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Difficulty: HardHematology and Oncology

A 28-year-old man presents to the clinic reporting a painless mass in his right neck that has been enlarging over the past 8 weeks. He also reports drenching night sweats and a 6-kg (13.2-lb) weight loss over the past 3 months. Physical examination reveals a 4.5-cm, firm, rubbery, non-tender lymph node in the right anterior cervical chain. There is no palpable hepatosplenomegaly. Routine laboratory tests, including a complete blood count and comprehensive metabolic panel, are within normal limits. A chest radiograph demonstrates mediastinal widening. The physician highly suspects a diagnosis of Hodgkin lymphoma.

Arrange the following steps in the most appropriate chronological sequence for the definitive diagnosis, staging, and initial management of this patient.

  1. 1Perform an excisional lymph node biopsy.
  2. 2Perform a positron emission tomography-computed tomography (PET-CT) scan.
  3. 3Obtain baseline pulmonary function tests and an echocardiogram.
  4. 4Initiate multi-agent chemotherapy consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine.

Answer

The correct sequence begins with establishing a histologic diagnosis via excisional biopsy, followed by disease staging with PET-CT, assessing baseline organ function with pulmonary function tests and an echocardiogram, and finally initiating targeted multi-agent chemotherapy.
The correct sequence follows fundamental oncologic principles: (1) Tissue diagnosis is paramount and must be obtained via excisional biopsy to preserve nodal architecture. (2) Once diagnosed, the disease must be staged using PET-CT to evaluate the extent of spread. (3) Based on the stage, a treatment plan is formulated (e.g., ABVD), requiring pre-treatment assessment of organ function (echocardiogram for doxorubicin, PFTs for bleomycin). (4) Once safety is established, definitive chemotherapy is initiated.

Step-by-Step Solution

1
Select 'Perform an excisional lymph node biopsy.'
Establishes the definitive histologic diagnosis.
Treatment cannot begin without a confirmed tissue diagnosis. Excisional biopsy provides intact tissue architecture necessary for identifying characteristic findings like Reed-Sternberg cells.
2
Select 'Perform a positron emission tomography-computed tomography (PET-CT) scan.'
Determines the clinical stage of the disease.
Once the diagnosis is confirmed, staging must be completed to identify all sites of involvement. This determines the treatment intensity and duration.
3
Select 'Obtain baseline pulmonary function tests and an echocardiogram.'
Evaluates baseline cardiac and pulmonary function.
The standard ABVD regimen includes bleomycin (pulmonary toxicity) and doxorubicin (cardiotoxicity). Baseline testing is mandatory to monitor for subsequent organ decline.
4
Select 'Initiate multi-agent chemotherapy consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine.'
Begins definitive therapeutic intervention.
Chemotherapy can only be safely and effectively administered after diagnosis, staging, and pre-treatment organ function testing are complete.

Key Concept

The sequential management of Hodgkin lymphoma requires histologic confirmation via excisional biopsy, followed by staging (PET-CT), baseline organ function testing (echocardiogram, pulmonary function tests) to prepare for toxicities, and finally the initiation of multi-agent chemotherapy (ABVD).
Estimated Time:1m 30s
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Topics

Hematology and Oncology

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