+
- 2Alcohol-induced lymph node pain is PATHOGNOMONIC of Hodgkin lymphoma — classic SBA distractor
- 3Contiguous spread = Hodgkin (lymph node groups in sequence). Non-contiguous = Non-Hodgkin
- 4B symptoms: fever, night sweats, >10% weight loss in 6 months. Present = suffix "B" to stage
- 5ABVD is the standard regimen. Bleomycin causes lung fibrosis — always check PFTs/DLCO
- 6Young woman + mediastinal mass = think nodular sclerosis Hodgkin lymphoma
- 7PET-CT is central: staging, interim response, end-of-treatment assessment
practicetest your knowledge on hodgkin lymphomaApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — haematology and beyond.
open q-bank