Nodular Sclerosis Classical Hodgkin Lymphoma in a Young Adult: A Comprehensive Case- Based Review of Pathophysiology, Diagnosis, and Contemporary Management

Classical Hodgkin lymphoma (CHL) constitutes approximately 10% of all lymphomas and is traditionally classified into four histopathologic subtypes: nodular sclerosis, mixed cellularity, lymphocyte-rich (also known as lymphocyte predominance), and the exceedingly rare lymphocyte-depleted variant (3). Among these, nodular sclerosis is the most prevalent, whereas mixed cellularity tends to present with more disseminated or advanced-stage disease. Together, these two subtypes account for nearly 80% of all CHL cases (3). Clinically, CHL is considered one of the most curable hematologic malignancies, with the majority of patients achieving durable remission following standard first-line chemotherapy regimens—often ABVD or related protocols—sometimes combined with involved-site radiotherapy depending on stage and risk stratification (1). The nodular sclerosis subtype (NS-CHL) is characterized by distinctive architectural and stromal features within the lymph node. Thick, collagen-rich fibrotic bands traverse the tissue, subdividing the lymphomatous infiltrate into nodules composed of inflammatory cells and scattered neoplastic Hodgkin and Reed–Sternberg (HRS) cells (3). These fibrotic bands reflect a marked expansion and activation of fibroblasts within the tumor microenvironment, driven in part by cytokines and growth factors released by both HRS cells and surrounding immune cells (2). The resulting fibroblast proliferation, extracellular matrix remodeling, and deposition of collagen contribute not only to the characteristic nodular appearance but also to the unique tumor biology of NS-CHL, influencing local immune interactions and the structural organization of the malignant niche (2,3).

METHODS AND MATERIALS

A 23-year-old male with newly diagnosed classical Hodgkin lymphoma, nodular sclerosis subtype, was admitted for chemotherapy. Diagnosis was confirmed by bone marrow and cervical lymph node biopsy demonstrating CD30-positive neoplastic cells. Baseline evaluation included complete blood count, biochemical panel, and PET scan. The patient received cycle 1A of ABVD chemotherapy (Adriamycin 25 mg/m², Bleomycin, Vinblastine 6 mg/m², Dacarbazine 375 mg/m²) with pegylated G-CSF 6 mg subcutaneously the following day. Supportive care included hydration, infection prophylaxis, and patient education. Follow-up was scheduled for assessment of treatment response and subsequent chemotherapy cycles.

Case Presentation

A 23-year-old male was newly diagnosed with Classical Hodgkin’s Lymphoma and admitted for initiation of chemotherapy with the ABVD regimen (Adriamycin, Bleomycin, Vinblastine, Dacarbazine). The patient had no history of fever, vomiting, diarrhea, chest pain, palpitations, or bleeding manifestations, and reported no drug allergies. He initially presented in June 2022 with swelling over the right side of the neck associated with sore throat. Bone marrow aspiration and biopsy suggested Classical Hodgkin’s Lymphoma – Nodular Sclerosis type, with CD30 positivity in neoplastic cells. A repeat bone marrow aspiration and biopsy confirmed the diagnosis from the right cervical lymph node. A PET scan was performed, with the report pending at the time of admission. After detailed discussion with the patient and family and obtaining informed consent, he was admitted for initiation of chemotherapy. On physical examination, the patient was conscious, oriented, and not in acute distress. ECOG performance status was 1. Vital signs were stable with a blood pressure of 110/70 mmHg, pulse 75/min, respiratory rate 20/min, SpO? 98% on room air, and temperature 37°C. General examination revealed a well-nourished young male. HEENT evaluation showed anicteric sclerae, clear conjunctivae, intact extraocular movements, patent nares, clear oropharynx, and a normal tongue. Cervical examination revealed palpable, rubbery, nontender lymphadenopathy. Chest examination was unremarkable with clear lung fields. Cardiovascular examination revealed normal S1 and S2 without murmurs. Femoral adenopathy was noted on genitourinary examination. Neurological assessment showed the patient alert and oriented ×3, cranial nerves II–XII intact, with a slow but normal gait. Musculoskeletal and abdominal examinations were unremarkable, with no hepatosplenomegaly and positive bowel sounds. Skin was normal. The patient was adequately hydrated before and after chemotherapy. He was premedicated and received cycle 1A of ABVD chemotherapy, which included Adriamycin 25 mg/m², Bleomycin, Vinblastine 6 mg/m², and Dacarbazine 375 mg/m². Pegylated G-CSF 6 mg was administered subcutaneously the following day. The patient tolerated chemotherapy well without acute adverse events. Baseline investigations, including prior bone marrow biopsies and PET scan, were reviewed and attached in patient records. At discharge, the patient was stable and advised to continue oral medications including folic acid 5 mg once daily and Nurokind once daily. He was instructed to report immediately to the nearest hospital in case of fever >100°F, sore throat, severe fatigue, or other emergencies. Guidance was provided for management of febrile neutropenia, blood transfusion (PRC if Hb <7 g/dL, platelets if <20,000), weekly CBC monitoring, and catheterization in case of urinary retention. Additional preventive measures included careful hand and oral hygiene, consumption of freshly prepared food, maintaining hydration, stool softeners if required, and avoiding contact with individuals with respiratory infections. Physical activity was advised as tolerated. The patient was scheduled for follow-up in the clinical hematology outpatient department with CBC and PET scan reports [Fig.1], and cycle 1B of ABVD chemotherapy was planned based on review of results. He was discharged in a stable condition, with instructions to continue close monitoring and promptly report any acute clinical changes.