Lymphoma is a group of cancers arising from lymphocytes (B cells, T cells, or NK cells). It is broadly divided into Hodgkin lymphoma (HL), characterised by Reed–Sternberg cells, and non-Hodgkin lymphoma (NHL), which includes many subtypes ranging from indolent to highly aggressive.

✅ UK guidance framing: in primary care, think first about recognition and urgent referral. Unexplained lymphadenopathy should raise suspicion for lymphoma; splenomegaly particularly increases concern for NHL. Associated symptoms such as fever, drenching night sweats, weight loss, pruritus, and shortness of breath strengthen suspicion.

🧬 Pathophysiology

Lymphomas arise from acquired genetic abnormalities in lymphocytes, causing clonal proliferation, impaired apoptosis, and disordered immune-cell behaviour.
Hodgkin lymphoma classically contains Reed–Sternberg cells within a prominent inflammatory background.
Non-Hodgkin lymphoma is biologically heterogeneous and may arise from B cells, T cells, or NK cells; extranodal disease is more common than in HL.

⚖️ Hodgkin vs Non-Hodgkin Lymphoma

Feature	Hodgkin Lymphoma 🟢	Non-Hodgkin Lymphoma 🔵
Pathology	Reed–Sternberg cells present.	Reed–Sternberg cells absent; multiple B-, T-, and NK-cell subtypes.
Typical pattern	Often orderly/contiguous nodal spread.	Often non-contiguous spread; extranodal disease more common.
Presentation	Painless lymphadenopathy, often cervical; may have B symptoms, pruritus, or mediastinal disease.	Painless lymphadenopathy or splenomegaly; may have B symptoms or site-specific symptoms depending on subtype and site.
Age	Often shows a bimodal age distribution.	Can occur at any age, but incidence rises with age overall.
Behaviour	Often highly treatable and frequently curable.	Variable: may be indolent, aggressive, or highly aggressive depending on subtype.

🚩 When to suspect lymphoma

Unexplained lymphadenopathy, especially if persistent.
Unexplained splenomegaly (particularly concerning for NHL).
B symptoms: fever, drenching night sweats, unexplained weight loss.
Other concerning features: pruritus, shortness of breath, mediastinal symptoms, fatigue, recurrent infections, bruising, or site-specific symptoms from extranodal disease.
Alcohol-induced node pain is a rare but classic association with HL.

🔍 Diagnosis

Excision biopsy is generally preferred as the first diagnostic procedure when lymphoma is suspected.
If excision biopsy is not suitable because procedural risk outweighs benefit, a needle core biopsy may be considered.
If a core biopsy is non-diagnostic and feasible, excision biopsy should be pursued.
Diagnosis depends on histology, immunophenotyping, and subtype classification.
Staging may involve CT or PET-CT, and additional tests such as bone marrow biopsy may be required in selected cases.

📊 Staging

Staging is usually described using the Ann Arbor system:
Stage I: single lymph node region or single extralymphatic site.
Stage II: 2 or more nodal regions on the same side of the diaphragm.
Stage III: nodal disease on both sides of the diaphragm.
Stage IV: disseminated extranodal involvement such as bone marrow, liver, or other organs.
B symptoms are commonly recorded because they have prognostic significance.

💊 Management

Management is specialist-led and depends on subtype, stage, bulk of disease, symptoms, comorbidity, and patient fitness.
Treatment may include chemotherapy, immunochemotherapy, radiotherapy, targeted therapy, stem cell transplantation, or in some cases active monitoring (“watch and wait”).
Supportive care is important, including infection prevention, fertility discussion where relevant, and management of complications such as tumour lysis syndrome.

🩺 Clinical Pearls

Do not reassure persistent unexplained lymphadenopathy without follow-up or further assessment.
Generalised lymphadenopathy, splenomegaly, or B symptoms should lower the threshold for urgent referral.
Extranodal disease (for example GI tract, skin, CNS) is more suggestive of NHL than HL.
Lymphoma may present with normal early blood tests, so normal FBC does not exclude it.

📚 Summary

👉 Lymphoma is a malignancy of lymphocytes. 🟢 HL is defined by Reed–Sternberg cells and often follows a more orderly nodal pattern. 🔵 NHL is a heterogeneous group with variable behaviour, from indolent to highly aggressive. 📌 In UK practice, NICE emphasis is on early recognition, suspected cancer referral, tissue diagnosis with appropriate biopsy, and subtype-specific specialist management.

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Hodgkin vs Non-Hodgkin Lymphoma: