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How is ESR used in the clinical staging/risk classification of classical Hodgkin Lymphoma in pediatric and adult patients?

The current NCCN guideline version 2.2021 is a little confusing. On page HODG-2, the clinical staging/risk classification did not include ESR, but on page HODG-4 and HODG-B, it says "NCCN Unfavorable Factors include bulky mediastinal or >10 cm disease, B symptoms or ESR>=50, and > 3 sites of disease."
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Do you use ESR as part of the clinical staging/risk stratification for classical Hodgkin lymphoma?

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Pediatric Hematology/Oncology · Aflac Cancer and Blood Disorders Center/ Children's Healthcare of Atlanta - Egleston
Answered on

There has not been a consistent initial risk classifier for childhood Hodgkin Lymphoma (in contrast to the IPS used in adults). ESR has been used to follow patients in terms of a trend if elevated at diagnosis and that continues to be suggested by the current pediatric guidelines. Schwartz et al., (PMID 27786406) have proposed the initial iteration of a score termed CHIPS, borne from historic Children's Oncology Group trials. In that paper, ESR did not hold up as a predictor in initial risk classification. The score will be further validated in the contemporary trials.

So, I think that the guidelines do not list ESR as a risk classifier at the start per se, even though elevated ESR is of concern and presents a marker for follow-up during and following treatment.