Hodgkin lymphoma (HL) is a lymphoproliferative neoplasm defined by the presence of Reed-Sternberg cells. It shows a bimodal age distribution (peaks at 15-35 years and >55 years). It constitutes approximately 10-15% of all lymphomas. Characteristically demonstrates contiguous spread along consecutive lymph node stations — this feature differentiates it from non-Hodgkin lymphoma (NHL). Anterior mediastinal (thymic) involvement is seen in 60-80% and is one of HL's most distinctive radiological features. Cervical and supraclavicular lymphadenopathy is the most common presenting finding. B symptoms (fever, night sweats, >10% weight loss) are present in 30-40% of patients and have prognostic significance.
Age Range
15-35
Peak Age
25
Gender
Male predominant
Prevalence
Uncommon
In Hodgkin lymphoma, neoplastic cells (Reed-Sternberg and Hodgkin cells) constitute only 1-2% of the total tumor mass; the remainder is reactive inflammatory infiltrate (lymphocytes, eosinophils, histiocytes, plasma cells). This rich reactive microenvironment is one reason for the intense FDG uptake on PET-CT — both neoplastic and reactive cells are metabolically active. The contiguous spread pattern results from tumor cell migration along lymphatic channels to consecutive stations — distinct from hematogenous spread and different from NHL's skip pattern. Anterior mediastinal predilection arises from thymic lymphoid tissue providing a suitable microenvironment for Reed-Sternberg cells. Fibrosis (especially in nodular sclerosis type) creates collagen bands and contributes to the nodular enhancing mass appearance on CT.
The most characteristic feature of Hodgkin lymphoma is sequential involvement of contiguous lymph node stations. Disease spreads from one station to adjacent station along lymphatic channels — skip involvement is rare. This feature is best assessed on PET-CT and is critically important in differentiation from NHL.
Contrast-enhanced CT shows homogeneous or mildly heterogeneous enhancing mass in anterior mediastinum. Mass is usually large (>5 cm, sometimes >10 cm, 'bulky disease'). Cervical, supraclavicular, and axillary lymph node stations are involved contiguously. Nodes are usually discrete, conglomerate formation is less prominent than in NHL. Necrosis and calcification are rare before treatment. Pericardial and pleural effusion may accompany.
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Homogeneously enhancing soft tissue mass measuring ... × ... cm in anterior mediastinum with contiguous cervical and supraclavicular lymph node station involvement — consistent with Hodgkin lymphoma.
PET-CT shows very intense FDG uptake — SUVmax usually 8-20 (Deauville score 4-5). Uptake is observed in contiguous nodal stations showing contiguous spread pattern. Mediastinal mass and cervical nodes show simultaneous intense uptake. Interim PET-CT is critically important for treatment response assessment — Deauville 1-3 indicates good response, 4-5 indicates inadequate response.
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Intense FDG uptake in anterior mediastinal mass and contiguous cervical-supraclavicular lymph node stations (SUVmax: ..., Deauville: ...) — consistent with Hodgkin lymphoma.
Ultrasonography shows round/ovoid, homogeneously hypoechoic lymph nodes. Central echogenic hilum is lost — lymphomatous infiltration has displaced hilar fat. Cortical thickening is prominent and diffuse. Short axis/long axis ratio >0.5 (rounding). Necrosis is usually absent — homogeneous hypoechoic internal structure predominates. Nodes of similar morphology in multiple stations.
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Multiple round, homogeneously hypoechoic lymph nodes with lost central hilum in cervical region — consistent with lymphoproliferative disease.
Color Doppler shows peripheral and/or mixed vascularity pattern. Normal hilar vascularity is lost with subcapsular and peripheral vascular branching predominating. Vascularity is usually increased — degree of hypervascularity correlates with tumor burden. RI values are variable (0.6-0.9). Power Doppler shows irregular vascular distribution.
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Lymph nodes show hilar vascularity loss with peripheral/mixed vascularity pattern — consistent with malignant lymphadenopathy.
Marked diffusion restriction on DWI — bright signal on high b-values (b=800-1000). ADC values usually 0.5-0.9 × 10⁻³ mm²/s — significantly lower than reactive nodes (>1.0). Intermediate-high signal intensity on T2-weighted images. Homogeneous enhancement on post-contrast T1, necrosis is rare. Anterior mediastinal mass shows homogeneous intermediate signal on T2.
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Marked diffusion restriction in lymph nodes on DWI (ADC: ... × 10⁻³ mm²/s), consistent with lymphoproliferative disease.
Homogeneous soft tissue density mass (40-60 HU) on non-contrast CT. Necrosis or calcification rare before treatment. Anterior mediastinal mass usually has symmetric and lobulated contour. Vascular structures may be encased but displaced rather than invaded (different from NHL). Pleural/pericardial effusion may accompany.
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Homogeneous soft tissue density mass measuring ... × ... cm in anterior mediastinum, no necrosis or calcification detected.
Criteria
Most common type (60-70%). Lacunar cells and thick fibrous bands are characteristic. Common in young women. Anterior mediastinal involvement >80%.
Distinct Features
Lobulated contour anterior mediastinal mass on CT. May be heterogeneous due to fibrous bands. Post-treatment residual fibrotic mass is common — PET assessment required.
Criteria
Second most common type (20-25%). Classic Reed-Sternberg cells are prominent. More common in males and older age. EBV association >70%.
Distinct Features
Peripheral lymphadenopathy is predominant, mediastinal involvement is less common than nodular sclerosis. Abdominal and retroperitoneal involvement is more prominent. Intense uptake on PET.
Criteria
Rare type (5%). Few Reed-Sternberg cells in abundant lymphocyte background. Subtype with best prognosis. Usually diagnosed at early stage.
Distinct Features
Peripheral localized LAP, bulky disease is rare. Small-sized, few involved nodes on CT. PET uptake may be less intense than other types.
Distinguishing Feature
NHL shows skip involvement pattern, frequent extranodal involvement, necrosis, and heterogeneous structure — HL shows contiguous spread, homogeneous structure, and anterior mediastinal predilection.
Distinguishing Feature
Sarcoidosis shows bilateral hilar and mediastinal symmetric LAP (lambda sign), parenchymal lung involvement (perilymphatic nodules), absence of necrosis, and usually low-moderate FDG uptake — HL shows asymmetric anterior mediastinal mass and very intense FDG uptake.
Distinguishing Feature
Reactive LAP shows oval shape, preserved echogenic hilum, hilar vascularity, and <10 mm short axis — HL shows round morphology, hilum loss, peripheral vascularity, and large size.
Distinguishing Feature
TB lymphadenitis shows central caseous necrosis (rim enhancement), nodal matting, calcification, and clinical TB findings (fever, night sweats, PPD positivity) — HL rarely shows necrosis, no calcification before treatment, and nodes are usually discrete.
Urgency
urgentManagement
medicalBiopsy
NeededFollow-up
specialist-referralExcisional lymph node biopsy is mandatory for diagnosis in suspected Hodgkin lymphoma — FNA is insufficient (architectural assessment required). Staging is performed with Ann Arbor/Lugano system and PET-CT is standard imaging for staging. Treatment is chemotherapy (ABVD) ± radiotherapy based on stage. HL has high cure rates (85-90% early stage, 70-80% advanced stage). Interim PET-CT (after 2 cycles) is critical for treatment response assessment — Deauville scoring system is used.
Hodgkin lymphoma is a malignancy with high cure rates (80-90% long-term survival). Ann Arbor staging + Lugano modification is used. PET-CT is the gold standard for staging and treatment response assessment. Treatment is chemotherapy (ABVD) ± radiotherapy. Deauville scoring evaluates treatment response.