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Difficulty: Very hardHematology and Oncology

A 24-year-old man presents to the clinic with a 2-month history of profound fatigue, intermittent fevers, and drenching night sweats. Physical examination reveals a 4-cm, painless, rubbery right supraclavicular lymph node. A preliminary CT scan of the neck and chest confirms the presence of an isolated 4.2-cm right supraclavicular lymph node without significant mediastinal or axillary lymphadenopathy. Laboratory studies show a normal complete blood count, but the erythrocyte sedimentation rate is elevated at 65 mm/hr.

Arrange the following steps in the most appropriate sequential order for the definitive diagnosis, staging, and management of this patient's most likely condition.

  1. 1Perform an excisional biopsy of the enlarged supraclavicular lymph node
  2. 2Obtain a whole-body FDG-PET/CT scan to determine the clinical stage
  3. 3Evaluate baseline organ function with an echocardiogram and pulmonary function tests
  4. 4Initiate systemic multi-agent chemotherapy with the ABVD regimen
  5. 5Perform an interim FDG-PET/CT scan to assess therapeutic response

Answer

The correct sequence is: 1) Excisional biopsy of the lymph node, 2) Whole-body FDG-PET/CT for staging, 3) Baseline echocardiogram and pulmonary function tests, 4) Initiation of ABVD chemotherapy, and 5) Interim FDG-PET/CT for response assessment.
This sequence perfectly outlines the standard of care for a young patient presenting with B symptoms and localized lymphadenopathy highly suspicious for Hodgkin lymphoma. Diagnosis must precede staging; staging and safety evaluations must precede treatment; and treatment must precede response assessment.

Step-by-Step Solution

1
Select excisional biopsy as the first action.
Establishes tissue diagnosis of classical Hodgkin Lymphoma.
Malignancy must always be proven histologically before undertaking expensive staging or toxic therapies. Excisional biopsy is preferred over fine-needle aspiration for lymphoma to preserve nodal architecture.
2
Select FDG-PET/CT scan as the second action.
Determines the clinical stage of the disease.
Once the diagnosis is established, staging is required to define the exact extent of disease, which dictates the prognosis and the specific treatment algorithm.
3
Select baseline organ function evaluation (Echocardiogram and PFTs) as the third action.
Ensures the patient can safely receive the planned chemotherapy.
The ABVD regimen contains doxorubicin (cardiotoxic) and bleomycin (pulmonary toxic). Baseline parameters must be documented before the first dose is administered.
4
Select initiation of ABVD chemotherapy as the fourth action.
Begins curative-intent treatment.
Treatment can safely commence only after diagnosis, staging, and safety evaluations are completed.
5
Select interim FDG-PET/CT scan as the final action.
Evaluates early response to the chemotherapy.
Modern management of Hodgkin lymphoma utilizes interim PET imaging (typically after 2 cycles) to guide whether subsequent therapy should be escalated or de-escalated to minimize long-term toxicity.

Key Concept

The sequential management of Hodgkin lymphoma mandates tissue diagnosis via excisional biopsy, accurate staging with PET/CT, pre-treatment baseline organ function assessment (tailored to expected chemotherapy toxicities), initiation of systemic therapy, and early response monitoring via interim imaging.
Estimated Time:2m 0s
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Topics

Hematology and Oncology

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