3.3 Hodgkin and Non-Hodgkin Lymphomas
Key Takeaways
- Pediatric Hodgkin lymphoma classically presents with cervical or mediastinal adenopathy and B symptoms; Reed-Sternberg cells define the histology.
- Childhood NHL is usually high-grade: Burkitt (MYC, abdomen, TLS), lymphoblastic (often T-cell mediastinal disease treated like ALL), ALCL, and DLBCL.
- Hodgkin staging uses Ann Arbor; many pediatric NHL protocols use the Murphy–St. Jude system designed for extranodal childhood patterns.
- An anterior mediastinal mass can cause airway collapse and superior vena cava syndrome; do not sedate casually for diagnosis.
- Hodgkin late effects include hypothyroidism, breast cancer risk after chest radiation, cardiomyopathy, and fertility impairment.
Pediatric lymphomas split into Hodgkin lymphoma and non-Hodgkin lymphoma (NHL). They are not the same disease, they do not share the same first-hour emergencies, and they do not share the same late-effect profile. Hodgkin lymphoma is typically a disease of older children and adolescents with cervical or mediastinal adenopathy and, often, B symptoms. Pediatric NHL is usually high-grade and fast: Burkitt lymphoma, lymphoblastic lymphoma, anaplastic large-cell lymphoma (ALCL), and diffuse large B-cell lymphoma (DLBCL) dominate, unlike the indolent nodal lymphomas of older adults.
Hodgkin lymphoma
Classic presentation is painless cervical lymphadenopathy, a mediastinal mass, or both. B symptoms—fever, drenching night sweats, and unexplained weight loss—are staging and prognostic data, not a passing viral illness. Pruritus and alcohol-induced node pain appear in textbooks; B symptoms are the triad to memorize for the exam. Diagnosis rests on finding Reed-Sternberg cells (or variant Hodgkin cells) in the proper immunophenotypic context, usually CD15-positive/CD30-positive classic Hodgkin lymphoma, with a minority of nodular lymphocyte-predominant disease that behaves differently.
Staging historically uses the Ann Arbor system (I–IV, with A/B for B symptoms and E for extranodal extension). PET-adapted therapy is the modern cooperative-group concept: an early PET response can de-escalate radiation or intensity, while a positive interim PET can escalate. Pediatric protocols are often ABVD-like or hybrid multiagent regimens using doxorubicin, bleomycin, vinblastine, and dacarbazine, sometimes combined with cyclophosphamide, vincristine, prednisone, etoposide, or similar agents depending on the study. The nursing job during treatment is not to recite every arm code. It is to watch bleomycin pulmonary toxicity, anthracycline cardiac risk, myelosuppression, infection, and the mediastinal airway.
Late effects drive survivorship teaching even during first-line therapy. Neck radiation can cause hypothyroidism. Chest radiation in young women raises later breast-cancer risk and, with doxorubicin, cardiomyopathy risk. Alkylators and gonadal or pelvic radiation impair fertility. Offer sperm banking and fertility counseling before gonadotoxic therapy whenever the clinical situation allows. A 16-year-old who is focused only on getting back to soccer still needs a thyroid, cardiac, breast-surveillance, and fertility conversation before discharge from active therapy.
Non-Hodgkin lymphomas of childhood
Children rarely present with low-grade follicular lymphoma. They present with high-grade disease that doubles in hours to days.
Burkitt lymphoma is a MYC-rearranged mature B-cell lymphoma. The endemic African form classically involves the jaw; in North America the typical child has a rapidly growing abdominal mass, intussusception, ascites, or a nasopharyngeal mass. LDH and uric acid are often already high before the first dose. Tumor lysis syndrome is expected, not surprising. Therapy is short, intense mature B-cell protocol treatment, not years of ALL-style maintenance. Hydration, uric-acid control, and electrolyte monitoring start before cytoreduction whenever possible. A child who looks well at 8 a.m. with a football-sized abdominal mass can be in renal failure from TLS by evening once therapy begins.
Lymphoblastic lymphoma is biologically a cousin of ALL, usually T-lineage, and typically presents with a mediastinal mass, pleural effusion, and adenopathy. Circulating blasts may be absent or few; by convention, heavier marrow replacement shifts the diagnosis toward T-ALL (often using a 25% marrow blast cutoff). Treatment is ALL-like: prolonged therapy, CNS prophylaxis, and the same corticosteroid–vincristine–asparaginase backbone concepts. The mediastinal mass is the immediate danger.
ALCL is often ALK-positive in children and can present with systemic symptoms, skin nodules, nodes, or unusual extranodal sites. DLBCL is a mature large B-cell lymphoma treated on mature B-cell backbones, generally without ALL-length maintenance. Rituximab appears on many mature B-cell pediatric protocols; it is a generic monoclonal antibody name you should recognize, not a brand.
Staging systems
Hodgkin lymphoma uses Ann Arbor (with Lugano PET conventions in many contemporary discussions). Pediatric NHL commonly uses the St. Jude/Murphy staging system, which was designed for the extranodal, abdominal, and mediastinal patterns of childhood NHL:
| Stage idea | Hodgkin (Ann Arbor) | Pediatric NHL (Murphy–St. Jude) |
|---|---|---|
| Localized node or single extranodal site | I | I |
| Multiple nodes, same side of diaphragm | II | II (often including primary GI tumor with or without mesenteric nodes) |
| Both sides of diaphragm or extensive intra-abdominal / mediastinal | III | III (including unresectable abdominal disease and mediastinal primary) |
| Marrow or CNS | IV | IV |
Know which system your protocol uses. Do not mix labels when teaching families. Murphy stage IV NHL with 5% marrow involvement is not the same sentence as leukemia, and Ann Arbor IV Hodgkin with marrow involvement is not Burkitt TLS physiology.
Mediastinal mass: do not sedate casually
An anterior mediastinal mass—T-lymphoblastic lymphoma, Hodgkin lymphoma, or T-ALL—can compress the trachea, bronchi, and superior vena cava. The child may sit forward, cough, swell in the face and neck, or desaturate when supine. Diagnostic anesthesia is a documented cause of arrest. Do not send this child to a procedure unit for a quick sedation for biopsy without pediatric anesthesia, oncology, and a plan for positioning (often sitting or lateral), possible steroid or radiation prephase if the airway is critical, and avoidance of neuromuscular blockade that removes remaining airway tone. Peripheral blood, pleural fluid, or a minimally sedated node biopsy may establish diagnosis without a general anesthetic.
Superior vena cava (SVC) syndrome is the venous counterpart: facial plethora, dilated chest-wall veins, headache, and risk of airway and cerebral edema. Elevate the head of the bed, avoid upper-extremity central lines on the obstructed side when possible, and treat the mass on protocol as soon as a safe diagnostic specimen exists.
Three scripts that cover most CPHON lymphoma items
If the adolescent has cervical or mediastinal nodes and Reed-Sternberg cells, think Hodgkin, PET-adapted combined-modality therapy, and late effects of thyroid, breast, heart, and fertility. If the school-age child has a racing abdominal mass and MYC-positive mature B-cell disease, think Burkitt and TLS. If the adolescent has a mediastinal mass and T-lymphoblasts, treat like ALL and protect the airway. Those three scripts, plus the rule that you do not sedate a mediastinal mass casually, are the high-yield core of this section.
A 16-year-old has painless cervical lymphadenopathy, a mediastinal mass, drenching night sweats, and unexplained weight loss. Biopsy shows Reed-Sternberg cells. Which diagnosis fits this presentation?
A 7-year-old with a rapidly enlarging abdominal mass is diagnosed with Burkitt lymphoma. Which complication must the nurse anticipate at the start of cytoreductive therapy?
A 12-year-old with T-lymphoblastic lymphoma and a large anterior mediastinal mass is scheduled for diagnostic sedation in the procedure unit. What is the safest nursing stance?