Involvement In Hodgkin Lymphoma Research Articles

Classic Hodgkin Lymphoma presenting as ANA positive chronic papular urticaria like skin lesions – A case report

The skin acts as a natural barrier between internal organs and the external environment. Many haematological neoplasms occur in the skin as a primary malignant transformation, as secondary involvement, or as paraneoplastic cutaneous manifestations. Malignant skin involvement in Hodgkin lymphoma is uncommon while paraneoplastic cutaneous involvement can occur as eczema, pruritus, erythema nodosum, and icthyosiform atrophy.1This case report describes a 25-year-old woman with a persistent pruritic rash, who was treated as chronic papular urticaria, before finally being diagnosed as Classic Hodgkin Lymphoma. This highlights the challenge of early diagnosis of cutaneous manifestations of Hodgkin lymphoma and the importance of considering malignancies in refractory dermatological conditions. This case also suggests a potential role for ANA patterns as diagnostic markers in Hodgkin lymphoma.

B-Mode Ultrasound and Contrast-Enhanced Ultrasound for the Detection of Splenic Involvement in Hodgkin Lymphoma: A Retrospective Analysis of 112 Patients.

To assess splenic involvement using B-mode ultrasound (US) and contrast-enhanced ultrasound (CEUS) compared with standard imaging with contrast-enhanced computerized tomography (CT) / 18-fluorodeoxyglucose positron-emission tomography (PET-CT) in patients with Hodgkin lymphoma. Imaging data from 112 patients from 12/2003 to 10/2022 with histologically confirmed Hodgkin lymphoma during staging or relapse were analyzed for splenic lymphoma involvement. In all patients, standard imaging (CT/PET-CT), along with B-mode US and CEUS examinations, was performed. Evidence of focal splenic lesions (FSLs) found by imaging procedures was suggestive of splenic involvement. Follow-up imaging was performed in each patient after treatment, and treatment response indicated definitive splenic involvement. 40 patients (35.7%) were identified by imaging modalities as having splenic involvement, which was confirmed by response during follow-up. Standard CT/PET-CT imaging detected splenic involvement in 36/112 patients (32.1%). FSLs were detected with B-mode US in 38 patients (33.9%) and CEUS in 36 patients (32.1%). The sensitivity of standard imaging, B-mode US, and CEUS was 90%, 95%, and 90%, respectively. B-mode US examination is a diagnostic method used in addition to standard imaging for the detection of splenic involvement in Hodgkin lymphoma. CEUS does not provide additional benefit compared to B-mode US and the standard reference procedure.

Challenges Encountered and Pattern-Based Analysis of Bone Marrow Biopsy in Lymphomas: An Institutional Experience.

Objective The evaluation of bone marrow (BM) status is an integral part of the initial workup of patients diagnosed with lymphoma as it plays an important role in staging and predicting prognosis in these patients. This article determines the incidence and pattern of BM involvement in lymphoma cases and distinguishes benign from malignant lymphoid aggregates in BM biopsies. Materials and Methods The study group included 121 cases of Hodgkin and non-Hodgkin lymphomas for which BM biopsies were performed, fixed in acetic acid-zinc formalin solution, decalcified using 10% formic acid, and subjected to hematoxylin and eosin and immunohistochemistry. Results The overall incidence of BM biopsy involvement in our study was 31.4% (37/118), including 34.7% (35/101) in cases of B cell lymphomas, 25% (2/8) in cases of T cell lymphomas, and no involvement in Hodgkin lymphoma. The predominant histological pattern of BM involvement was diffused (14/37; 37.8%), followed by interstitial (10/37; 27.1%). Five cases revealed benign nonparatrabecular lymphoid aggregates which could be confused with lymphomatous involvement, especially in low grade lymphomas. Conclusion A careful examination of the BM biopsies along with clinical history, peripheral blood examination, flow cytometry, and immunohistochemistry will help in arriving at the correct diagnosis.

Cutaneous Involvement in Hodgkin Lymphoma: A Rare Case Report.

Cutaneous Involvement in Hodgkin Lymphoma: A Rare Case Report.

Meningeal Relapse of Nodular Lymphocyte Predominant Hodgkin Lymphoma Transformed to T-Cell/Histiocyte-Rich Large B-Cell Lymphoma: A Case Report

Central nervous system involvement in Hodgkin lymphoma is extremely rare, especially in nodular lymphocyte predominant Hodgkin lymphoma (NLPHL), which usually carries a favorable prognosis. Here we report a case of a young patient with NLPHL, who developed a progressive and fatal neurological deterioration requiring a very extensive work-up including two biopsies to obtain the diagnosis of T-cell/histiocyte-rich large B-cell lymphoma like transformation. This report, which includes post-mortem analysis, highlights the correlations between clinical, radiological, and biological data but also the difficulties encountered in reaching the correct diagnosis.

Liver involvement in pediatric Hodgkin lymphoma: A systematic review by an international collaboration on Staging Evaluation and Response Criteria Harmonization (SEARCH) for Children, Adolescent, and Young Adult Hodgkin Lymphoma (CAYAHL).

Hepatic involvement in Hodgkin lymphoma (HL) is uncommon (∼5% of patients) but always implies stage IV disease. Accurate staging is mandatory for making the appropriate risk assignment and treatment decisions. The Staging Evaluation and Response Criteria Harmonization for Childhood, Adolescent and Young Adult Hodgkin Lymphoma (SEARCH for CAYAHL) international working group conducted a systematic literature review of liver involvement in HL patients with the aim to propose a universally acceptable definition for liver involvement in pediatric HL. Thirty-three articles describing 6985 pediatric and adult HL patients were reviewed, of which 539 (7.7%) mentioned liver involvement. The literature did not provide a uniform definition of hepatic involvement and we propose consensus criteria derived from the EuroNet and Children's Oncology Group protocols, where liver involvement is defined as any hepatic lesion on computed tomography scan that correlates with 18 F-FDG uptake greater than background liver. A clear definition of liver lesions is necessary to consistently identify liver involvement and compare its impact on outcomes among protocols worldwide.

Mummified Cells are a Common Finding in Cutaneous Hodgkin Lymphoma and Can Be Used as a Diagnostic Clue.

Specific cutaneous involvement in Hodgkin lymphoma is rare. In cutaneous lesions, the diagnosis is usually based on the recognition of diagnostic Reed-Sternberg cells and its variants. In nodal Hodgkin lymphoma, so-called mummified cells (cells with condensed cytoplasm and pyknotic eosinophilic or basophilic nuclei) are often seen. They are sometimes conspicuous and easy to recognize, thus serving as a clue to the diagnosis. Our objective was to study cases of cutaneous Hodgkin lymphoma to identify the occurrence of mummified cells. We studied 12 patients (4 women and 8 men; age range 23-80 years). In 6 patients, cutaneous and extracutaneous disease was identified almost simultaneously; in 4 patients, lymph node disease preceded cutaneous involvement; and in the remaining 2 patients, the skin lesions were the presenting sign, whereas lymph node involvement occurred later. Histopathological, immunohistochemical, and molecular-genetic studies, including rearrangements for TCR, IgH genes, and PCR for EBV, were performed. Cutaneous biopsy specimens revealed either a multinodular or diffuse infiltrate, included small lymphocytes, eosinophils, plasma cells, and macrophages, but in all cases, diagnostic Reed-Sternberg cells and its variants were identified. Mummified cells were detected in 9 cases, either as occasional scattered mummified cells often requiring a search (6 cases) or being conspicuous, grouped and therefore easily identified (3 cases). Immunohistochemically, in all 7 cases studied, mummified cells were positive for both CD30 and CD15. It is concluded that mummified cells are encountered in a majority of cases of cutaneous Hodgkin lymphoma.

Definition of cortical bone involvement in the staging of newly diagnosed pediatric Hodgkin lymphoma: A report from the International Working Group on Staging Evaluation and Response Criteria Harmonization (SEARCH).

The International Working Group on Staging Evaluation and Response Criteria Harmonization (SEARCH) seeks to provide a universally acceptable definition of cortical bone involvement in the staging of newly diagnosed pediatric Hodgkin lymphoma. A comprehensive literature search was performed using PubMed and Google Scholar with the search terms "Hodgkin lymphoma," "osseous lesions," "bony involvement," and "pediatric." Publications reviewed included case reports, retrospective analyses, and literature reviews. Each was evaluated for study design, number of participants, median age and age range at diagnosis, percentage of pediatric patients, criteria of interest definition, diagnostic tools, study objectives, and level of evidence. The final definition was based on the available data and consensus of the SEARCH working group. Twenty-five papers specifically addressing cortical bone involvement in Hodgkin lymphoma met the inclusion criteria. Eighteen papers were case reports with literature reviews; the remainder were observational cohort studies. Of these, 14 included pediatric patients (aged 0-21 years). The criteria for cortical bone involvement were not clearly defined in any paper, often varied within a study, and were inconsistent between publications. The SEARCH group for Childhood, Adolescent, and Young Adult Hodgkin Lymphoma (CAYAHL) proposes the following criteria as defining cortical bone involvement: anycorticalbone biopsy-proven lesion; a positive bony window lesion on computer tomography (CT), with an FDG-PET positive correlate in a patient with biopsy-proven Hodgkin lymphoma,if there is no other typical skeletal pathology;auspiciousskeletallesions on FDG-PET or magnetic resonance imaging should be confirmed by CT or Tc-99m scan to distinguish cortical lesions from bone marrow involvement. Nodal masses that extend into bone with bony destruction are considered extranodal extension or "E" lesions and do not represent metastatic or stage IV disease.

The Role of PET/CT to Detect Bone Marrow Involvement in Hodgkin Lymphoma

The Role of PET/CT to Detect Bone Marrow Involvement in Hodgkin Lymphoma

Value of bone marrow biopsy in Hodgkin lymphoma patients staged by FDG PET: results from the German Hodgkin Study Group trials HD16, HD17, and HD18

BackgroundBone marrow (BM) involvement defines advanced-stage Hodgkin lymphoma and thus has impact on the assignment to treatment. Our aim was to evaluate whether the established BM biopsy may be omitted in patients if 18F-fluorodeoxyglucose positron emission tomography (PET) scanning is carried out during staging. Patients and methodsOur analysis set consisted of 832 Hodgkin lymphoma patients from the German Hodgkin Study Group trials HD16, HD17, and HD18 who underwent both PET scanning and BM biopsy before treatment. All PET studies were centrally reviewed and BM was categorized as showing focal involvement or not. ResultsTaking BM biopsy as reference standard, baseline PET showed a negative predictive value of 99.9% [95% confidence interval (CI) 99.2% to 100%] with true-negative results in 702 of 703 cases. The sensitivity of PET for detecting BM involvement was 95.0% (95% CI 75.1% to 99.9%) as it could identify 19 out of 20 patients with positive BM biopsy. Moreover, PET found 110 additional subjects with focal BM lesions who would have been considered negative by biopsy. ConclusionsWhen compared with BM biopsy, PET was able to detect focal BM lesions in a large number of additional patients. This indicates that conventional BM biopsy may substantially underestimate the actual incidence of BM involvement. Given the high negative predictive value, baseline PET scanning can safely be used to exclude BM involvement in Hodgkin lymphoma. BM biopsy should be considered only in such patients in whom PET-detected lesions lead to a change of treatment protocol. Registered trialsThe trials included in this analysis were registered at ClinicalTrials.gov: HD16—NCT00736320, HD17—NCT01356680, and HD18—NCT00515554.

The role of PET/CT to detect bone marrow involvement in Hodgkin lymphoma

The role of PET/CT to detect bone marrow involvement in Hodgkin lymphoma

Outcome of Patients With Early-Stage Infradiaphragmatic Hodgkin Lymphoma: A Comprehensive Analysis From the German Hodgkin Study Group.

Purpose The prognostic effect of isolated infradiaphragmatic involvement in Hodgkin lymphoma (HL) is controversial, and there are little data about patients treated with current therapies. Therefore, we performed a risk factor analysis to focus on isolated nodal infradiaphragmatic disease in patients treated within the German Hodgkin Study Group trials HD13 (clinical trial information: ISRCTN63474366) and HD14 (clinical trial information: ISRCTN04761296) for early-stage HL. Patients and Methods Characteristics and outcomes of patients who had infradiaphragmatic HL were compared with patients who had supradiaphragmatic disease. Progression-free survival (PFS) and overall survival (OS) were estimated according to Kaplan-Meier methods and were compared between groups using the log-rank test and Cox proportional hazards regression, which was also applied for multivariable analyses that adjusted for relevant baseline characteristics. Results Of 2,903 qualified patients, 223 (7.7%) were diagnosed with isolated nodal infradiaphragmatic disease. In general, these patients were older, had a poorer performance status, were more often male, and had the nodular sclerosis subtype less often than those with supradiaphragmatic disease. After a median follow-up time of 51 months, PFS and OS were significantly worse in patients with infradiaphragmatic disease (5-year PFS and OS, 80.1% and 91.5% v 91.2% and 97.6% in patients with supradiaphragmatic disease; each P < .001). In multivariable analyses, infradiaphragmatic HL remained a significant risk factor in terms of PFS (hazard ratio [HR], 1.5; 95% CI, 1.04 to 2.2; P = .03) and OS (HR, 2.0; 95% CI, 1.2 to 3.5; P = .01). However, inferior PFS and OS could not be observed among those patients treated with the more intensive chemotherapy (two cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine [ABVD] in HD13, and two cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone [BEACOPPescalated] plus two cycles of ABVD in HD14; all patients received 30 Gy of involved-field radiotherapy). Conclusion Early-stage HL that presents with infradiaphragmatic disease only represents a distinct patient group with an inferior outcome. However, this adverse outcome can be outweighed by appropriate combined modality treatment.

18F-FDG PET Response of Skeletal (Bone Marrow and Bone) Involvement After Induction Chemotherapy in Pediatric Hodgkin Lymphoma: Are Specific Response Criteria Required?

To determine whether the current 18F-FDG PET response criterion for skeletal involvement in Hodgkin lymphoma (HL) is suitable, we performed a systematic evaluation of the different types of skeletal involvement and their response on PET after 2 cycles of chemotherapy (PET-2). A secondary objective was to observe the influence of the initial uptake intensity (measured as qPET) and initial metabolic tumor volume (MTV) of skeletal lesions on the PET-2 response. Methods: The initial PET scans of 1,068 pediatric HL patients from the EuroNet-PHL-C1 trial were evaluated for skeletal involvement by central review. Three types of skeletal lesions were distinguished: PET-only lesions (those detected on PET only), bone marrow (BM) lesions (as confirmed by MRI or BM biopsy), and bone lesions. qPET and MTV were calculated for each skeletal lesion. All PET-2 scans were assessed for residual tumor activity. The rates of complete metabolic response for skeletal and nodal involvement on PET-2 were compared. Results: Of the 1,068 patients, 139 (13%) showed skeletal involvement (44 PET-only, 32 BM, and 63 bone). Of the 139 patients with skeletal involvement, 101 (73%) became PET-2-negative in the skeleton and 94 (68%) became PET-2-negative in the lymph nodes. The highest number of PET-2-negative scans in the skeleton was 42 (95%) in the 44 PET-only patients, followed by 22 skeletal lesions (69%) in the 32 BM patients and 37 (59%) in the 63 bone patients. Lesions that became PET-2-negative showed a lower initial median qPET (2.74) and MTV (2 cm3) than lesions that remained PET-2-positive (3.84 and 7 cm3, respectively). Conclusion: In this study with pediatric HL patients, the complete response rate for skeletal involvement on PET-2 was similar to that for nodal involvement. Bone flare seemed to be irrelevant. Overall, the current skeletal PET response criterion-comparison with the local skeletal background-is well suited. The initial qPET and MTV of skeletal lesions were predictive of the PET-2 result. Higher values for both parameters were associated with a worse PET-2 response.

Comparison and Evaluation of Different Treatment Plans with IFRT Field and 6 and 18 MV Energies in Hodgkin's Lymphoma Involvement Neck and Mediastinum.

Radiotherapy with large mantle field is an effective technique in increasing the risk of secondary cancers among HL (Hodgkin Lymphoma) patients; therefore, it is essential to choose an effective treatment field including the least medical conditions in radiotherapy. The present study aimed to plan separate fields for neck and mediastinum using various energies, to compare dose distribution with MLC and to block field formation. In this study, 3D conformal treatments, Siemens Oncor accelerator equipped with multi-leaf collimator (MLC) were performed to create anterior-posterior fields. CT-scan data of 18 female patients with neck and mediastinal involvement was imported in TIGRT treatment planning system, and then treatment plans were introduced. Using treatment plan 1, photon 6 MV in neck weighting 1 from interior, 0.5 from posterior, photon 18MV in mediastinum weighting 1 from interior and 0.5 from posterior, it was shown that regarding the common treatment plan used with photon 6 MV, mean dose delivered to breast, lung, esophagus and larynx reduced 6, 7, 41 and 10 percent, respectively and uniformity index improved by 10 percent. Using block compared to MLC in all treatment plans offered improved average dose in all organs under study. To protect breast and lung while using MLC and block in the first treatment plan seemed to be more appropriate; however, using blocks in comparison to MLC increased delivered mean dose in all organs under study. Using separate fields with Pb blocks, though, showed smaller increase.

Prognostic Significance of Bone Marrow Involvement in Hodgkin Lymphoma

Background:The utility of bone marrow biopsy (BMB) in patients with Hodgkin lymphoma (HL) has been a controversial topic. Clinical stage 4 (CS4) has been shown to be an independent poor prognostic marker and is also included in the International Prognostic Scoring (IPS) index for predicting both progression-free survival (PFS) and overall survival (OS). The current guidelines still recommend performing a BMB in patients with stage IIB (with unfavorable risk factors), III and IV HL, mainly for staging purposes. Though bone marrow involvement (BMI) upstages the HL to stage IV, the prognostic significance of BMI remains unclear. The study was aimed to determine the prognostic significance of BMI in underserved patients with HL and to determine the prognostic importance of other blood parameters.Methods:The study was conducted at John H. Stroger Hospital of Cook County, an inner city tertiary care hospital providing care to the underserved population of Chicago. Charts of 241 patients diagnosed with HL were screened from tumor registry. Patients with incomplete charts were not included in the study. Socio-demographic, clinical and pathologic factors were recorded at the time of diagnosis. For comparative purpose, CS4 disease did not include patients with BMI. Kaplan-Meier and bivariate analyses were performed. Cox regression analyses were conducted to explore predictors of OS and PFS. Hazard ratios (HR) with 95% confidence intervals (CI) were obtained.Results:The study included 192 patients of which 41% were Afro-Americans, 34% were Hispanics and 21% were Caucasians. Median age was 34 years with 25.5% patients being older than 45 years and 68% patients being women. Seventeen percent patients were positive for HIV. Nodular sclerosis was the most common histologic subtype (55%), bulky disease was recorded in 19% patients and 61.5% patients had B-symptoms. CS4 disease was seen in 12% patients while 28% patients were stage III, 47% were stage II and 13% were stage I. Single-site BMB was done in 96% patients. BMB was positive for involvement with HL in 19% patients (n=37). Out of these 37 patients, 84% (n=31) had advanced stage (III & IV) HL. BMI was seen in 5% patients with early-stage HL (stages I-II) and 41% patients with advanced-stage HL. Median IPS score was 2 (range 0-6). Median values for clinical factors were: hemoglobin-11.8 g/dL, platelets 314.5 x103/uL, leukocytes 8.3 x103/uL, neutrophils 6x103/uL, lymphocytes 1.2 x103/uL and albumin 3.7 g/dL. Mean OS was 143 months (95% CI 126-160) with 5-year OS of 89%. Significant correlates of OS included: age 45 years or older (HR 2.83, 95%CI 1.25-6.43, P =0.013), HIV (HR 2.80, 95%CI 1.19-6.61, P =0.019), nodular sclerosistype (HR 0.29, 95%CI 0.12-0.71, P =0.006), CS4 disease (HR 3.05, 95%CI 1.20-7.77, P =0.019), BM positive for involvement with HL (HR 5.76, 95%CI 2.56-12.98, P <0.001), IPS score (HR 1.57, 95%CI 1.20-2.06, P =0.001), hemoglobin <10.5 g/dL (HR 3.57, 95%CI 1.56-8.19, P =0.003), platelets <150 x103/uL (HR 5.32, 95%CI 2.19-12.96, P <0.001) and lymphocytes <0.6 x103/uL (HR 2.97, 95%CI 1.21-7.28, P =0.017). Gender, albumin level, leukocytosis (>15 x103/uL) and relative lymphopenia (<8%) did not have a significant association with OS. When adjusted for CS4 disease, BMI remained an independent predictor of OS (HR 2.17, 95%CI 1.04-4.55, P =0.039). Mean PFS was 105 months (95% CI 97-117) with 5-year PFS of 78%. BMI (HR 2.38, 95%CI 1.21-4.67, P =0.012), albumin level (HR 0.71, 95%CI 0.53-0.94, P =0.017) and albumin-globulin ratio (HR 0.41, 95%CI 0.18-0.93, P =0.032) predicted PFS. None of the other factors had a significant association with PFS. BMI had inverse association with OS (mean OS 97.5 months vs. 164 months, P <0.001; 5-year OS 70% vs. 93.5%, P<0.001) and PFS (mean PFS 74 months vs. 112 months, P = 0.004; 5-year PFS 65% vs. 81%, P=0.030).Conclusion:BMI in HL indicates disseminated disease. Our study shows that BMI in patients with HL has a significant inverse relation with OS and PFS, independent of stage. Our data indicates that in patients with HL important prognostic information can be achieved by demonstrating BMI and it should be considered for inclusion in the IPS score. The rate of BMI is higher in our cohort, for both early and advanced stage HL, when compared with literature and maybe a limitation of our retrospective study. However our results still warrant that long term prospective studies should be designed to explore the prognostic significance of BMI. DisclosuresNo relevant conflicts of interest to declare.

Pulmonary alterations in Hodgkin lymphoma

Most of Hodgkin lymphoma patients survive due to combined chemo/radiotherapy. Improved survival brings long-term side effects to the front, which may determine the patients' subsequent quality of life and expected lifetime. This manuscript aims to analyze lung manifestations of Hodgkin lymphoma and treatment related pulmonary complications, demonstrated with own cases. The lung involvement in Hodgkin lymphoma is often secondary, and primary pulmonary involvement is very rare. The authors found 8-12% of lung involvement among their patients. Side effects of treatment consist of pulmonary infections in conjuction with immunosuppression, while on the other hand bleomycin and chest irradiation as part of current standard of care induced pneumonitis and fibrosis are reported. The pulmonary involvement in Hodgkin lymphoma may cause differential diagnostic difficulty. Lung involvement could modify stage and consequently treatment, and the development of side effects might determine later quality of life and expected lifetime. Therefore, identification of lung involvement is crucial.

FDG-PET in lymphoma

FDG-PET has changed lymphoma management at staging and for response assessment due to its capability to improve disease characterization and treatment selection. New recommendations have been made by the ICML working group in 2014. FDG-PET is now recommended for staging in the vast majority of lymphoma since almost all types of lymphoma are FDG-avid. It has been shown recently that FDG-PET due to its high sensitivity for bone marrow involvement in Hodgkin lymphoma can obviate the bone marrow biopsy. In addition FDG PET may be used to target biopsy and based on the local SUVmax to detect transformation. For response assessment after treatment or during chemotherapy the HIP2007 criteria have now been replaced by the Deauville criteria using a 5-point scale. Initially proposed for the evalaution of interim PET these criteria are now extended for end treatment evaluation. The residual activity observed after treatment is scored against different levels of backgroung i.e: 1.no uptake, 2. uptake uptake ≤ mediastinum but ≤ liver, 3. uptake > mediastinum, 4. uptake moderately higher than liver, 5. uptake markedly higher than liver and/or new lesions. A score 4 has been chosen as the threshold for positivity both at interim and end treatment. The value of this choice has been demonstrated in validation studies. Using these criteria FDG PET has demonstrated its prognostic value early in the course of the treatment or at end treatment in Hodgkin lymphoma, Diffuse large B cell lymphoma and Follicular Lymphoma. A tailored therapy based on interim PET is under study in many ongoing trials but at the present time it is not recommendend to change therapy on the basis of the results of an interim FDG-PET. Quantitative analysis of metabolic volume at staging or Δ SUVmax response assessment and their prognostic values and various trends in the future will be discussed.

Diffusion‐weighted MRI compared to FDG PET‐CT in the staging and response assessment of Hodgkin lymphoma

A 29-year-old man presented with a large right supraclavicular mass, weight loss and night sweats. A diagnosis of stage 4B nodular sclerosis Hodgkin lymphoma was made. F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG PET-CT) and whole-body magnetic resonance imaging with diffusion-weighting (DW-MRI) were performed before and after escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) chemotherapy. The pre-treatment FDG PET-CT (top left) demonstrated extensive nodal disease above and below the diaphragm, including the right supraclavicular fossa. Post-treatment FDG PET-CT (top right) showed physiological FDG uptake only. The pre-treatment DW-MRI (bottom left) showed extensive nodal disease in the same distribution as the pre-treatment FDG PET-CT. DW-MRI revealed a bone lesion (arrow) not diagnosed on the FDG PET-CT, confirmed on the source axial images. Post-treatment morphological MRI (not shown) demonstrated residual nodal disease in the right lower neck and upper abdomen but this was all inactive on DW-MRI (bottom right). FDG PET-CT and DW-MRI independently established a complete response. FDG PET-CT is a recommended imaging method for determining disease activity in residual masses after treatment for Hodgkin lymphoma. There is an increasing body of evidence to support its use in the assessment of early response to chemotherapy and it has been established as reliable for staging Hodgkin lymphoma. However, it involves radiation exposure for both the CT and FDG components of the test. MRI does not use ionizing radiation and offers higher soft tissue contrast compared with CT. The reduction of exposure to ionizing radiation is of particular significance in patients with lymphoma who have a high chance of cure, especially in younger patients. Water diffusion whole body MRI also allows functional assessment of lymphoma response. DW-MRI relies on measuring the random motion of water molecules in tissues. Many malignant tumours, including lymphomas, are more cellular than benign/normal tissue and therefore show more restricted water diffusion, appearing bright on normal images or dark on inverted images such as those shown above. The disadvantages of MRI include the exclusion of patients with pacemakers, implantable defibrillators or significant claustrophobia. In addition, bulk tissue movements and physiological water motion can sometimes affect DW-MRI image quality. In general, FDG PET-CT is accurate for diagnosis of marrow and bone involvement in Hodgkin lymphoma but, in this case, DW-MRI revealed bone disease not diagnosed on FDG PETCT. Further research is needed to compare the relative merits of DW whole-body MRI with FDG PET-CT in the staging and monitoring of lymphoma.

Neurological presentation of Hodgkin lymphoma in the Italian Association of Pediatric Hematology and Oncology LH-2004 protocol

Neurological symptoms can represent the first clinical manifestation of central nervous system (CNS) involvement in Hodgkin lymphoma (HL). Because of its rarity, it is often misunderstood for other pathological processes. We report two cases of pediatric CNS HL, presenting with neurological symptoms at diagnosis. We have also reviewed the literature and few cases are reported, only 19 of them concerning children. In both primary and metastatic CNS HL, all patients complained of neurological symptoms at presentation. Despite it being uncommon, physicians should regard the possibility of CNS localization in all children affected by HL presenting with neurological signs and/or symptoms.

Bilateral breast involvement of Hodgkin lymphoma revealed by FDG PET/CT

The involvement of breast tissue with Hodgkin's lymphoma (HL) has been reported in very few cases up to date. We report a 33-year-old woman who had been treated and followed up with nodular sclerosing HL for 7 years, and admitted with recurrent disease. The fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) images revealed disseminated disease with the involvement of bilateral breast tissues showing FDG uptake. In this case, the breast involvement of HL was confirmed by histopathological results.