What are the next steps after diagnosing Hodgkin's lymphoma on biopsy?

From the Guidelines

After diagnosing Hodgkin's lymphoma on biopsy, the next steps involve staging the disease and initiating appropriate treatment, with the most recent guidelines from 2018 recommending a comprehensive staging workup including PET-CT scan, complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and possibly bone marrow biopsy in advanced cases 1. The patient should undergo a thorough medical history and physical examination, with laboratory tests including full blood cell count and blood chemistry, ESR, HBV, HCV, and HIV screening, as well as imaging studies such as contrast-enhanced CT scan of the neck, chest, and abdomen, and PET scan 1.

Staging and Risk Stratification

The staging and risk stratification of Hodgkin's lymphoma is crucial in determining the appropriate treatment approach. The Ann Arbor staging system is commonly used, with stages I-IV indicating the extent of disease spread 1.

• Stage I: Involvement of a single lymph node region or a single lymphoid organ
• Stage II: Involvement of two or more lymph node regions on the same side of the diaphragm
• Stage III: Involvement of lymph node regions on both sides of the diaphragm
• Stage IV: Widespread involvement of one or more extralymphatic organs

Treatment Approach

The treatment approach for Hodgkin's lymphoma typically consists of combination chemotherapy with ABVD regimen (Adriamycin/doxorubicin, Bleomycin, Vinblastine, and Dacarbazine) for 2-6 cycles depending on stage, often followed by involved-field radiation therapy for early-stage disease 1. For advanced disease (stages III-IV), 6 cycles of chemotherapy are usually recommended. Alternative regimens include escalated BEACOPP for high-risk patients 1.

• ABVD regimen: 2-6 cycles, depending on stage and risk factors
• Escalated BEACOPP: for high-risk patients, 6-8 cycles
• Involved-field radiation therapy: for early-stage disease, 20-30 Gy

Fertility Preservation and Follow-up

Fertility preservation options should be discussed before treatment initiation, as chemotherapy can affect reproductive function 1. Regular follow-up with interim PET-CT scans is essential to assess treatment response, and patients should be monitored for potential long-term toxicities, such as cardiac and pulmonary dysfunction, and secondary cancers 1.

From the FDA Drug Label

INDICATIONS AND USAGE ADCETRIS is a CD30-directed antibody and microtubule inhibitor conjugate indicated for treatment of: • Adult patients with previously untreated Stage III or IV classical Hodgkin lymphoma (cHL), in combination with doxorubicin, vinblastine, and dacarbazine (1. 1). • Pediatric patients 2 years and older with previously untreated high risk classical Hodgkin lymphoma (cHL), in combination with doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide (1.2). • Adult patients with classical Hodgkin lymphoma (cHL) at high risk of relapse or progression as post-autologous hematopoietic stem cell transplantation (auto-HSCT) consolidation (1. 3). • Adult patients with classical Hodgkin lymphoma (cHL) after failure of auto-HSCT or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not auto-HSCT candidates (1. 4).

The next steps after diagnosing Hodgkin's lymphoma on biopsy may include treatment with brentuximab vedotin (ADCETRIS) in combination with other chemotherapy agents, depending on the stage and risk of the disease. The specific treatment regimen will depend on the individual patient's circumstances, including their age, overall health, and the extent of their disease.

• Treatment options for adult patients with previously untreated Stage III or IV classical Hodgkin lymphoma (cHL) may include brentuximab vedotin in combination with doxorubicin, vinblastine, and dacarbazine 2.
• Treatment options for pediatric patients 2 years and older with previously untreated high-risk classical Hodgkin lymphoma (cHL) may include brentuximab vedotin in combination with doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide 2.
• Treatment options for adult patients with classical Hodgkin lymphoma (cHL) at high risk of relapse or progression as post-autologous hematopoietic stem cell transplantation (auto-HSCT) consolidation may include brentuximab vedotin 2.
• Treatment options for adult patients with classical Hodgkin lymphoma (cHL) after failure of auto-HSCT or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not auto-HSCT candidates may include brentuximab vedotin 2.

From the Research

Next Steps After Diagnosing Hodgkin's Lymphoma on Biopsy

The diagnosis of Hodgkin's lymphoma on biopsy is a critical step in the management of the disease. After diagnosis, several steps are taken to determine the best course of treatment.

• Staging: The first step is to determine the stage of the disease, which involves identifying the extent of the lymphoma in the body 3.
• PET/CT Scan: A positron emission tomography/computed tomography (PET/CT) scan is commonly used for staging and monitoring treatment response in Hodgkin's lymphoma 3, 4.
• Risk Stratification: Patients are stratified into different risk groups based on factors such as age, stage, and presence of symptoms 5.
• Treatment: Treatment options for Hodgkin's lymphoma include chemotherapy, radiation therapy, and immunotherapy 5, 6, 7.
• Interim PET/CT Scan: An interim PET/CT scan is often performed after 1-4 cycles of chemotherapy to assess early response to treatment and guide further therapy 5, 4, 6.
• Response-Adapted Treatment: Patients with a negative interim PET/CT scan may receive a less intensive treatment regimen, while those with a positive scan may require more intensive therapy 5, 6.

Monitoring and Follow-Up

After completing treatment, patients with Hodgkin's lymphoma require regular follow-up to monitor for signs of recurrence or late effects of treatment.

• PET/CT Scan: PET/CT scans are used to monitor response to treatment and detect early signs of recurrence 3, 4.
• Imaging Patterns: New imaging patterns related to immune checkpoint inhibitors have been observed in patients with Hodgkin's lymphoma, emphasizing the need for close collaboration between imaging and oncology specialists 7.
• Survivorship Care: Long-term follow-up care is essential to address the physical, emotional, and social needs of survivors of Hodgkin's lymphoma.