by Jason Wasserman MD PhD FRCPC
April 16, 2026
Hodgkin lymphoma is a type of cancer that starts in the immune system, most often in the lymph nodes — the small, bean-shaped glands distributed throughout the body that filter lymph fluid and house immune cells. It is defined by the presence of specific abnormal cells called Reed-Sternberg cells, which can be identified under the microscope and confirmed with additional laboratory tests. Hodgkin lymphoma is one of the most treatable cancers, and most people — including those diagnosed at an advanced stage — are cured with modern treatment. This article provides an overview of Hodgkin lymphoma to help you understand your diagnosis. Because the specific type of Hodgkin lymphoma affects treatment and prognosis, more detailed articles for each subtype are linked throughout this page.
What are the symptoms of Hodgkin lymphoma?
The most common first sign of Hodgkin lymphoma is a painless, slowly or rapidly enlarging lump — usually a swollen lymph node in the neck, armpit, or groin. A large mass in the chest (mediastinum) is particularly characteristic and is often first noticed as a feeling of chest pressure, cough, or shortness of breath. In some people, it is found incidentally on imaging performed for another reason.
Many people also experience general symptoms known as B symptoms, which are recorded as part of staging because they can influence treatment planning. These are: unexplained fever, drenching night sweats, and unintentional weight loss of more than 10% of body weight over six months. Fatigue is also very common. Some people notice widespread skin itching. A less common but characteristic symptom is alcohol-induced pain — discomfort felt in lymph node areas shortly after drinking alcohol — which, when present, is suggestive of Hodgkin lymphoma.
What causes Hodgkin lymphoma?
Hodgkin lymphoma starts in a B cell — a white blood cell that normally matures inside the germinal center of a lymph node, the region where B cells refine their ability to recognize and fight infections. Through a combination of genetic changes, this cell loses most of its normal B cell identity and transforms into an abnormal Reed-Sternberg cell that can grow uncontrollably.
The exact cause is not fully understood in most cases. Infection with Epstein-Barr virus (EBV) — the virus that causes mononucleosis — is found inside the Reed-Sternberg cells in approximately 30–40% of classic Hodgkin lymphoma cases and is thought to contribute to lymphoma development in those cases. A weakened immune system (from HIV infection, organ transplant immunosuppression, or other causes) substantially increases risk. A personal or family history of infectious mononucleosis or having a sibling with Hodgkin lymphoma also increases risk. In most people, however, no single identifiable cause is found.
How is the diagnosis made?
The diagnosis of Hodgkin lymphoma is made by examining tissue from an affected lymph node or other site under the microscope. An excisional biopsy — removal of an entire lymph node — is the preferred method because the full architecture of the node is needed to identify the specific type of Hodgkin lymphoma. A core needle biopsy may be used when an excisional biopsy is not readily accessible. Fine needle aspiration alone is not sufficient. The pathologist examines the tissue to identify the characteristic abnormal cells and performs immunohistochemistry — a test that detects specific proteins in the cells — to confirm the diagnosis and determine which type of Hodgkin lymphoma is present. Once the diagnosis is confirmed, PET/CT imaging, blood tests, and sometimes bone marrow biopsy are used to determine the stage of disease.
What are the types of Hodgkin lymphoma?
Hodgkin lymphoma is divided into two main groups that are biologically and clinically distinct. Understanding which group your lymphoma belongs to is important because the two types differ in their typical cell morphology under the microscope, their protein expression patterns, their age distributions, and their treatment.
Classic Hodgkin lymphoma
Classic Hodgkin lymphoma (CHL) accounts for approximately 95% of all Hodgkin lymphoma cases and is defined by the presence of Reed-Sternberg cells — very large, abnormal cells with two or more nuclear lobes and prominent nucleoli that give them a characteristic “owl-eye” appearance. Despite being the dominant cell type that defines the disease, Reed-Sternberg cells typically make up only a tiny fraction (less than 1–5%) of all cells in the lymph node; the surrounding tissue is mostly composed of non-cancerous immune cells recruited in response to the Reed-Sternberg cells. Classic Hodgkin lymphoma is further divided into four subtypes based on the appearance of the tissue and the types of surrounding immune cells:
- Nodular sclerosis (60–80% of cases) — The most common subtype, defined by bands of scar-like fibrous tissue dividing the lymph node into nodules. Most common in adolescents and young adults, and equally common in men and women. Frequently involves the chest. Generally has an excellent prognosis.
- Mixed cellularity (20–25% of cases) — The second most common subtype, with Reed-Sternberg cells scattered among a diverse background of immune cells. More common in older adults and children, and strongly associated with EBV infection. Responds well to treatment.
- Lymphocyte-rich (~5% of cases) — An uncommon subtype with few Reed-Sternberg cells against a background of predominantly normal-appearing lymphocytes. Usually presents at an early stage. Very favorable prognosis.
- Lymphocyte-depleted (<2% of cases) — The rarest subtype, strongly associated with EBV and HIV infection. May involve the abdomen or bone marrow in addition to lymph nodes. Has historically had a less favorable prognosis, though outcomes continue to improve.
For detailed information about classic Hodgkin lymphoma — including the full description of each subtype, immunohistochemistry, staging, prognosis, and treatment — see the dedicated article: Classic Hodgkin Lymphoma: Understanding Your Pathology Report.
Nodular lymphocyte-predominant Hodgkin lymphoma
Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) — also called nodular lymphocyte-predominant B cell lymphoma (NLPBCL) in some classifications — accounts for approximately 5% of all Hodgkin lymphoma cases and is a distinct disease with important differences from classic Hodgkin lymphoma. It is slow-growing (indolent) rather than aggressive, typically involves peripheral lymph nodes without the mediastinal mass common in classic Hodgkin lymphoma, and has a very favorable long-term prognosis for most patients.
The abnormal cells in this type are called LP cells (lymphocyte-predominant cells), sometimes described as “popcorn cells” because of their folded, multi-lobed nucleus shape. LP cells are found within nodules filled with normal-appearing lymphocytes. The protein expression profile of LP cells is fundamentally different from Reed-Sternberg cells: LP cells strongly express B cell proteins such as CD20 and CD79a, and are typically negative for CD30 and CD15 — the opposite pattern from classic Hodgkin lymphoma. This difference explains why treatment approaches also differ between the two types.
For detailed information about this subtype — including staging, prognosis, treatment, and the naming controversy between NLPHL and NLPBCL — see the dedicated article: Nodular Lymphocyte-Predominant Hodgkin Lymphoma.
How are the two types different?
The table below summarizes the key differences between classic Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma. If you are unsure which type you have, your pathology report should state it — or your care team can tell you.
- Abnormal cells — Reed-Sternberg cells in classic Hodgkin lymphoma; LP (“popcorn”) cells in NLPHL.
- Behavior — Classic Hodgkin lymphoma is aggressive and requires prompt treatment; NLPHL is slow-growing and treatment is sometimes deferred.
- Typical location — Classic Hodgkin lymphoma often involves the chest; NLPHL typically involves peripheral lymph nodes (neck, armpit, groin) without chest involvement.
- CD30 protein — Positive in classic Hodgkin lymphoma; negative (or rare) in NLPHL. CD30 is the target of brentuximab vedotin, a drug used in classic Hodgkin lymphoma but not in NLPHL.
- CD20 protein — Negative (or rare) in classic Hodgkin lymphoma; strongly positive in NLPHL. CD20 is the target of rituximab, an antibody treatment used in NLPHL but not standard in classic Hodgkin lymphoma.
- Prognosis — Both types are highly treatable. Classic Hodgkin lymphoma is cured in 85–90% of patients overall. NLPHL has an excellent long-term survival rate, though late relapses are more common than in classic Hodgkin lymphoma.
What are Reed-Sternberg cells?
Reed-Sternberg cells are the defining abnormal cells of classic Hodgkin lymphoma, and identifying them is the most important step in making the diagnosis. They are the cells your pathologist is looking for under the microscope. Classic Reed-Sternberg cells are very large — much larger than any normal immune cell in the tissue — and have at least two nuclear lobes, each containing a very large, prominent, reddish-staining nucleolus (a dense structure inside the nucleus). The two pale nuclei, each with a large central nucleolus, give the cell an “owl-eye” appearance that is essentially diagnostic of Hodgkin lymphoma when seen in the right context.
Despite being the defining cells of the disease, Reed-Sternberg cells are very rare in the lymph node — they typically account for less than 5% of all cells present. The majority of what the pathologist sees is a background of normal and reactive immune cells (T cells, B cells, eosinophils, histiocytes, plasma cells) that have gathered in response to the Reed-Sternberg cells. This unusual feature — a cancer defined by cells that are a tiny minority of the tissue — is one of the things that makes Hodgkin lymphoma biologically unique.
Staging
Hodgkin lymphoma is staged using the Lugano classification, which describes how widely the lymphoma has spread in the body. Staging is based on PET/CT imaging and, in some cases, bone marrow biopsy, and is essential for selecting the right treatment.
- Stage I — A single lymph node region or a single site outside the lymph nodes is involved.
- Stage II — Two or more lymph node regions on the same side of the diaphragm (the muscle separating the chest from the abdomen) are involved.
- Stage III — Lymph node regions on both sides of the diaphragm are involved.
- Stage IV — The lymphoma has spread to one or more organs outside the lymphatic system, such as the bone marrow or liver.
The letters A and B are added to the stage to indicate the absence (A) or presence (B) of B symptoms. Bulky disease — typically defined as a mass measuring 10 cm or more, or a mediastinal mass exceeding one third of the chest diameter — is also noted because it affects treatment decisions. Stages I and II are considered limited or early-stage disease; stages III and IV are considered advanced-stage disease. PET/CT is the preferred imaging modality because it identifies metabolically active disease and serves as the baseline for assessing treatment response.
What is the prognosis?
Hodgkin lymphoma has one of the highest cure rates of any cancer. For classic Hodgkin lymphoma, approximately 85–90% of patients are cured with modern treatment, including many patients with advanced-stage disease. Nodular lymphocyte-predominant Hodgkin lymphoma also has an excellent prognosis, though its slower-growing nature means it can occasionally relapse many years after initial treatment.
Prognosis depends on the type of Hodgkin lymphoma, the stage, the presence or absence of B symptoms, whether disease is bulky, and how well the lymphoma responds to initial treatment. Response assessed by PET/CT — particularly the result after the first two cycles of chemotherapy (called the interim PET) — is one of the strongest predictors of long-term outcome and is used to guide treatment intensity in many centers.
What happens after the diagnosis?
After a diagnosis of Hodgkin lymphoma is confirmed, staging evaluation is completed to determine the extent of disease before treatment begins. Most patients are referred to a hematologist or lymphoma oncologist.
For classic Hodgkin lymphoma, treatment depends on stage and subtype. Limited-stage disease (I–II without unfavorable features) is typically treated with a short course of chemotherapy — most commonly ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), often followed by radiation therapy to the affected lymph node areas. Advanced-stage disease (III–IV) is treated with longer chemotherapy courses, with or without radiation. Newer regimens such as BV-AVD (which includes brentuximab vedotin, targeting CD30) are used in some patients. PET/CT is used after early treatment cycles to assess response and guide whether radiation and additional treatment are needed. The goal of treatment in virtually all patients with classic Hodgkin lymphoma is cure.
For nodular lymphocyte-predominant Hodgkin lymphoma, management depends on stage and symptoms. Early-stage disease may be treated with radiation alone or with rituximab (which targets CD20, strongly expressed in this type). More advanced or symptomatic disease is treated with rituximab-based chemotherapy. Because this subtype is slow-growing, active surveillance (watch and wait) is sometimes appropriate in selected patients. Transformation to an aggressive lymphoma — which occurs in a small proportion of patients — requires a change in treatment approach.
Long-term follow-up after treatment is important for all patients, not only to monitor for relapse but also to screen for late effects of therapy — including cardiovascular disease, secondary cancers, and endocrine effects — which are increasingly recognized as a priority, particularly for patients treated at a young age.
What does it mean if my report mentions transformation?
Transformation refers to a change in which a slower-growing lymphoma acquires additional genetic changes and becomes more aggressive. In Hodgkin lymphoma, transformation is primarily a concern in nodular lymphocyte-predominant Hodgkin lymphoma, which can occasionally transform into diffuse large B cell lymphoma. Transformed disease is more aggressive than the original lymphoma and requires a different treatment approach — typically intensive chemoimmunotherapy similar to that used for de novo DLBCL. Your pathology report will note whether transformation is present, and your care team will explain what this means for your treatment plan.
Questions to ask your doctor
- Which type of Hodgkin lymphoma do I have — classic Hodgkin lymphoma or nodular lymphocyte-predominant Hodgkin lymphoma?
- If I have classic Hodgkin lymphoma, which subtype is it — nodular sclerosis, mixed cellularity, lymphocyte-rich, or lymphocyte-depleted?
- What stage is my lymphoma, and do I have B symptoms or bulky disease?
- Was EBV found in my tumor, and does that affect my treatment plan?
- What treatment is recommended — chemotherapy alone, chemotherapy and radiation, or another approach?
- Will my treatment response be assessed with a PET/CT scan partway through chemotherapy?
- What is the expected cure rate for my specific type and stage?
- What are the most important short-term and long-term side effects I should be aware of?
- Should I consider fertility preservation before starting treatment?
- What follow-up will I need after completing treatment, and what late effects should I be monitored for?
- Are there clinical trials I should consider?
Learn more about your specific type
For more detailed information about your specific type of Hodgkin lymphoma — including the full microscopic description, immunohistochemistry results, staging, prognosis, and treatment — visit the dedicated articles below:
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