Case #003

A firm rubbery node that has grown painlessly for six weeks, with fever, drenching sweats and weight loss behind it, is lymphoma until a biopsy says otherwise; infection and reactive nodes do not behave this way. Two features then separate Hodgkin from the non-Hodgkin lymphomas before any pathology arrives. Alcohol-induced pain in the node is uncommon but carries real weight when present, and the disease has spread contiguously from neck to mediastinum rather than in the scattered skip lesions typical of non-Hodgkin disease. Hodgkin lymphoma travels station by station, which is why staging it is meaningful. The immunophenotype settles it, and the negatives do the work: CD30 and CD15 positive is consistent with Reed-Sternberg cells, but CD45 negative is the discriminator, since that leukocyte common antigen is expressed by nearly every other lymphoma. The eosinophilia and raised ESR reflect the cytokine-rich reactive background those cells recruit, which is most of the visible tumour. Treatment is ABVD, four drugs given together: doxorubicin, bleomycin, vinblastine and dacarbazine. Escalated BEACOPP controls high-risk advanced disease better but is markedly more toxic, and at 24 that trade matters, because cure already exceeds 80 per cent and he has decades in which infertility, secondary leukaemia, bleomycin lung injury and doxorubicin cardiotoxicity would be felt. Interim PET after two cycles is what allows the intensity to be raised or lowered on evidence rather than guessed at the start.