Hodgkin’s Disease is an uncommon lymphoma accounting for approximately 1 percent of cancers registered in developed countries each year. The incidence is approximately one-half to one-third of that for non-Hodgkin’s lymphoma. The annual incidence ranges from 3 per 100,000 in Europe and the United States to less than 1 per 100,000 in Japan. There is a striking bimodality in incidence with peaks in young adulthood and in older adulthood. This pattern is quite different from those of non-Hodgkin’s lymphoma and other leukemias. In young adults the nodular-sclerosing subtype predominates (>50%).

Histological classification of Hodgkin’s disease is based on that of Lukes and Butler (1966) which was modified at the Rye Conference of 1966 and has since been known as the Rye Classification. Four subtypes of disease are defined. Again, the nodular sclerosing subtype is the most common (>50%) histological type of Hodgkin’s disease, particularly in the young adult. Prognosis after treatment is generally very good. Young patients with substantial mediastinal disease are frequently diagnosed with the nodular-sclerosing subtype, and these patients are more frequently young women.

Nearly all patients with Hodgkin’s disease present with painless lymphadenopathy. In a minority of patients there are complaints of night sweats and weight loss. Most patients with nodular-sclerosing histology present with supra-diaphragmatic disease and mediastinal lymph node involvement. In the majority of patients the disease spreads predictably via lymphatic channels to contiguous lymph node groups.

Staging of Hodgkin’s disease patients is made according to the criteria established at the Workshop on the Staging of Hodgkin’s Disease held at Ann Arbor, Michigan, in April 1971. The Ann Arbor classification defines four stages (abbreviated below):


I.   Involvement of a single extra-nodal site or a single lymph node region or structure.

II.   Involvement of two or more lymph node regions or lymph structures on the same side of the diaphragm

III.   Involvement of lymph node regions or lymph node structures on both sides of the diaphragm

IV.   Diffuse of disseminated involvement of one or more extra-nodal organs or tissues with or without associated lymph node involvement


Clinical stage is based on information derived from the initial biopsy, history, physical examination, laboratory tests, radiographic examinations and radioisotope scans.

CT Scanning is a routine part of the initial evaluation of Hodgkin’s disease. Radioisotope studies are also a valuable staging tool and they are essential in monitoring the response to therapy. Gallium-67 scanning has traditionally been used for these purposes. It has a high sensitivity for detection of Hodgkin’s disease but Gallium scanning has been largely supplanted by FDG in recent years, as in the case of these images. Gallium imaging cannot be performed during radiotherapy and chemotherapy because binding to transferring is markedly impaired. F-18 FDG offers the advantage of allowing scanning during treatment, its uptake being altered little by the effects of drugs or radiation.

F-18 FDG is a glucose analog that enters metabolically active cells in the manner of glucose. It enters the same enzymatic pathway as glucose but does not proceed past phosphorylation to FDG-6-phospate. Uptake of the radiotracer is highest in the brain and heart with considerably less in the liver. Excretion is via the kidneys, and, consequently, the bladder receives the highest radiation dose, 4 rads/10mCi. Optimal scanning results occur when glucose uptake is physiologically maximized, hence, patients are instructed to fast for at least 4 hours prior to scanning. This is especially important in the case of tumor imaging. Elevated levels of glucose in the blood will compete with FDG uptake and result in decreased tumor uptake. The radionuclide F-18 decays by positron emission and it has a half-life of 108 minutes. The emission of two high-energy 511 keV photons at 180-degree angles forms the basis for detection by PET imaging systems or coincidence SPECT systems. The image seen here is a coincidence SPECT product.

Coincidence SPECT scanning uses either a specially designed collimator which is adapted for use with the high-energy 511keV photon, or, preferably, an a dual-headed SPECT camera which incorporates an “electronic collimator”, a detector and associated software that can sense 511keV photon events which occur simultaneously at opposite orientations. This “poor man’s” PET is well suited to locating malignant tumors, although it is less sensitive than FDG PET for small tumors (<1.5 cm). FDG PET and coincidence SPECT using FGD are excellent tools for staging of Hodgkin’s disease. For several types of cancer they offer more cost-effective and more accurate staging of patients than CT. They are a preferred means of determining the effectiveness of therapy because of the ability to image the entire body, allowing localization of new metastases, and to distinguish residual tumor from necrotic or fibrotic tissue.