What is the treatment for stage II unfavorable Hodgkin lymphoma (Hodgkin's lymphoma)?

From the Guidelines

The standard treatment for stage II unfavorable Hodgkin lymphoma is four cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) followed by 30 Gy involved field (IF) radiotherapy, as this approach has been shown to result in tumor control and overall survival in excess of 85% or 90% at 5 years 1.

Treatment Overview

The treatment for stage II unfavorable Hodgkin lymphoma typically involves combined modality therapy with chemotherapy followed by radiation therapy.

• The standard chemotherapy regimen is ABVD administered intravenously every 2 weeks for 4 cycles.
• After chemotherapy, involved-field radiation therapy (IFRT) is usually given at doses of 30 Gy to initially involved sites.

Rationale

The choice of ABVD followed by IFRT is based on studies such as those from the German Hodgkin Study Group (GHSG) and the EORTC trials, which have demonstrated the efficacy of this approach in reducing relapses and improving survival rates 1.

Considerations

• PET/CT scanning is typically performed after 2 cycles of chemotherapy to assess response.
• Common side effects include fatigue, nausea, hair loss, and increased infection risk.
• Long-term monitoring is essential due to potential late effects including secondary malignancies and cardiovascular disease.

Administration and Supportive Care

Treatment should be administered at centers experienced in managing lymphoma, with supportive care including antiemetics, growth factors if needed, and fertility preservation discussions before starting therapy.

• The use of more aggressive chemotherapy regimens or alternative approaches, such as chemotherapy only, may be considered in certain cases, but these are not currently the standard of care 1.

From the FDA Drug Label

Vinblastine Sulfate Injection is indicated in the palliative treatment of the following: I Frequently Responsive Malignancies Generalized Hodgkin’s disease (Stages III and IV, Ann Arbor modification of Rye staging system)

The FDA drug label does not answer the question.

From the Research

Treatment Options for Stage II Unfavorable Hodgkin Lymphoma

The treatment for stage II unfavorable Hodgkin lymphoma typically involves a combination of chemotherapy and radiation therapy.

• The most widely accepted chemotherapy regimen is ABVD (Adriamycin, bleomycin, vinblastine, and dacarbazine) 2.
• Recent trials have also evaluated other regimens such as BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) 3, 4.
• After chemotherapy, the standard radiation field is involved-field RT, although there is increasing interest in involved-node RT 2.

Chemotherapy Regimens

• A study comparing 4 cycles of ABVD with an intensified treatment consisting of 2 cycles of escalated BEACOPP followed by 2 cycles of ABVD found that the intensified regimen demonstrated superior freedom from treatment failure (FFTF) and progression-free survival (PFS) 3.
• Another study found that 4 cycles of ABVD followed by involved-field radiation therapy (IFRT) resulted in long-term tumor control of approximately 80% 3.
• A comparison of 4 versus 6 cycles of ABVD chemotherapy with radiation found that patients with early unfavorable HL have excellent outcomes with 4 cycles of ABVD chemotherapy followed by ISRT, and 6 cycles of chemotherapy does not appear superior for disease control, even for bulky disease 5.

Radiation Therapy

• Involved-field RT is the standard radiation field after chemotherapy 2.
• Involved-node RT is also being considered as an alternative 2.
• A study found that ISRT and IFRT had similar outcomes in terms of freedom from relapse (FFR) 5.

Treatment Efficacy and Toxicity

• The administration of 6 ABVD cycles is an effective and safe treatment in patients with stage I and II Hodgkin's lymphoma, with overall survival and progression-free survival rates at 7 years of 96% and 84%, respectively 6.
• Treatment with BEACOPP, as compared with ABVD, resulted in better initial tumor control, but the long-term clinical outcome did not differ significantly between the two regimens 4.
• Severe adverse events occurred more frequently in the BEACOPP group than in the ABVD group 4.