AAVD Protocol in Hodgkin Lymphoma Treatment
AAVD (Adriamycin, AVD) is a chemotherapy protocol for Hodgkin lymphoma that omits bleomycin from the standard ABVD regimen to reduce pulmonary toxicity while maintaining efficacy, and is most commonly used after 2 cycles of ABVD when PET scan shows good response (Deauville score 1-3). 1
Components of AAVD Protocol
AAVD consists of:
- Adriamycin (doxorubicin): 25 mg/m² IV on days 1 and 15
- Vinblastine: 6 mg/m² IV on days 1 and 15
- Dacarbazine: 375 mg/m² IV on days 1 and 15
The protocol is recycled every 28 days (day 29 is day 1 of next cycle).
Clinical Applications
Stage III-IV Disease
- Start with 2 cycles of ABVD
- If interim PET shows Deauville score 1-3, switch to 4 cycles of AVD (total 6 cycles)
- Consider observation or ISRT to initially bulky or selected PET-positive sites after completion 1
Stage I-II Unfavorable Disease
- After 2 cycles of ABVD with Deauville score 1-3 on PET
- Option to complete 4 cycles of AVD (total 6 cycles) with or without ISRT
- Alternative: 2 cycles of AVD (total 4 cycles) followed by ISRT 1
Older Adults (>60 years)
- Particularly beneficial in older patients due to reduced pulmonary toxicity
- For stage I-II favorable disease: 2 cycles of ABVD or AVD followed by ISRT (20-30 Gy)
- For stage I-II unfavorable or stage III-IV: Consider omitting bleomycin from ABVD regimen 1
Evidence Supporting AAVD Protocol
The RATHL trial demonstrated that omitting bleomycin after negative interim PET (after 2 cycles of ABVD) does not compromise efficacy while reducing pulmonary toxicity 1.
In the HD15 trial, PET-guided therapy showed that patients with PET-negative residual disease after chemotherapy had similar outcomes to those in complete remission, suggesting that consolidative radiotherapy could be omitted in these patients 1.
Advantages of AAVD Protocol
- Reduced pulmonary toxicity: Particularly important in older patients and those with underlying lung disease
- Maintained efficacy: Similar outcomes to ABVD in PET-negative patients after 2 cycles
- Decreased treatment-related morbidity: Fewer grade III-IV toxicities compared to full ABVD regimen 1
Clinical Considerations
- Regular monitoring for treatment-related toxicities is essential
- Cardiac function should be monitored due to anthracycline (doxorubicin) component
- Growth factor support may be needed to manage myelosuppression
- Treatment decisions should be based on interim PET results to guide therapy
Comparison with Other Regimens
- ABVD: Standard regimen with higher risk of pulmonary toxicity due to bleomycin
- Escalated BEACOPP: More intensive regimen for high-risk patients (IPS ≥4), higher toxicity profile
- Stanford V: Alternative regimen for selected patients with IPS <3 1
The AAVD protocol represents an important advancement in Hodgkin lymphoma treatment by maintaining efficacy while reducing toxicity through PET-guided therapy adaptation.