Clinical staging for patients with Hodgkin lymphoma (HL) includes a history, physical examination, laboratory studies (including sedimentation rate), and thoracic and abdominal/pelvic computerized tomographic (CT) scans.
Positron emission tomography (PET) scans, usually combined with CT scans, have replaced gallium scans and lymphangiography for clinical staging.[2,3,4] A prospective, multinational study of 260 newly diagnosed patients with HL obtained PET scans at baseline and after two cycles (four doses) of ABVD (doxorubicin plus bleomycin plus vinblastine plus dacarbazine); with a median follow-up of 2.2 years, the 2-year progression-free survival was 12.8% with a positive PET scan after two cycles and 95% with a negative PET scan after two cycles (P < .0001). In a prospective trial of BEACOPP-based therapy—which includes the drugs bleomycin, etoposide, doxorubicin hydrochloride, cyclophosphamide, vincristine sulfate, procarbazine, and prednisone— for previously untreated patients with advanced-stage HL, patients with residual abnormalities measuring 2.5 cm or more received a PET scan at the end of therapy. A negative PET scan predicted no progression or relapse within 1 year for 94% of patients (confidence interval, 91%–97%). Whether consolidation with radiation therapy can be omitted for PET-negative patients must await overall survival data at 5 years. Only further prospective studies that compare a PET response–adapted strategy versus standard therapy without alteration can assess whether improved outcomes can be achieved by altering the therapeutic strategy based on PET scan results.[7,8]
Bone marrow involvement occurs in 5% of patients; biopsy may be indicated in the presence of constitutional B symptoms or anemia, leukopenia, or thrombocytopenia. In a retrospective review of 454 patients, no patients with a positive bone marrow biopsy had only stage I or II disease on PET-CT scans; omission of the bone marrow biopsy for PET-CT–designated early-stage patients did not change treatment selection. Staging laparotomy is no longer recommended; it should be considered only when the results will allow substantial reduction in treatment. It should not be done in patients who require chemotherapy. If the laparotomy is required for treatment decisions, the risks of potential morbidity should be considered.[10,11,12,13] The staging classification that is currently used for HL was adopted in 1971 at the Ann Arbor Conference  with some modifications 18 years later from the Cotswolds meeting.