Eduovisual
Blood & Lymphoreticular
Hodgkin lymphoma: staging and treatment overview
— Classical HL (~95%): nodular sclerosing (most common, mediastinal, young women), mixed cellularity (EBV-associated, older/HIV), lymphocyte-rich, lymphocyte-depleted (worst prognosis, HIV).
— Nodular lymphocyte-predominant HL (NLPHL): CD20+, CD15/CD30 negative, "popcorn cells," indolent, behaves more like indolent NHL.
— Painless, rubbery, non-tender cervical or supraclavicular lymphadenopathy in a young adult persisting >2–4 weeks
— Mediastinal mass found on chest imaging (cough, dyspnea, SVC symptoms, or incidental on CXR)
— B symptoms: unexplained fevers >38°C, drenching night sweats, weight loss >10% body weight over 6 months
— Generalized pruritus or alcohol-induced nodal pain (classic but uncommon)
— Contiguous spread pattern of nodal involvement (unlike NHL)
Board pearl: FNA is inadequate for diagnosing HL — architecture is essential to identify RS cells in their reactive background. Always order excisional lymph node biopsy.
Step 3 management: A 22-year-old with a 4-week painless supraclavicular node and night sweats → refer for excisional biopsy and obtain a CXR before the visit ends to screen for a mediastinal mass that could complicate anesthesia.
— Painless, firm, rubbery, mobile; >1 cm and persistent
— Supraclavicular nodes are highly concerning — always abnormal in adults
— Contiguous spread: cervical → mediastinal → axillary → para-aortic
— Waldeyer's ring and mesenteric nodes are typically spared (helps distinguish from NHL)
— Fever >38°C, often cyclical (Pel-Ebstein — days-to-weeks fever cycles, classic but rare)
— Drenching night sweats (changing sheets)
— Unintentional weight loss >10% body weight over 6 months
— Pruritus (not a B symptom but prognostically relevant)
— Alcohol-induced lymph node pain — pathognomonic but rare
— Fatigue, malaise
— Dry cough, dyspnea on exertion, retrosternal chest pressure
— Facial plethora, neck/arm swelling → SVC syndrome (oncologic urgency)
— Hoarseness (recurrent laryngeal compression)
— Prior mononucleosis or EBV exposure
— HIV risk factors and testing history
— Family history of lymphoma
— Fertility goals (critical before chemo/RT planning)
— Tobacco/cardiac risk factors (impacts long-term anthracycline/RT toxicity counseling)
— Vaccination history, especially if splenectomy is anticipated (rare now)
Key distinction: HL spreads contiguously node group to adjacent node group, while NHL skips around and often involves extranodal sites (GI tract, skin, CNS) and Waldeyer's ring. This pattern guides staging logic and explains why HL is more often curable with localized radiation in early stages.
Board pearl: Pruritus and alcohol-induced nodal pain in a young adult with adenopathy → think HL even before biopsy results return.
— Document fever pattern
— Tachycardia/hypotension → consider sepsis (neutropenia later), SVC obstruction, or pericardial effusion from bulky mediastinal disease
— Tachypnea or hypoxia → large mediastinal mass, pleural effusion, or pulmonary involvement
— Cervical, supraclavicular (Virchow's on left, scalene), axillary, epitrochlear, inguinal, femoral, popliteal
— Document size, mobility, tenderness, matting, and laterality
— Bulky disease = single node/mass ≥10 cm or mediastinal mass >1/3 thoracic diameter on upright CXR
— Dullness, decreased breath sounds → pleural effusion
— Muffled heart sounds, pulsus paradoxus, elevated JVP → pericardial effusion/tamponade from mediastinal mass
— Facial/upper extremity swelling, dilated chest wall veins, plethora → SVC syndrome
— Splenomegaly (~30%) — note size in cm below costal margin
— Hepatomegaly suggests advanced (stage IV) disease
— Mesenteric masses are unusual (favor NHL)
Step 3 management: A patient with newly diagnosed HL and a bulky mediastinal mass develops orthopnea that improves sitting forward — obtain bedside echocardiogram to assess for pericardial effusion/tamponade before any sedation, anesthesia, or supine procedure.
Board pearl: Anesthesia in patients with large anterior mediastinal masses can cause cardiovascular collapse on induction due to airway/SVC/great-vessel compression — always image the chest before lymph node biopsy under general anesthesia in suspected HL.
— May show anemia of chronic disease, leukocytosis with neutrophilia, eosinophilia, thrombocytosis
— Lymphopenia is a poor prognostic factor (IPS component)
— Cytopenias suggest marrow involvement (advanced disease) or hypersplenism
— LFTs (hepatic involvement; baseline before chemo)
— Renal function (dose chemo; tumor lysis risk, lower than NHL)
— Calcium, uric acid, LDH, phosphate
— Elevated ESR is a prognostic factor in early-stage HL (≥50 without B symptoms, ≥30 with B symptoms = unfavorable)
— LDH less prognostically central than in NHL but still drawn
— HIV, HBV (HBsAg, anti-HBc, anti-HBs), HCV — mandatory before any rituximab-containing or steroid regimen due to HBV reactivation risk
— Pregnancy test in women of childbearing potential
— Consider EBV serology in select cases
— Echocardiogram or MUGA — baseline LVEF before anthracyclines (doxorubicin in ABVD)
— PFTs with DLCO — baseline before bleomycin
— CXR — quickly identifies bulky mediastinal disease and mediastinal-to-thoracic ratio
— Contrast-enhanced CT of neck, chest, abdomen, pelvis
— FDG-PET/CT — the cornerstone modality for staging, response assessment, and prognosis (HL is highly FDG-avid)
— Sperm banking for men, oocyte/embryo cryopreservation for women — discuss before chemotherapy begins
CCS pearl: Pre-chemo order set in HL — CBC, CMP, LDH, ESR, uric acid, HIV/HBV/HCV, β-hCG, echocardiogram, PFTs with DLCO, PET/CT, and fertility consult. Missing the pregnancy test or HBV screen is a recurrent Step 3 trap.
Board pearl: PET/CT both stages and prognosticates — interim PET after 2 cycles (PET-2, Deauville scoring) guides response-adapted therapy in modern HL care.
— Provides architecture, RS cells, and reactive background
— FNA and core biopsy are inadequate alone — they may suggest lymphoma but cannot reliably subtype HL vs NHL
— Choose the most accessible, abnormal node; avoid inguinal if possible (more reactive changes)
— Reed-Sternberg cells: large, bi/multinucleated, prominent eosinophilic nucleoli ("owl eyes")
— Background of lymphocytes, eosinophils, plasma cells, neutrophils, histiocytes
— Classical HL: CD15+, CD30+, CD20− (usually), PAX5+ (dim), CD45−
— NLPHL: CD20+, CD45+, CD15−, CD30−, "popcorn" L&H cells
— Historically routine; now largely replaced by PET/CT for staging marrow involvement in classical HL
— Still performed if PET findings are ambiguous or in cytopenias unexplained by other disease
— Stage I: single nodal region or single extralymphatic site (IE)
— Stage II: ≥2 nodal regions same side of diaphragm
— Stage III: nodes both sides of diaphragm (spleen = nodal); IIIE if contiguous extralymphatic
— Stage IV: disseminated extralymphatic involvement (liver, marrow, lung non-contiguous)
— Suffixes: A = no B symptoms; B = B symptoms present; X = bulky disease; E = extranodal contiguous extension
— Early favorable, early unfavorable, advanced — defined by stage plus risk factors (bulk, ESR, # of nodal sites, age, extranodal involvement) per GHSG/EORTC criteria
Key distinction: Classical HL is CD15+/CD30+/CD20−; NLPHL is CD20+/CD30− — this drives drastically different treatment (NLPHL may use rituximab-based regimens).
— Early-stage favorable (I–II, no risk factors): 2 cycles ABVD + 20 Gy involved-site radiation therapy (ISRT), or 2–4 cycles ABVD alone if PET-2 negative (response-adapted)
— Early-stage unfavorable (I–II with risk factors: bulk, B symptoms, ↑ESR, ≥3 nodal sites, extranodal extension): 4 cycles ABVD + 30 Gy ISRT, or response-adapted approach
— Advanced-stage (III–IV): 6 cycles of ABVD, or brentuximab vedotin + AVD (BV-AVD / A+AVD), or escalated BEACOPP in select high-risk patients (more common in Europe)
— PET-2 (interim PET after 2 cycles) drives escalation/de-escalation; Deauville score 1–3 = favorable
— Brentuximab vedotin (anti-CD30 ADC) replaces bleomycin in advanced disease in many US protocols (eliminates bleomycin pulmonary toxicity)
— PD-1 inhibitors (nivolumab, pembrolizumab) are now used in frontline advanced HL trials and standard in relapsed/refractory disease
— Stage IA/IIA non-bulky: ISRT alone often curative
— Advanced or symptomatic: rituximab-based chemoimmunotherapy (R-CHOP, R-ABVD)
— Fertility preservation
— Baseline LVEF and DLCO
— Vaccinations: inactivated influenza, pneumococcal; avoid live vaccines during/after chemo
— HBV prophylaxis if HBsAg+ or anti-HBc+
Step 3 management: Newly diagnosed stage IIA non-bulky classical HL in a 25-year-old → ABVD ×2 cycles, then PET-2: if Deauville 1–3, complete with ISRT 20 Gy; if PET-2 positive, escalate. Do not start chemo before fertility counseling is documented.
— Adriamycin (doxorubicin) 25 mg/m² IV days 1, 15
— Bleomycin 10 units/m² IV days 1, 15
— Vinblastine 6 mg/m² IV days 1, 15
— Dacarbazine 375 mg/m² IV days 1, 15
— Cycle length: 28 days (one cycle = days 1 + 15)
— Doxorubicin → cardiomyopathy, cumulative-dose dependent. Monitor with baseline echo/MUGA; lifetime dose cap historically 450–550 mg/m².
— Bleomycin → pulmonary fibrosis (10–20% incidence). Get baseline PFTs/DLCO; discontinue if DLCO drops ≥25% or new dyspnea/cough; avoid high-FiO₂ exposure (anesthesia risk).
— Vinblastine → myelosuppression, neuropathy, constipation
— Dacarbazine → nausea/vomiting (highly emetogenic — use 5-HT3 + dexamethasone + NK1 antagonist), flu-like syndrome
— Antiemetics per HEC/MEC regimens
— G-CSF generally NOT routine with ABVD — paradoxically associated with worse bleomycin pulmonary toxicity; treat through neutropenia at standard doses on schedule
— PJP prophylaxis with steroid-heavy regimens; usually not required for standard ABVD
— Replaces bleomycin in advanced (stage III–IV) HL
— Toxicities: peripheral neuropathy, neutropenia (requires G-CSF primary prophylaxis)
— Avoids pulmonary fibrosis risk
— More intensive: higher cure rate in advanced disease but greater infertility, secondary leukemia, and toxicity
— Reserved for selected high-IPS patients
Board pearl: A patient on ABVD develops a new dry cough and exertional dyspnea — stop bleomycin immediately, obtain PFTs with DLCO and HRCT chest; do not wait for the next scheduled dose. Bleomycin pulmonary toxicity can be fatal and is exacerbated by supplemental oxygen — alert anesthesia teams permanently.
— Involved-site RT (ISRT) has replaced extended-field RT to reduce long-term toxicity
— Typical doses: 20 Gy (early favorable), 30 Gy (early unfavorable/consolidation), 30–36 Gy for bulky residual disease
— Late effects: secondary malignancies (breast, lung, thyroid, sarcoma), coronary artery disease, hypothyroidism, premature menopause, pulmonary fibrosis
— Second-line chemotherapy (ICE, DHAP, GDP, or brentuximab-based salvage) to achieve a second remission
— Followed by high-dose chemotherapy + autologous stem cell transplant (ASCT) — standard of care for chemosensitive first relapse
— Post-ASCT maintenance brentuximab vedotin for high-risk patients (improves PFS)
— Brentuximab vedotin for R/R disease (CD30+ targeting)
— PD-1 inhibitors (nivolumab, pembrolizumab) — highly effective in R/R HL because RS cells have 9p24.1 amplification → PD-L1 overexpression
— Allogeneic SCT in select refractory cases
— SVC syndrome from mediastinal HL: do not give empiric steroids until biopsy is obtained (steroids can obscure diagnosis); urgent biopsy → start therapy promptly
— Bulky mediastinal disease: consolidation RT often retained even in PET-negative cases
Step 3 management: A 30-year-old in remission from stage IIIB HL after ABVD ×6 relapses 14 months later with biopsy-proven recurrence — proceed to salvage chemotherapy (e.g., ICE) followed by autologous stem cell transplant, not repeat ABVD.
Board pearl: Reed-Sternberg cells overexpress PD-L1 due to 9p24.1 amplification, making HL exquisitely responsive to checkpoint inhibitors — a uniquely high response rate among lymphomas.
— Comprises ~20% of HL; worse prognosis than younger adults due to comorbidities, reduced tolerance of ABVD, and more aggressive biology (mixed cellularity, EBV+)
— Higher rate of bleomycin pulmonary toxicity (up to 25–30%, often fatal) — many oncologists drop bleomycin after 2 cycles or use AVD/A+AVD upfront
— Anthracycline cardiotoxicity risk amplified by baseline CAD, hypertension, prior cardiotoxic exposure
— Functional status assessment (ECOG, geriatric assessment) drives regimen choice
— Consider A+AVD (brentuximab + AVD) or AVD alone to avoid bleomycin
— Reduced-dose regimens (e.g., PVAG, BV-based regimens) in frail patients
— Aggressive supportive care: G-CSF, antimicrobial prophylaxis, careful fluid management
— Dacarbazine and vinblastine: dose adjust in severe renal dysfunction
— Bleomycin: renally cleared — reduce dose if CrCl <50 mL/min; contraindicated/avoided if CrCl <40
— Doxorubicin: minimal renal adjustment needed
— Monitor for tumor lysis (less common than NHL but possible with bulky disease) — IV hydration, allopurinol
— Doxorubicin and vinblastine: dose reduce based on bilirubin
— Bili 1.2–3 → 50% dose
— Bili 3–5 → 25% dose
— Bili >5 → hold
— Dacarbazine: hepatically metabolized; caution
— Distinguish hepatic dysfunction from HL liver involvement — biopsy if uncertain
Step 3 management: A 72-year-old with stage IIIB HL, EF 55%, CrCl 45, and DLCO 60% predicted — avoid bleomycin; use A+AVD with G-CSF primary prophylaxis, baseline echo, and proactive geriatric assessment for transitions of care.
Board pearl: Bleomycin lung toxicity in elderly HL is a leading cause of treatment-related mortality — switching to brentuximab-AVD has improved outcomes meaningfully.
— HL is among the most common malignancies during pregnancy (peaks overlap with reproductive years)
— First trimester: avoid chemotherapy; if disease is indolent/asymptomatic, defer treatment to 2nd trimester; if life-threatening, discuss termination
— 2nd/3rd trimester: ABVD is generally safe — no significant increase in fetal malformation when given after the first trimester; vinblastine monotherapy is an alternative bridge
— Avoid radiation to fields including the abdomen/pelvis; supradiaphragmatic RT with abdominal shielding may be considered in select cases after delivery
— Avoid PET/CT during pregnancy — use MRI (without gadolinium) and CXR with shielding for staging
— Plan delivery ≥3 weeks after last chemo dose to allow maternal/fetal marrow recovery
— Curable in >95% of early-stage cases; emphasis on minimizing late effects (growth, cardiac, breast cancer risk, fertility)
— Combined modality with reduced RT doses and field; response-adapted PET strategies
— Pediatric protocols (e.g., AHOD0431, AHOD1331) often use OEPA/COPDAC or ABVE-PC
— Men: sperm cryopreservation before chemo (ABVD has lower infertility risk than BEACOPP, but counsel all)
— Women: oocyte or embryo cryopreservation; ovarian tissue cryopreservation in select cases; GnRH agonist co-administration may offer some ovarian protection (debated)
— BEACOPP causes near-universal male infertility and high female infertility — disclose explicitly
Board pearl: ABVD is safe in 2nd/3rd-trimester pregnancy. Always document fertility counseling and consult reproductive endocrinology before starting chemotherapy, regardless of patient age — it is a recurrent Step 3 quality-of-care vignette.
— Febrile neutropenia — most common cause of inpatient admission during ABVD; manage with broad-spectrum antibiotics within 1 hour
— Bleomycin pulmonary toxicity — cough, dyspnea, bilateral interstitial infiltrates; HRCT shows reticular changes, often bibasilar; PFTs show falling DLCO. Treat: stop bleomycin, steroids, avoid supplemental O₂ when possible.
— Anthracycline cardiotoxicity — acute (arrhythmia, pericarditis) and chronic (dilated cardiomyopathy)
— Infusion reactions to brentuximab or rituximab
— Tumor lysis syndrome — uncommon in HL, but possible in bulky disease
— SVC syndrome — facial plethora, JVD, upper extremity edema; oncologic urgency
— Airway compromise / mediastinal mass syndrome — anesthesia danger
— Pericardial effusion / tamponade from mediastinal mass
— Spinal cord compression from paraspinal disease — rare but emergent
— Pancytopenia from marrow infiltration
— Secondary malignancies: breast cancer (after chest RT — especially in women treated before age 30), lung cancer, thyroid cancer, sarcomas, secondary AML/MDS (alkylators, etoposide)
— Premature CAD/MI — chest RT and anthracyclines
— Hypothyroidism after neck RT (up to 50% lifetime)
— Pulmonary fibrosis — bleomycin + RT
— Infertility, premature ovarian failure
— Avascular necrosis from steroids
— Functional/anatomic asplenia after splenic RT or splenectomy → vaccinate against encapsulated organisms; lifetime increased sepsis risk
— Herpes zoster reactivation
Step 3 management: A 35-year-old woman treated for HL with mantle-field RT at age 18 — start annual mammography + breast MRI at age 25 or 8 years post-RT, whichever later, and continue lifelong. Also screen TSH annually and assess cardiovascular risk aggressively.
— Febrile neutropenia (ANC <500, T ≥38.3°C once or ≥38°C × 1 hour)
— Suspected SVC syndrome with airway/neurologic compromise
— New significant dyspnea on bleomycin-containing regimens
— Tumor lysis syndrome
— Symptomatic pericardial effusion
— Spinal cord compression
— Severe nausea/vomiting or dehydration impairing oral intake
— Hemodynamic instability from sepsis or tamponade
— Respiratory failure (mediastinal mass airway compression, severe bleomycin toxicity)
— Tumor lysis with severe electrolyte derangements requiring CRRT
— Stridor or impending airway loss — call anesthesia and thoracic surgery before sedation
— Hematology/oncology — drives all systemic therapy decisions
— Radiation oncology — staging-dependent involvement, palliative emergencies (cord compression, SVC, airway)
— Cardiology — pre-anthracycline and survivorship surveillance
— Pulmonology — pre-bleomycin and any new respiratory symptoms
— Reproductive endocrinology — fertility, urgent before treatment
— Infectious disease — opportunistic infection workup
— Palliative care — symptom control and goals of care, even in curative-intent disease
CCS pearl: New HL patient admitted with febrile neutropenia post-ABVD cycle 2 — order: blood cultures ×2 (peripheral + line), urine culture, CXR, lactate, CBC, CMP, broad-spectrum antibiotics (cefepime or pip-tazo) within 1 hour, IV fluids, antipyretics, isolate per neutropenic precautions, hold next chemo dose, consult oncology. Do not delay antibiotics to obtain imaging.
Board pearl: In SVC syndrome from suspected but unconfirmed HL, obtain tissue diagnosis (mediastinoscopy or core biopsy) before starting steroids or RT when feasible — premature treatment can render biopsy nondiagnostic.
— Heterogeneous group; more common than HL overall
— More likely to involve extranodal sites (GI, skin, CNS, testis), Waldeyer's ring, mesenteric nodes
— Non-contiguous nodal spread
— Histology lacks RS cells; immunophenotype reflects B- or T-cell lineage (CD19, CD20, CD3, etc.)
— Treatment differs fundamentally — R-CHOP is standard for DLBCL, not ABVD
— Rapidly enlarging nodal or extranodal masses; B symptoms common
— Distinguished by CD20+, CD15−, CD30 variable; treat with R-CHOP ± RT
— Primary mediastinal B-cell lymphoma (PMBCL) — young women, bulky mediastinal mass; can mimic nodular sclerosing HL; treated with DA-EPOCH-R
Key distinction: Both classical HL and ALCL are CD30+ — distinguish by morphology, CD15 (positive in HL), and ALK (positive in many ALCL). Both respond to brentuximab vedotin, but management strategies differ — always confirm with hematopathology, not just immunohistochemistry headline.
Board pearl: Mediastinal mass + young woman + B symptoms = nodular sclerosing HL or PMBCL — biopsy and immunophenotype are mandatory before treatment.
— Infectious mononucleosis (EBV) — young adult, fevers, pharyngitis, splenomegaly, atypical lymphocytes, heterophile +; can mimic HL exactly. Diagnosis by serology; lymph node biopsy in mono can falsely suggest lymphoma if pathologist is uninformed.
— CMV, HIV acute seroconversion, toxoplasmosis, secondary syphilis
— Cat-scratch disease (Bartonella) — tender regional adenopathy after cat exposure
— Tuberculosis (scrofula) — chronic cervical adenopathy with caseation
— Atypical mycobacteria in children
— Histoplasmosis, coccidioidomycosis — endemic exposure history
— Systemic lupus erythematosus, rheumatoid arthritis — diffuse adenopathy with systemic features
— Sarcoidosis — bilateral hilar adenopathy with non-caseating granulomas; mimics mediastinal HL
— Kikuchi-Fujimoto disease — young Asian women, cervical adenopathy, fever; self-limited
— Castleman disease — HHV-8-associated, multicentric form mimics lymphoma
— IgG4-related disease
— Phenytoin, allopurinol, carbamazepine, lamotrigine (DRESS) — lymphadenopathy + rash + eosinophilia + organ involvement
— Localized to drainage of an infection or skin lesion; usually resolves in 2–4 weeks
— Hard, fixed, often unilateral — supraclavicular Virchow's node suggests GI/thoracic primary; consider age-appropriate workup
Key distinction: A young adult with fever, pharyngitis, posterior cervical adenopathy, and splenomegaly — get heterophile (Monospot) and EBV-specific serologies first before excisional biopsy. Mono can pathologically mimic HL and lead to misdiagnosis if biopsied prematurely.
Step 3 management: Persistent painless cervical adenopathy >4 weeks without infectious explanation in an adult → excisional biopsy. Do not loop through repeated antibiotic trials.
— End-of-treatment PET/CT to confirm complete metabolic response
— First 2 years: history, exam, CBC, CMP, LDH, TSH every 3–6 months; selective imaging for symptoms (avoid routine PET in remission)
— Years 3–5: visits every 6–12 months
— After 5 years: transition to survivorship clinic for late-effect monitoring; annual visits lifelong
— Breast cancer: women treated with chest RT before age 30 → annual mammogram + breast MRI starting 8 years post-RT or age 25–30, whichever is later; lifelong
— Cardiovascular: aggressive risk-factor control (BP, lipids, diabetes, smoking cessation); echocardiogram every 5–10 years in patients with chest RT or anthracycline exposure; stress testing or coronary calcium per cardiology in high-risk individuals
— Thyroid: annual TSH after neck RT; hypothyroidism extremely common, also nodule risk → palpate thyroid yearly
— Lung: smoking cessation (synergistic with bleomycin/RT for lung cancer); low-dose CT screening criteria are extrapolated in high-risk survivors
— Skin: annual skin exam (especially within RT field)
— Secondary leukemia/MDS: monitor CBC for unexplained cytopenias
— Fertility/menopause counseling; bone density screening if premature ovarian failure
— Annual inactivated influenza
— Pneumococcal series, meningococcal, Hib (especially if splenectomy or splenic RT)
— Avoid live vaccines for 3–6 months post-chemo; recombinant zoster preferred
— HPV vaccination through age 26 (consider through 45)
Step 3 management: A 30-year-old woman is 8 years out from stage IIA classical HL treated with ABVD + mantle RT — start annual mammography and breast MRI, annual TSH, baseline echocardiogram, lipid panel, and document cardiovascular risk factors. Refer to survivorship clinic.
— CBC with differential before each chemo cycle; hold or modify for ANC <1000 or platelets <100k (regimen-specific)
— CMP, LDH each cycle; pulmonary symptom check; cardiac symptom check
— PET-2 (interim PET) after 2 cycles — Deauville 1–3 favorable, 4–5 unfavorable → response-adapted plan
— End-of-treatment PET to confirm complete response
— New cough, dyspnea, decreased exercise tolerance (bleomycin toxicity)
— Chest pain, palpitations, orthopnea (cardiotoxicity)
— Numbness/tingling (vincristine/vinblastine, brentuximab neuropathy)
— Fever ≥38°C (neutropenic fever)
— New lumps or B symptoms (relapse)
— Exercise during chemo improves fatigue, preserves cardiac function; refer to oncology rehab/physical therapy
— Cancer-related fatigue: nonpharmacologic first (exercise, sleep hygiene); rule out anemia, hypothyroidism, depression
— Chemotherapy-induced peripheral neuropathy: duloxetine has best evidence; avoid further neurotoxic agents
— Nutritional support: registered dietitian referral if weight loss or nausea-limited intake
— Screen for depression and anxiety at each visit (PHQ-9, GAD-7)
— Young-adult oncology support groups
— Address financial toxicity early — social work referral
— Provide a survivorship care plan at end of treatment summarizing diagnosis, regimen, total doses (especially anthracycline and RT dose/fields), late-effect risks, and surveillance schedule for the PCP
CCS pearl: Order CBC, CMP, LDH before every cycle, PET after 2 cycles and at end of treatment, and echo + PFTs/DLCO at baseline and as clinically indicated. Don't forget the TSH post-treatment if the patient received neck/upper-mediastinal RT.
Board pearl: Survivorship care plans bridge oncologist → PCP and are a high-yield patient-safety expectation on Step 3.
— Must include infertility risk, secondary malignancy risk, cardiopulmonary toxicity, and treatment-related mortality
— Document patient understanding of fertility preservation options before initiating therapy — failing to offer this is a recurrent medicolegal failure point
— Patients aged 14–17 should be engaged with assent; parents/guardians provide consent in most US states unless emancipated
— Mature minor doctrine varies by state
— Pregnant patients must be counseled about maternal vs fetal risks; shared decision-making with maternal-fetal medicine and oncology
— Therapeutic abortion may be discussed in first-trimester aggressive disease but is patient's choice; document non-coercive counseling
— Cancer diagnosis is private health information — disclosure to family requires patient consent
— Workplace disclosure, FMLA paperwork, disability — patient-driven
— Handoff between inpatient oncology and PCP at discharge: medication reconciliation (especially steroids, antiemetics, prophylactic antimicrobials), clear follow-up date, and return precautions for febrile neutropenia
— Missed PET-2 timing or missed survivorship surveillance (mammogram after chest RT) — system-level errors that are board-favorite vignettes
— HL has many active trials; offer enrollment as standard ethical practice
— Equipoise must be genuine; informed consent processes must be free of coercion
— Even in highly curable disease, document code status and healthcare proxy, especially before high-risk procedures
— Cancer registries — required by law in all US states; clinicians report new diagnoses
— Two-provider verification of chemotherapy orders; weight-based and BSA-based dosing checks
— Never event: intrathecal vincristine (always fatal) — vincristine must be dispensed in a mini-bag, never a syringe
Step 3 management: A 19-year-old newly diagnosed with HL declines fertility preservation citing time pressure — pause, re-counsel with reproductive endocrinology consult, document shared decision-making; do not start chemo the same day unless oncologic urgency truly precludes the 1–2 week delay.
Board pearl: If you see "young adult + mediastinal mass + B symptoms + cervical/supraclavicular adenopathy + alcohol-induced pain or pruritus" — that is HL until proven otherwise; next step is excisional biopsy.
— "22-year-old with 6 weeks of painless cervical lymphadenopathy, night sweats, 5-kg weight loss, and a CXR showing mediastinal widening. Best next step?" → Excisional lymph node biopsy (not FNA, not antibiotics, not steroids).
— "Newly diagnosed HL. What test must be obtained before initiating ABVD?" → Baseline echocardiogram (LVEF) and PFTs with DLCO, plus HIV/HBV serologies, β-hCG, and fertility counseling.
— "Patient on cycle 3 of ABVD develops new dry cough and dyspnea, DLCO down 30%." → Stop bleomycin, evaluate for bleomycin pulmonary toxicity, consider steroids; avoid high-FiO₂ in future anesthesia.
— "PET-2 after 2 cycles ABVD shows Deauville 2." → Favorable interim response → continue planned therapy, possibly omit bleomycin in remaining cycles (RATHL strategy).
— "Patient relapses 18 months after completing ABVD." → Salvage chemo (e.g., ICE) followed by autologous SCT.
— "20-week pregnant patient newly diagnosed with stage IIB HL." → ABVD is appropriate; avoid RT; avoid PET; use MRI/CXR for staging; multidisciplinary care.
— "30-year-old woman treated with mantle RT at age 18 — when to start breast cancer screening?" → Annual mammogram + breast MRI 8 years post-RT or by age 25–30.
— "HL survivor 15 years post chest RT and ABVD presents with exertional chest pain." → Pursue ischemic workup aggressively; premature CAD is common.
— "Patient with large anterior mediastinal mass requires biopsy under GA." → Risk of airway/cardiovascular collapse on induction; involve anesthesia, consider awake biopsy or local.
— "Young patient with HL about to start ABVD." → Offer fertility preservation referral before chemo.
Step 3 management: When the question asks "next best step," default first to tissue diagnosis (excisional biopsy) before any treatment, then PET/CT staging, then fertility counseling + cardiopulmonary baseline before chemotherapy.
Hodgkin lymphoma is a curable, CD15+/CD30+ Reed-Sternberg B-cell malignancy of bimodal age distribution, diagnosed by excisional biopsy, staged with PET/CT (Lugano), and treated with risk-adapted ABVD or A+AVD ± involved-site radiation, with cure rates exceeding 80–90% but lifelong survivorship surveillance for cardiopulmonary toxicity, secondary malignancies, and endocrine late effects.
Board pearl: HL is the prototypical "curable cancer with toxic cure" — Step 3 questions test whether you balance cure today against decades of survivorship surveillance through appropriate pre-treatment workup, response-adapted therapy, and proactive late-effect screening.