What is the recommended treatment for a patient with early-stage Hodgkin's lymphoma, negative Positron Emission Tomography (PET) scan, and no systemic symptoms, with negative Hepatitis and Human Immunodeficiency Virus (HIV) tests?

Treatment for Early-Stage Hodgkin's Lymphoma with Negative PET Scan

For a patient with early-stage Hodgkin's lymphoma with negative PET scan and negative hepatitis/HIV tests, the recommended treatment is combined modality therapy consisting of 2 cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) chemotherapy followed by 30 Gy involved-field radiotherapy (IFRT).

Risk Stratification and Treatment Selection

The treatment approach depends on whether the patient has favorable or unfavorable early-stage disease:

For Early Favorable Disease (Stage I-II without risk factors):

• Standard treatment: 2 cycles of ABVD + 30 Gy IFRT 1
• This approach provides excellent outcomes with 5-year overall survival rates >95% and freedom from treatment failure rates >90% 1

For Early Unfavorable Disease (Stage I-II with risk factors):

• Standard treatment: 4 cycles of ABVD + 30 Gy IFRT 1
• Risk factors include: bulky mediastinal disease (>1/3 thoracic width), extranodal involvement, elevated ESR (>50 for A stages, >30 for B stages), ≥3 involved lymph node areas 1

PET Scan Significance

The negative PET scan is a favorable prognostic indicator:

• Patients with PET-negative status after initial chemotherapy have significantly better 2-year event-free survival (82% vs 50% for PET-positive) 2
• The negative PET scan confirms the absence of active disease and supports continuing with the planned treatment regimen 1

Treatment Algorithm

1. Confirm disease stage and risk factors

   • Early favorable: Stage I-II without risk factors
   • Early unfavorable: Stage I-II with risk factors

2. Administer chemotherapy

   • Early favorable: 2 cycles of ABVD
   • Early unfavorable: 4 cycles of ABVD

3. Follow with involved-field radiotherapy

   • Standard dose: 30 Gy to initially involved sites
   • Begin optimally within 3 weeks after completing chemotherapy 1

Important Considerations

• Pulmonary function monitoring: Perform pulmonary function tests (including DLCO) before treatment and after completion of ABVD due to bleomycin-related pulmonary toxicity 1

• Cardiac evaluation: Assess ejection fraction before doxorubicin-based chemotherapy 1

• Fertility preservation: Consider fertility preservation options before initiating treatment, especially for patients of reproductive age 1

Common Pitfalls to Avoid

1. Overtreatment: Using more intensive regimens like BEACOPP for early-stage disease increases toxicity without improving survival 1

2. Undertreatment: Using chemotherapy alone without radiation in early-stage disease may lead to higher relapse rates, although overall survival remains similar 3

3. Inadequate follow-up: After treatment completion, patients require regular monitoring every 3 months for the first year, every 6 months for years 2-3, and annually thereafter 1

4. Missing late effects: Long-term surveillance should include monitoring for secondary malignancies and cardiac toxicity, particularly in patients who received mediastinal radiation 1

The negative hepatitis and HIV tests are reassuring as they confirm the absence of comorbidities that might complicate treatment decisions or affect tolerance to chemotherapy.