What are the treatment options for Hodgkin lymphoma?

Treatment Options for Hodgkin Lymphoma

Treatment for Hodgkin lymphoma should be based on disease stage, risk factors, and patient characteristics, with ABVD chemotherapy remaining the standard regimen for many patients, while BEACOPP escalated offers superior outcomes in advanced disease for younger patients. 1

Disease Classification and Staging

Hodgkin lymphoma is classified into two main types:

• Classical Hodgkin lymphoma (cHL)
• Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL)

Staging follows the Ann Arbor classification system, with patients categorized into three treatment groups:

• Limited stage (Stage I-II without risk factors)
• Intermediate stage (Stage I-II with risk factors)
• Advanced stage (Stage III-IV and some Stage IIB) 2

Risk factors include:

• Large mediastinal mass
• Extranodal disease
• Elevated ESR
• Multiple nodal areas
• Age ≥50 years 2

Treatment Approaches by Stage

Limited Stage Disease

• Standard treatment: 2-3 cycles of ABVD followed by involved-site radiation therapy (ISRT) 2
• Combined-modality treatment has shown superior tumor control compared to radiation therapy alone 2
• For NLPHL Stage IA without risk factors: 30 Gy ISRT alone is standard 2

Intermediate Stage Disease

• Standard treatment: 4 cycles of ABVD followed by 30 Gy ISRT 2
• Alternative for patients <60 years: 2 cycles of BEACOPPescalated followed by 2 cycles of ABVD and 30 Gy ISRT 2
• PET-guided approach: Patients with positive interim PET after 2 cycles of ABVD should receive 2 cycles of BEACOPPescalated before ISRT 2

Advanced Stage Disease

• Standard treatment options:
  • Patients <60 years: Either 6-8 cycles of ABVD or 4-6 cycles of BEACOPPescalated 2, 1
  • Patients >60 years: 6-8 cycles of ABVD (BEACOPP should be avoided due to increased toxicity) 2, 1
• After 2 cycles of ABVD, consider omitting bleomycin in cycles 3-6 if interim PET is negative, especially in elderly patients or those with lung disease risk 2, 1
• Radiation therapy is generally confined to patients with residual disease after chemotherapy 2

Special Considerations

Bleomycin Toxicity Management

• Consider omitting bleomycin after cycle 2 in ABVD, especially in patients >60 years or with lung disease 2, 1
• Bleomycin should not be given for more than two cycles in patients >60 years 2

NLPHL Treatment

• Stage IA without risk factors: 30 Gy ISRT alone 2
• Other stages: Treat identically to classical HL 2
• Consider incorporating anti-CD20 antibodies (rituximab) in treatment regimens 2, 1

Relapsed or Refractory Disease

• Standard approach: High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) 2, 1
• Salvage regimens before ASCT: DHAP, IGEV, or ICE 2
• For patients failing ASCT: Brentuximab vedotin is approved 2, 3
• For patients failing ASCT and brentuximab vedotin: Consider PD-1 inhibitors (nivolumab, pembrolizumab) 2
• Allogeneic SCT may be considered for young, chemosensitive patients who fail HDCT followed by ASCT 2

Follow-up and Monitoring

• Regular follow-up schedule: Every 3 months for first 6 months, every 6 months until 4th year, then annually 2
• Annual thyroid function tests if neck was irradiated 2
• Monitor for late effects including second cancers and cardiovascular disease 2, 1

Treatment Toxicity Considerations

• BEACOPP escalated: Higher rates of infertility, myelosuppression, and infections; requires G-CSF support 1
• ABVD: Lower toxicity profile but still carries risks of bleomycin-induced pulmonary toxicity 4
• Long-term monitoring is essential due to risks of secondary malignancies and cardiac toxicity 2, 1

By following these evidence-based treatment approaches and considering individual patient factors, Hodgkin lymphoma can be effectively managed with high cure rates while minimizing treatment-related toxicity.