What is the recommended first-line chemotherapy regimen for Hodgkin lymphoma, specifically the ABVD (Adriamycin (doxorubicin), Bleomycin, Vinblastine, Dacarbazine) regimen?

ABVD as First-Line Chemotherapy Regimen for Hodgkin Lymphoma

ABVD (Adriamycin/doxorubicin, Bleomycin, Vinblastine, Dacarbazine) is the recommended standard first-line chemotherapy regimen for most patients with Hodgkin lymphoma, with 6-8 courses recommended for advanced disease. 1

Treatment Recommendations by Disease Stage

Early Stage (I-II) Favorable Disease

• Treatment options:
  • 2 cycles of ABVD followed by 20 Gy involved-site radiation therapy (ISRT) 1
  • For elderly patients (>60 years): 2 cycles of ABVD or AVD (omitting bleomycin) followed by ISRT (20-30 Gy) 1

Early Stage (I-II) Unfavorable Disease

• Treatment options:
  • 4 cycles of ABVD followed by involved-field radiation therapy (IFRT) (30 Gy) 1
  • For elderly patients: ABVD with bleomycin potentially omitted after 2 cycles if PET scan is negative (Deauville score 1-3) 1

Advanced Stage (III-IV) Disease

• Treatment options:
  • 6-8 cycles of ABVD as first-line therapy 1
  • Alternative regimens like escalated BEACOPP may be considered in clinical trials but have significantly higher toxicity 1, 2

ABVD Regimen Details

Dosing

• Doxorubicin (Adriamycin): 25 mg/m²
• Bleomycin: 10 units/m²
• Vinblastine: 6 mg/m² (standard adult dosing starts at 3.7 mg/m² and may increase up to 18.5 mg/m² based on tolerance) 3
• Dacarbazine: 375 mg/m² (alternative: 150 mg/m²/day for 5 days) 4

Administration

• Typically administered every 2 weeks (days 1 and 15 of a 28-day cycle)
• Vinblastine should be administered intravenously over approximately one minute 3
• Dacarbazine should be administered intravenously 4

Efficacy of ABVD

• Complete response rates of 82-94% have been reported 5, 6
• 5-year progression-free survival rates of 71-84% 6, 7
• 5-year overall survival rates of 74-96% 5, 6
• Long-term studies show 7-year overall survival of 96% and progression-free survival of 84% for early-stage disease 5

Comparison with Other Regimens

ABVD vs. BEACOPP

• Escalated BEACOPP shows better initial disease control and complete metabolic remission rates (85% vs. 76% for ABVD) 2
• However, BEACOPP is associated with significantly higher toxicity 1, 2
• No significant difference in overall survival between the two regimens 1, 2
• BEACOPP should only be considered in clinical trials due to limited evidence of superiority compared to ABVD 1

ABVD vs. MOPP or MOPP-like Regimens

• MOPP or MOPP-like regimens are not recommended 1
• ABVD is associated with lower rates of sterility and secondary leukemia compared to MOPP 1

Special Considerations

Elderly Patients (>60 years)

• Consider omitting bleomycin due to increased risk of pulmonary toxicity 1, 7
• Bleomycin-free regimens may show better survival trends in elderly patients 7
• Alternative regimens like CHOP or VEPEMB may be considered 1

Bleomycin Toxicity Management

• Monitor for bleomycin-induced pulmonary toxicity, especially in:
  • Older patients
  • Those with prior lung disease
  • Patients receiving pulmonary irradiation 1
• Pulmonary function tests including diffusing capacity of the lungs for carbon monoxide are recommended 1
• Growth factors are not routinely recommended with ABVD regimens 1

Fertility Considerations

• ABVD is rarely associated with infertility, unlike BEACOPP which may cause immediate and permanent infertility 1
• Fertility preservation should be considered before treatment initiation 1

Follow-up and Monitoring

• PET/CT for restaging after treatment to assess response using Deauville criteria (5-point scale) 1
• Long-term follow-up is essential to monitor for late treatment-related effects 1
• Vaccination against pneumococcal, meningococcal, and H-flu is recommended every 5 years for patients treated with splenic radiation or splenectomy 1

In conclusion, ABVD remains the standard first-line chemotherapy regimen for Hodgkin lymphoma across all disease stages due to its favorable efficacy and toxicity profile compared to more intensive regimens. The number of cycles and addition of radiation therapy should be tailored based on disease stage and risk factors.