A 24-year-old woman presents to the clinic with a 6-week history of a painless, progressively enlarging mass in her right lower neck. She also reports intermittent fevers and drenching night sweats over the past month. Physical examination reveals a 3.5-cm, rubbery, mobile, non-tender lymph node in the right supraclavicular region. No other lymphadenopathy or hepatosplenomegaly is appreciated. Laboratory studies show a normal complete blood count, but the erythrocyte sedimentation rate is elevated at . The physician suspects a hematologic malignancy. Arrange the following steps in the most appropriate chronological sequence for the diagnostic workup, staging, and initial management of this patient's most likely condition.
- 1Perform an excisional biopsy of the right supraclavicular lymph node
- 2Obtain a whole-body fluorodeoxyglucose (FDG) PET/CT scan
- 3Perform baseline echocardiography and pulmonary function testing
- 4Initiate systemic multiagent chemotherapy with the ABVD regimen
Answer
The correct sequence is: Excisional biopsy, followed by FDG PET/CT scan, then baseline echocardiography and pulmonary function testing, and finally initiation of ABVD chemotherapy.
The patient presents with classic features of Hodgkin lymphoma (young adult, painless supraclavicular lymphadenopathy, B symptoms). The definitive first step is establishing a histologic diagnosis via excisional biopsy. Once diagnosed, disease extent must be mapped using FDG PET/CT (Ann Arbor staging). Because standard therapy (ABVD) utilizes doxorubicin and bleomycin, documenting baseline cardiac (echocardiography) and pulmonary (PFTs) reserve is mandatory. Finally, with diagnosis, staging, and safety clearance complete, chemotherapy can safely begin.
Step-by-Step Solution
Key Concept
The sequential diagnostic and staging workup for classic Hodgkin lymphoma requires excisional biopsy for diagnosis, PET/CT for staging, and cardiopulmonary function testing prior to anthracycline and bleomycin exposure.
Estimated Time:1m 30s