Survival by design: Cell fate dynamics in classical Hodgkin lymphoma

Abstract

Classical Hodgkin lymphoma (cHL) is singular because rare Hodgkin and Reed-Sternberg (HRS) cells survive within an abundant inflammatory tumor microenvironment (TME) – despite originating from germinal center (GC) B cells that would normally be negatively selected, they persist through coordinated disruption of lineage fidelity, immune recognition, and cell-death execution. The present review integrates mechanistic, translational, and therapeutic evidence on apoptosis resistance, survival signaling, microenvironmental support, immune evasion, Epstein-Barr virus-associated rescue mechanisms, and senescence-like phenotypes in cHL, with particular emphasis on how these processes converge to stabilize an aberrant HRS-cell fate by raising the apoptotic threshold. HRS cells retain several elements of apoptotic competence, including death receptors, functional mitochondrial apoptotic machinery, and frequently wild-type TP53; however, these factors are functionally restrained by multiple antagonistic mechanisms: c-FLIP inhibits pro-caspase-8 activation, constitutive NF-κB, JAK/STAT and PI3K/AKT signaling sustain survival, BCL-2-superfamily overexpression confers resistance to intrinsic apoptotic stimuli, MDM2 overactivity suppresses p53, and microenvironment-derived secretory products and contact-dependent ligands provide stabilizing support. The inflammatory niche reinforces HRS-cell persistence by converting immune proximity into immune privilege through altered antigen presentation, PD-1/PD-L1 signaling, spatially inhibitory rosetting structures, regulatory T-cell prevalence, M2-macrophage polarization, and cytokine-mediated paracrine and autocrine survival circuits. Emerging evidence indicates that Reed-Sternberg cells (RS) acquire senescence-like features and secretory programs that contribute to constructing the inflammatory niche. cHL can therefore be understood as a malignancy of failed fate execution, in which apoptosis, differentiation and immune clearance remain available but are rendered non-executable by convergent intrinsic and microenvironmental survival circuits.