A 35-year-old woman undergoes staging investigations for newly diagnosed Hodgkin lymphoma. Which is the most common site of involvement at presentation in Hodgkin lymphoma?

Question

Accepted Answer

D. Cervical and mediastinal lymph nodes. ## Sites of Involvement in Hodgkin Lymphoma

**Key Point:** The **cervical and mediastinal lymph nodes** are the most common sites of involvement at presentation in Hodgkin lymphoma, occurring in approximately 80% of patients.

### Frequency of Nodal Involvement at Presentation

| Site | Frequency at Presentation | Notes |
|------|--------------------------|-------|
| **Cervical nodes** | ~80% | Most common single site; often the presenting symptom |
| **Mediastinal nodes** | ~60% | Especially in nodular sclerosis subtype; may cause respiratory symptoms |
| **Axillary nodes** | ~30% | Less common than cervical |
| **Inguinal nodes** | ~25% | More common at relapse than at presentation |
| **Splenic involvement** | ~25% | Detected on imaging; rarely symptomatic |
| **Hepatic involvement** | ~10% | Indicates advanced disease; usually with splenic involvement |

**High-Yield:** Hodgkin lymphoma shows a characteristic **orderly, contiguous spread** from one lymph node group to adjacent groups (unlike non-Hodgkin lymphoma, which is often random). This predictable pattern is why the **cervical and mediastinal nodes** — which are anatomically contiguous — are frequently involved together.

### Clinical Presentation Pattern

**Clinical Pearl:** Patients typically present with **painless cervical lymphadenopathy** (often unilateral initially), which may be accompanied by a mediastinal mass discovered on routine chest imaging. The mediastinal involvement can cause:
- Cough
- Chest discomfort
- Superior vena cava syndrome (in advanced cases)

**Mnemonic:** **"Cervical-first, then down"** — Hodgkin tends to involve the cervical nodes first, then spread downward to mediastinal, axillary, and eventually inguinal nodes in a predictable fashion.

### Why Inguinal Nodes Are NOT Most Common

Inguinal nodes are involved in only ~25% of patients at presentation. They become more frequent at **relapse** or in **advanced disease**, but are not the primary site of involvement. The orderly spread pattern means inguinal involvement usually occurs only after cervical and mediastinal disease is established.

Answer

A. Splenic involvement

Answer

B. Inguinal and mesenteric lymph nodes

Answer

C. Hepatic involvement

A 35-year-old woman undergoes staging investigations for newly diagnosed Hodgkin lymphoma. Which is the most common site of involvement at presentation in Hodgkin lymphoma?

Explanation

Sites of Involvement in Hodgkin Lymphoma

Frequency of Nodal Involvement at Presentation

Clinical Presentation Pattern

Why Inguinal Nodes Are NOT Most Common

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Site	Frequency at Presentation	Notes
Cervical nodes	~80%	Most common single site; often the presenting symptom
Mediastinal nodes	~60%	Especially in nodular sclerosis subtype; may cause respiratory symptoms
Axillary nodes	~30%	Less common than cervical
Inguinal nodes	~25%	More common at relapse than at presentation
Splenic involvement	~25%	Detected on imaging; rarely symptomatic
Hepatic involvement	~10%	Indicates advanced disease; usually with splenic involvement