Hodgkin LymphomaClinical Notes for Practicing Oncologists
From classification and IPS risk stratification through early-stage combined modality therapy, advanced-stage ABVD vs BrECADD with PET-adapted strategies, and R/R management with brentuximab vedotin, checkpoint inhibitors, and transplant.
HD21: BrECADD 4-yr PFS
~94.3%
vs ~90.9% eBEACOPP
Nivolumab R/R HL ORR
~65-70%
Post-ASCT, post-BV
Nodular Sclerosis
~70%
Most common subtype
NLPHL
~5%
CD20+, indolent course
How is Hodgkin lymphoma classified, and how do IPS and early-stage risk scores guide the treatment conversation?
| Subtype | Frequency | Key Features |
|---|---|---|
| Classical HL — Nodular Sclerosis | ~70% | Most common subtype; mediastinal mass common; Reed-Sternberg cells in a fibrous/nodular background |
| Classical HL — Mixed Cellularity | ~20-25% | Associated with HIV and EBV; more often advanced stage/B symptoms at diagnosis |
| Classical HL — Lymphocyte-Rich | ~5% | Favourable prognosis; often early stage |
| Classical HL — Lymphocyte-Depleted | Rare | Associated with HIV; older patients; more aggressive course |
| Nodular Lymphocyte-Predominant HL (NLPHL) | ~5% | CD20+ LP cells (not Reed-Sternberg); indolent course; managed differently — often with rituximab-containing regimens; distinct entity from classical HL |
Treatment approach diverges fundamentally between early-stage (I-II) and advanced-stage (III-IV) HL. Within early-stage disease, further stratification into "favourable" and "unfavourable" risk groups (per GHSG/EORTC criteria) determines treatment intensity.
Early-Stage Unfavourable Risk Factors (GHSG)
- Large mediastinal mass (>1/3 max thoracic diameter)
- Extranodal extension
- Elevated ESR (>50 without B symptoms, >30 with B symptoms)
- ≥3 nodal areas involved
International Prognostic Score (IPS) — 7 factors
- Albumin <40 g/L
- Haemoglobin <105 g/L
- Male sex
- Age ≥45 years
- Stage IV disease
- Leukocytosis (WBC ≥15 × 10⁹/L)
- Lymphocytopenia (<8% of WBC or <0.6 × 10⁹/L)
How IPS is used clinically
Viva Questions & Clinical Pearls
Q: How does nodular lymphocyte-predominant HL differ biologically from classical HL?
A: NLPHL is characterised by CD20-positive lymphocyte-predominant (LP) cells rather than Reed-Sternberg cells, follows a more indolent course with late relapses, and is treated with approaches incorporating rituximab given CD20 expression, distinct from classical HL.
Q: Name three factors used to classify early-stage HL as "unfavourable" per GHSG criteria.
A: Any of: large mediastinal mass >1/3 thoracic diameter, extranodal extension, elevated ESR, or ≥3 nodal areas involved.
Clinical Decision Support
Pair these clinical notes with our validated calculators for a complete decision workflow.
ECOG Performance Status
Functional status assessment
International Prognostic Score (IPS-7)
Advanced HL risk stratification
International Prognostic Score (IPS)
Classic 7-factor advanced HL score
Early-Stage HL Risk Classification
Favourable vs unfavourable early-stage risk
Charlson Comorbidity Index
Comorbidity-adjusted prognosis
Clinical reference only. These notes are intended to support, not replace, clinical judgment. Treatment decisions should be individualised based on patient-specific factors, local protocols, and multidisciplinary team input. Always apply clinical judgment and consult local institutional guidelines where applicable.