What are the treatment options for patients with Hodgkin lymphoma, including those participating in the Ukrapid trial?

Treatment Options for Hodgkin Lymphoma Including UKRAPID Trial

The standard treatment for Hodgkin lymphoma varies by disease stage, with ABVD chemotherapy remaining the backbone of therapy for most patients, while BEACOPP escalated offers superior progression-free survival in younger patients with advanced disease. 1

Treatment by Disease Stage

Limited Stage (I-II) Hodgkin Lymphoma

• Standard approach: 2-3 cycles of ABVD followed by involved-site radiation therapy (ISRT) 1
• Combined modality treatment shows superior tumor control compared to radiation therapy alone 1
• For Stage IA Nodular Lymphocyte-Predominant Hodgkin Lymphoma without risk factors, 30 Gy ISRT alone is standard 1

Intermediate Stage Hodgkin Lymphoma

• Standard approach: 4 cycles of ABVD followed by 30 Gy involved-field radiation therapy (IF-RT) 2
• Alternative for patients <60 years: 2 cycles of BEACOPP escalated followed by 2 cycles of ABVD and 30 Gy IF-RT 2
  • This approach has shown superior freedom from treatment failure at 4 years compared to ABVD 2
  • However, long-term toxicity data (particularly regarding fertility) is still lacking 2

Advanced Stage (III-IV) Hodgkin Lymphoma

• For patients <60 years:
  • Either 6-8 cycles of ABVD or 4-6 cycles of BEACOPP escalated 1
  • BEACOPP escalated offers superior progression-free survival but with higher toxicity 3
  • Radiotherapy typically limited to residual masses >1.5 cm after chemotherapy 2
• For patients >60 years:
  • 6-8 cycles of ABVD followed by radiation to residual masses >1.5 cm 2, 1
  • BEACOPP should be avoided due to excessive toxicity in this age group 2, 1

PET-Guided Treatment Approaches

• Multiple ongoing trials are evaluating PET-guided treatment strategies 2
• Interim PET-CT appears to be a good predictor of treatment failure in advanced HL treated with ABVD 2
• Recent analyses suggest radiotherapy might be omitted in patients with residual disease but negative PET after chemotherapy 2
• Treatment stratification based on interim PET is promising but not yet standard practice 2

Relapsed/Refractory Hodgkin Lymphoma

• Standard approach: High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) 2, 1
• Salvage regimens before ASCT include DHAP, IGEV, or ICE 1
• For post-ASCT failure: Brentuximab vedotin is approved 1
• For patients failing brentuximab: PD-1 inhibitors (nivolumab, pembrolizumab) 1
  • Nivolumab is FDA-approved for classical Hodgkin lymphoma that has relapsed or progressed after:
    1. Autologous HSCT and brentuximab vedotin, or
    2. Three or more lines of systemic therapy including autologous HSCT 4

Treatment Toxicities and Considerations

• BEACOPP escalated toxicities include higher rates of:
  • Infertility
  • Myelosuppression
  • Infections
  • Requires G-CSF support 1
• ABVD toxicity includes risk of bleomycin pulmonary toxicity (20-31% of patients) 5
• Recent studies incorporating brentuximab vedotin and PD-1 blockade into frontline and salvage regimens are changing treatment paradigms 6

Follow-up Care

• Regular follow-up schedule: every 3 months for 2 years, then every 4-6 months for 3 years, then annually 1
• Annual thyroid function tests for patients who received neck radiation 1
• Long-term monitoring for late effects including secondary malignancies and cardiac toxicity 1

UKRAPID Trial Context

While the UKRAPID trial is mentioned in the question, specific details about this trial are not provided in the evidence. However, it likely represents one of the ongoing studies evaluating PET-guided treatment approaches for Hodgkin lymphoma, which are mentioned in the guidelines as promising but not yet standard practice.