Clinical features

• Presentation commonly with painless 'rubbery' supradiaphragmatic lymph node enlargement: frequently cervical gland(s).

• Initial mode of spread occurs predictably to contiguous nodal chains.

• Often involves supraclavicular and axillary glands and other sites.

• Waldeyer's ring involvement is rare and suggests a diagnosis of NHL.

• Lymphadenopathy in HL may wax and wane during observation.

• Spleen involved in ~30% but palpable splenomegaly only in 10%, hepatomegaly 5%.

• Abdominal lymphadenopathy is unusual without splenic involvement.

• Supradiaphragmatic disease ± intra-abdominal involvement is usual, and regional disease limited to subdiaphragmatic sites is uncommon (except NLPHL).

• Bulky mediastinal and hilar lymphadenopathy may produce local symptoms (e.g. bronchial or SVC compression) or direct extension (e.g. to lung, pericardium, pleura or rib). Pleural effusions in 20%.

• Extranodal spread may also occur via bloodstream (e.g. to bone marrow (1-4%), lung or liver). Presence of disseminated extranodal disease is generally accompanied by generalised lymphadenopathy and splenic involvement; usually a late event.

• ~33% patients have >1 associated constitutional 'B' symptoms at presentation: weight loss >10% body weight during the previous 6 months, unexplained fever or drenching night sweats. 'B' symptoms correlate with disease extent, bulk and prognosis. Further systemic symptoms associated with HD (but not 'B' symptoms) are generalized pruritus and alcohol-induced lymph node pain.

• A defect in cellular immunity has been documented in patients with HL rendering them more susceptible to TB, fungal, protozoal and viral infections including P carinii and HZV.

• NLPHL more frequent in 9(2-3x); median age 35 years; typically localised at presentation; usually cervical or inguinal; infrequent 'B' symptoms; late relapses occur; increased risk of DLBCL; otherwise favourable prognosis; 10 year OS 80-90%.

• NSHL occurs typically in young adults (median age 26) and has a good prognosis if stage I/II.

• MCHL has a median age of 30 years and an intermediate prognosis.

• LDHL is more common in older adults; has a relatively poor prognosis.

• LRCHL d>9; tendency to localised disease; favourable prognosis.

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