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We commend Li et al.[1] for their article “Clinical characteristics of the patients with Hodgkin's lymphoma involving extranodal sites” (published in the Chinese Journal of Cancer in July 2012). We agree that in comparison with extranodal non-Hodgkin's lymphoma (NHL), the incidence of extranodal Hodgkin's lymphoma (HL) is much rarer and thus described much less frequently in the literature. We would like add a few points to complement the above mentioned article.  Patients with extranodal lymphoma (either NHL or HL) have a higher risk of being infected with the human immunodeficiency virus (HIV) than do those with lymphoma confined to the lymphoreticular system. As a corollary, HIV-infected patients who develop lymphomas are more likely to manifest extranodal disease compared with the non-HIV-infected population. Indeed, various series consistently showed that more than 50% of HIV-associated lymphomas present with extranodal disease[2]–[5].  HL patients with HIV infection, especially those carrying a high risk of extranodal involvement, are nearly always co-infected with the Epstein-Barr virus and often have other high risk features, such as (but not limited to) B symptoms, high stage at presentation, and poor outcome to standard therapy[3]–[5].  Bearing the above points in mind, we suggest that every patient with extranodal HL should be evaluated to assess the HIV status and also to ascertain the CD4+ T cell count. If done, the highly active anti-retroviral therapy could be initiated to improve CD4+ T cell counts, which in turn could improve patient survival by reducing the risk of infection-related deaths and indirectly improving patient tolerance for chemotherapy[6],[7].  Lastly, we also suggest the routine use of whole body 18-fluorodeoxyglucose positron emission tomography scan among all HIV-positive individuals who develop lymphomas to detect foci of extranodal involvement that would otherwise be missed.

Hodgkin's lymphoma involving extranodal sites: potential association with HIV infection and the implications for clinical management