What is the full management plan for a 37-year-old female with stage III Hodgkin lymphoma (HL)?

From the Guidelines

The management plan for a 37-year-old female with stage III Hodgkin lymphoma should focus on curative-intent combined modality therapy, with the recommended first-line treatment being 6 cycles of ABVD chemotherapy. The ABVD regimen consists of Adriamycin/doxorubicin 25 mg/m², bleomycin 10 units/m², vinblastine 6 mg/m², and dacarbazine 375 mg/m², administered intravenously every 2 weeks 1. Prior to initiating treatment, baseline assessments should include complete blood count, comprehensive metabolic panel, echocardiogram (due to doxorubicin's cardiotoxicity), pulmonary function tests (due to bleomycin's pulmonary toxicity), and fertility preservation counseling.

Key Considerations

• PET-CT scanning should be performed after 2 cycles to assess early response 1.
• If the interim PET scan is negative (Deauville score 1-3), bleomycin can be omitted from subsequent cycles (converting to AVD) to reduce pulmonary toxicity while maintaining efficacy 1.
• If bulky disease (>10 cm mass) is present at diagnosis, involved-site radiation therapy (30-36 Gy) should follow chemotherapy 1.
• Throughout treatment, regular monitoring includes biweekly blood tests, symptom assessment, and pulmonary monitoring.
• After completing therapy, surveillance includes history and physical examinations every 3-4 months for the first 2 years, then every 6 months for 3 years, then annually.
• CT or PET-CT scans are typically performed at 6,12, and 24 months post-treatment.
• Long-term follow-up should include screening for secondary malignancies, cardiovascular disease, and thyroid dysfunction, as these are significant concerns due to the late effects of therapy 1.

Treatment Outcomes and Future Directions

The chosen approach offers approximately 80-90% cure rates for stage III Hodgkin lymphoma, with the intensity of the regimen balanced against potential long-term toxicities 1. Research into novel agents such as brentuximab vedotin and checkpoint inhibitors (nivolumab and pembrolizumab) shows promise for improving outcomes in relapsed or refractory disease 1. However, for a patient with newly diagnosed stage III Hodgkin lymphoma, the established ABVD regimen remains the standard of care, given its proven efficacy and manageable toxicity profile 1.

From the FDA Drug Label

Vinblastine sulfate has been shown to be one of the most effective single agents for the treatment of Hodgkin’s disease Advanced Hodgkin’s disease has also been successfully treated with several multiple-drug regimens that included vinblastine sulfate. Patients who had relapses after treatment with the MOPP program— mechlorethamine hydrochloride (nitrogen mustard), vincristine sulfate, prednisone and procarbazine—have likewise responded to combination-drug therapy that included vinblastine sulfate A protocol using cyclophosphamide in place of nitrogen mustard and vinblastine sulfate instead of vincristine sulfate is an alternative therapy for previously untreated patients with advanced Hodgkin’s disease The recommended dosage of dacarbazine for injection in the treatment of Hodgkin's Disease is 150 mg/square meter body surface/day for 5 days, in combination with other effective drugs. Treatment may be repeated every 4 weeks.

The full management plan for a 37-year-old female with stage III Hodgkin lymphoma (HL) may include:

• Combination chemotherapy: using multiple drugs such as vinblastine sulfate and dacarbazine, as part of a regimen like MOPP (mechlorethamine hydrochloride, vincristine sulfate, prednisone, and procarbazine) or an alternative protocol with cyclophosphamide and vinblastine sulfate.
• Vinblastine sulfate: as a single agent or in combination with other drugs, with a goal of achieving a greater percentage of response than a single-agent regimen.
• Dacarbazine: at a dosage of 150 mg/square meter body surface/day for 5 days, in combination with other effective drugs, with treatment repeated every 4 weeks 2 3.

From the Research

Management Plan for Stage III Hodgkin Lymphoma

The management plan for a 37-year-old female with stage III Hodgkin lymphoma (HL) involves a combination of chemotherapy and radiation therapy.

• The standard treatment for advanced-stage HL is doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy, with or without consolidation radiation therapy 4.
• According to the GATLA study, patients with stage III HL are classified as unfavorable and receive 6 cycles of ABVD plus involved-field radiation therapy (IFRT) at 30 Gy to bulky areas at diagnosis or to those areas remaining positive after the third cycle of ABVD 5.
• The use of consolidative radiation therapy after complete response to ABVD chemotherapy has been shown to improve disease-free survival and overall survival in patients with stage III HL, particularly those with initial mediastinal involvement or bulky head and neck disease 6.
• Alternative chemotherapy regimens, such as brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine (AVD), have been evaluated in clinical trials and may be considered for patients with limited-stage HL, but their use in stage III HL is not well established 7.

Chemotherapy Regimens

• ABVD chemotherapy is the standard of care for advanced-stage HL, with a complete response rate of 85% in unfavorable patients 5.
• The AVD regimen has been shown to be effective in limited-stage HL, with a complete response rate of 100% in a phase 2 study, but its use in stage III HL requires further evaluation 7.
• Escalated BEACOPP regimens have more acute and late toxicities, and their survival benefits have yet to be confirmed 4.

Radiation Therapy

• Involved-field radiation therapy (IFRT) is used in combination with ABVD chemotherapy for patients with stage III HL, with a dose of 30 Gy to bulky areas at diagnosis or to those areas remaining positive after the third cycle of ABVD 5.
• Consolidative radiation therapy after complete response to ABVD chemotherapy may improve disease-free survival and overall survival in patients with stage III HL, particularly those with initial mediastinal involvement or bulky head and neck disease 6.