Bit · Heme/Onc
Hodgkin vs Non-Hodgkin lymphoma
Two lymphoma families that share the chief complaint of lymphadenopathy but split sharply on the biopsy finding. The pivot is the Reed-Sternberg cell.
Mechanism
Both are malignancies of lymphocytes. The defining split is whether Reed-Sternberg cells (giant, multinucleated, 'owl-eye' B-cell-derived cells) are present:
- Hodgkin lymphoma (HL) — Reed-Sternberg cells present (CD15+, CD30+). The malignant cells are a small minority; the rest of the node is a reactive inflammatory infiltrate. Spreads in an orderly, contiguous fashion through adjacent lymph node groups. Bimodal age distribution (young adults and >55). Strongly associated with EBV in some subtypes.
- Non-Hodgkin lymphoma (NHL) — no Reed-Sternberg cells. The malignant lymphocyte is the dominant population. Includes a large, heterogeneous group: diffuse large B-cell lymphoma (most common adult NHL), follicular lymphoma, Burkitt lymphoma, mantle cell, MALT, mycosis fungoides, and many more. Spreads non-contiguously. Wider age range; many NHL subtypes occur in immunosuppressed patients (HIV).
Differentiator Table
| Hodgkin | Non-Hodgkin | |
| Reed-Sternberg cells | Present (CD15+, CD30+) | Absent |
| Spread | Contiguous through nodal groups | Non-contiguous, often extranodal |
| Age distribution | Bimodal (~20s and >55) | Median ~65; some pediatric (Burkitt) |
| B symptoms (fever, night sweats, weight loss) | Common | Variable |
| EBV association | Yes (esp. mixed cellularity) | Yes (Burkitt, CNS lymphoma in HIV, some others) |
| HIV association | Some increase | Strong — DLBCL, primary CNS, Burkitt |
| Major subtypes | Nodular sclerosing (most common), mixed cellularity, lymphocyte-rich, lymphocyte-depleted, NLP-HL | DLBCL, follicular, Burkitt (t(8;14)), mantle cell (t(11;14)), MALT, CLL/SLL |
| Prognosis | Often curable, even advanced | Highly variable by subtype |
| Classic stem clue | Young adult, painless cervical/supraclavicular node, mediastinal mass on CXR, B symptoms, biopsy with RS cells | Older adult OR HIV patient with rapidly enlarging extranodal mass; Burkitt = jaw mass in African child, 'starry sky' biopsy |
The Pivot
One question almost always settles it: are Reed-Sternberg cells on the biopsy? Yes → Hodgkin. No → Non-Hodgkin (then ask the subtype).
If you don't have biopsy data: contiguous spread + young adult + bulky mediastinal node + B symptoms → Hodgkin. Extranodal mass, HIV patient, or non-contiguous involvement → NHL.
NBME-Style Stem
A 22-year-old man presents with painless cervical lymphadenopathy, fever, night sweats, and 12 lb weight loss over 2 months. Chest x-ray reveals a large mediastinal mass. Excisional lymph node biopsy shows large multinucleated cells with prominent eosinophilic inclusion-like nucleoli in a background of small lymphocytes, eosinophils, and plasma cells. Which of the following is the most likely diagnosis?
Concept Anchor
The Reed-Sternberg cell is a malignant B cell that recruits a reactive infiltrate of its own — most of the node is bystanders. The presence or absence of this one giant cell on biopsy decides which of the two lymphoma families you're dealing with.