Hodgkin Lymphoma Diagnosis
Hodgkin lymphoma is a type of cancer that develops when certain white blood cells known as lymphocytes become abnormal and grow uncontrollably in the lymphatic system. This large network of lymph nodes, vessels and organs is an important part of the body’s immune system.
In many cases, Hodgkin lymphoma is first suspected after noticeable symptoms develop, such as a persistent, usually painless swollen lymph node or unexplained fever, drenching night sweats or unintended weight loss. Because there is no routine screening test, an accurate diagnosis relies on a careful clinical evaluation followed by a biopsy that allows a pathologist to examine lymph node tissue and, if lymphoma is found, determine the precise type.
At Moffitt Cancer Center, patients with suspected or confirmed Hodgkin lymphoma can receive comprehensive evaluation through our Malignant Hematology Program, where our multispecialty team focuses on lymphoma and other blood and bone marrow cancers. Hematologist-oncologists, pathologists, radiologists, radiation oncologists and other specialists work together to establish the diagnosis, determine the stage and develop an individualized treatment plan based on the specific lymphoma type, extent of disease and other clinical factors.
Quick facts: diagnosing Hodgkin lymphoma
- Symptoms often prompt the evaluation. Hodgkin lymphoma is commonly investigated after a patient develops an enlarged lymph node, particularly in the neck, chest, underarm or groin, or symptoms such as unexplained fever, drenching night sweats, weight loss or fatigue. Because infections and other conditions can also cause lymph node enlargement, additional testing is needed to determine the cause.
- A biopsy confirms the diagnosis. An excisional biopsy, which removes an entire lymph node, is generally preferred because it provides enough tissue for a pathologist to examine both abnormal cells and the surrounding lymph node architecture. An incisional biopsy that removes part of a larger lymph node or mass may be appropriate in some situations.
- PET/CT helps establish the stage. After Hodgkin lymphoma is diagnosed, positron emission tomography/computed tomography (PET/CT) can show metabolically active lymphoma in lymph nodes and other parts of the body, helping the healthcare team determine the extent and stage of the disease.
- Specialized pathology distinguishes the lymphoma type. In classic Hodgkin lymphoma, pathologists evaluate tissue for characteristic Hodgkin and Reed-Sternberg cells and use immunohistochemistry to identify proteins such as CD30 and CD15. These findings help confirm the diagnosis and distinguish Hodgkin lymphoma from other lymphoid diseases.
How Hodgkin lymphoma is diagnosed
A Hodgkin lymphoma evaluation typically begins with a review of the patient’s symptoms and medical history and a physical examination, including an assessment of the enlarged lymph nodes and the liver and spleen. Blood tests and imaging may provide important clues, but neither can confirm Hodgkin lymphoma on its own. A tissue biopsy is needed for a definitive diagnosis.
For classic Hodgkin lymphoma, a hematopathologist examines the biopsy specimen for Hodgkin and Reed-Sternberg cells, which are large abnormal lymphocytes with distinctive features. The pathologist also evaluates the surrounding cells and tissue architecture and performs immunohistochemistry to identify proteins expressed by the abnormal cells. This combination of findings is important because cells resembling Reed-Sternberg cells can occur in other diseases.
Removing an entire lymph node through an excisional biopsy is generally preferred when feasible. Fine needle aspiration usually does not collect enough tissue to establish a Hodgkin lymphoma diagnosis, while a core needle biopsy obtains more tissue but may still be insufficient in some cases.
Laboratory and blood tests used to evaluate Hodgkin lymphoma
Lab testing cannot confirm Hodgkin lymphoma, but it provides information about the patient’s overall health, possible effects of the disease and factors that may influence treatment planning. The diagnostic process may include:
- Complete blood count (CBC) – A CBC measures red blood cells, white blood cells and platelets. Hodgkin lymphoma is sometimes associated with abnormalities such as anemia or changes in white blood cell counts, although these findings are not specific to lymphoma.
- Blood chemistry tests – Kidney and liver function testing can help identify organ abnormalities and establish baseline information that may be important when planning imaging studies or treatment.
- Erythrocyte sedimentation rate (ESR) – This blood test measures inflammation in the body. An elevated ESR is not specific to Hodgkin lymphoma, but it can provide additional clinical information and has historically been used as a prognostic factor in certain patients with early-stage disease.
- Infection testing – Testing for infections such as HIV or hepatitis B and C may be recommended based on the patient’s clinical situation and anticipated treatment because certain infections can affect lymphoma management.
- Lactate dehydrogenase (LDH) – LDH is an enzyme found in tissues throughout the body that can enter the bloodstream when cells are damaged or destroyed. An elevated LDH level is not specific to Hodgkin lymphoma, but it can provide additional information about disease activity and the patient’s overall clinical picture.
Unlike many solid tumors, Hodgkin lymphoma does not have a routinely used blood tumor marker, such as prostate-specific antigen (PSA) for prostate cancer or cancer antigen 125 (CA-125) for ovarian cancer. Blood-based circulating tumor DNA testing is being studied in Hodgkin lymphoma for disease classification and response assessment, but tissue evaluation remains fundamental to establishing the diagnosis.
Imaging tests used to diagnose and stage Hodgkin lymphoma
Imaging alone cannot determine whether an enlarged lymph node contains Hodgkin lymphoma. However, certain types of scans can identify suspicious lymph nodes or masses, guide biopsy in selected situations and, once lymphoma is confirmed, show where disease is present throughout the body.
Imaging tests that may be used for diagnosing and staging Hodgkin lymphoma include:
- PET/CT scan – PET/CT combines information about cellular activity with detailed anatomical images. Hodgkin lymphoma is typically metabolically active on PET, making PET/CT particularly useful for identifying involved areas, establishing the stage and providing a baseline for later assessment of treatment response.
- CT scan – Computed tomography provides detailed cross-sectional images that can show enlarged lymph nodes and involvement of organs in the neck, chest, abdomen and pelvis. CT may be incorporated into PET/CT or used separately in selected circumstances.
- MRI – Magnetic resonance imaging is not routinely needed for most patients with Hodgkin lymphoma, but it can provide detailed images when involvement of certain areas, such as the brain or spinal cord, is a concern. Because MRI does not use ionizing radiation, it may also have specific applications when radiation exposure needs to be minimized.
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Procedures and biopsies used to diagnose Hodgkin lymphoma
A biopsy is the definitive test for Hodgkin lymphoma because the diagnosis depends on microscopically examining the abnormal cells within their surrounding tissue. Whenever possible, the biopsy method is selected to obtain enough tissue for a hematopathologist to accurately classify the lymphoma while minimizing unnecessary procedures.
Depending on the location of the abnormal lymph node or mass, biopsy options for Hodgkin lymphoma may include:
- Excisional lymph node biopsy – A surgeon removes an entire enlarged lymph node through a small incision. A superficial lymph node can sometimes be removed using local anesthesia, but sedation or general anesthesia may be needed for a node located deeper in the body. This is generally the preferred biopsy method for Hodgkin lymphoma because it preserves the lymph node architecture and usually provides ample tissue for detailed pathological analysis.
- Incisional biopsy – If removing an entire lymph node or mass is not practical, a physician may surgically remove a portion of it. The goal is still to obtain enough intact tissue for an accurate diagnosis and lymphoma classification.
- Core needle biopsy – A physician uses a larger hollow needle to remove small cylinders, or cores, of tissue. Ultrasound or CT guidance may be used when the targeted lymph node is deep within the body. A core biopsy may be appropriate when surgical biopsy is difficult, although additional tissue may be necessary if the sample does not provide enough information for a definitive diagnosis.
- Fine needle aspiration – A physician uses a thin needle to withdraw cells and fluid from an abnormal lymph node. Although this procedure is minimally invasive, it usually does not collect enough tissue or preserve enough lymph node architecture to establish an initial Hodgkin lymphoma diagnosis and therefore is generally not the preferred biopsy approach.
A bone marrow aspiration and biopsy is not routinely used to establish the initial Hodgkin lymphoma diagnosis. It may be performed in selected patients after lymphoma has been confirmed if the healthcare team needs additional information about possible bone marrow involvement. During the procedure, local anesthetic is used to numb the area, usually at the back of the pelvic bone, before samples of liquid marrow and a small core of bone and marrow are collected.
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Once tissue has been collected, a hematopathologist evaluates both the appearance of the cells and the pattern in which they occur within the lymph node. Immunohistochemistry uses antibodies to identify specific proteins expressed by the abnormal cells and is particularly important when distinguishing Hodgkin lymphoma from other lymphomas and conditions that can produce similar-looking cells.
In classic Hodgkin lymphoma, Hodgkin and Reed-Sternberg cells characteristically express CD30 and frequently CD15, along with a broader immunophenotypic pattern that helps establish the diagnosis. Additional markers may be evaluated when needed to distinguish among lymphoma types or resolve an unusual pathological finding.
Other specialized testing may be appropriate in selected cases. For example, tissue can be evaluated for evidence of Epstein-Barr virus (EBV), which is associated with a subset of Hodgkin lymphomas. More extensive molecular testing may also be performed in specific clinical or research settings, although broad genomic profiling is not routinely needed to establish a diagnosis of classic Hodgkin lymphoma or plan initial treatment.
At Moffitt, hematopathology specialists have access to advanced diagnostic methods including immunohistochemistry, flow cytometry and molecular diagnostics. These capabilities can be particularly valuable when the initial findings are unusual or when a patient comes to Moffitt for confirmation of a diagnosis made elsewhere.
Frequently asked questions (FAQs) about Hodgkin lymphoma diagnosis
Questions often arise about what an enlarged lymph node means and why several different tests may be necessary. Understanding the purpose of each part of the diagnostic process can help clarify how the healthcare team reaches a definitive diagnosis.
What does a swollen lymph node mean for Hodgkin lymphoma?
A persistent, painless enlarged lymph node can be a sign of Hodgkin lymphoma, particularly when it occurs in the neck, above the collarbone, under an arm or in the groin. However, swollen lymph nodes are much more often caused by infections or other noncancerous conditions, so an enlarged lymph node alone does not necessarily indicate lymphoma.
Why is an excisional lymph node biopsy preferred over a needle biopsy for diagnosing Hodgkin lymphoma?
An excisional biopsy removes the entire lymph node, giving the pathologist enough tissue to examine abnormal cells as well as their relationship to the surrounding cells and lymph node architecture. A fine needle aspiration generally provides too little tissue for an initial Hodgkin lymphoma diagnosis, while a core needle biopsy may be sufficient in some circumstances but can sometimes require follow-up sampling.
What are Reed-Sternberg cells?
Reed-Sternberg cells are large, abnormal lymphocytes that are characteristic of classic Hodgkin lymphoma. When examining a tissue sample, a hematopathologist evaluates the appearance of the cells and the proteins they express to determine whether the findings support a diagnosis of classic Hodgkin lymphoma.
Can a blood test detect Hodgkin lymphoma?
No single blood test can confirm Hodgkin lymphoma. Blood testing can identify abnormalities in blood cell counts, measure inflammation, assess kidney and liver function and provide other information that helps the healthcare team evaluate the patient and plan care, but a tissue biopsy is needed for a definitive diagnosis.
Is a bone marrow biopsy always necessary for Hodgkin lymphoma?
No. Bone marrow aspiration and biopsy are not used to establish the initial Hodgkin lymphoma diagnosis and are not necessary for every patient. This test may be recommended in selected circumstances if additional evaluation of possible bone marrow involvement is needed.
What happens after Hodgkin lymphoma is confirmed?
The healthcare team determines the lymphoma’s stage, which describes the extent of disease in the body. PET/CT findings, the location and number of involved lymph node areas, involvement of organs outside the lymphatic system, symptoms and other clinical findings can all contribute to treatment planning.
The Moffitt Cancer Center difference for diagnosing Hodgkin lymphoma
Hodgkin lymphoma is relatively uncommon, and distinguishing it from other lymphoid diseases requires careful interpretation of the biopsy specimen. At Moffitt, our Malignant Hematology Program brings together specialists who focus on lymphoma and other blood and bone marrow cancers, allowing diagnostic findings to be evaluated within the context of the patient’s complete clinical picture.
Moffitt also has hematopathologists who specialize in diagnosing blood and lymphatic diseases as well as subspecialized radiologists and advanced imaging capabilities, including PET/CT. Working together, these experts can correlate pathology and imaging findings to confirm the lymphoma type, determine its extent and provide the information needed to develop an individualized treatment plan.
A patient who has already received a Hodgkin lymphoma diagnosis elsewhere can also come to Moffitt for a second opinion. Moffitt’s hematopathologists can review tissue from a previous biopsy to verify the diagnosis and lymphoma type, while subspecialized radiologists can review imaging to help clarify the extent of disease. When necessary, additional immunohistochemical or molecular studies can help resolve complex findings or further characterize the lymphoma.
As a National Cancer Institute (NCI)-designated Comprehensive Cancer Center, Moffitt combines specialized clinical care with lymphoma research and clinical trials, giving patients access to expertise across the continuum from diagnosis through treatment.
To learn more about diagnosing Hodgkin lymphoma, you can request an appointment with a specialist in Moffitt’s Malignant Hematology Program by calling 1-888-663-3488 or submitting a new patient registration form online. We do not require referrals.
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