Should bilateral (versus unilateral) bone marrow biopsies be routine in paediatric classical Hodgkin Lymphoma where PET-CT is unavailable?

Introduction: Paediatric classical Hodgkin Lymphoma (cHL) can be treated successfully with modern therapeutic regimens. In the context of risk-adapted treatment strategies, accurate staging and risk stratification are crucial to improve outcomes. Although fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) detects bone marrow (BM) involvement accurately in cHL and is recommended over BM biopsies in the staging of paediatric cHL, this imaging modality is not widely available in most African countries, and BM biopsies continue to be performed. Case presentation: An 8-year-old HIV-negative boy from Lesotho was referred to the Universitas Academic Hospital Paediatric Oncology Unit, South Africa, in March 2024, with a 2-year history of a progressively enlarging neck mass, fever, loss of appetite, hepatosplenomegaly, and cytopenias. Bilateral BM aspirate and trephine biopsies revealed discrepant results: The right-sided biopsy showed only reactive features, whereas the left side confirmed a diagnosis of stage 4 cHL. Management and Outcome: The child was initiated on the high-risk arm of the South African cHL treatment protocol. Owing to availability and cost constraints, a PET-CT could neither be done at diagnosis nor to evaluate his initial therapeutic response. Instead, repeat bilateral BM and CT investigations were performed to guide management as per the protocol. He completed all treatment and remains in complete remission 2 years later. Conclusion: Delayed referral and diagnosis of paediatric cancers remain a problem in Africa and may contribute to advanced disease at presentation. In this child, correct staging and risk stratification of cHL ensured optimal treatment selection and a favourable outcome. What this study adds: Bilateral, rather than unilateral BM biopsies should be considered for cHL staging where PET-CT is unavailable.