What is the recommended treatment for Classical Hodgkin Lymphoma (CHL) stage IIB?

Treatment of Classical Hodgkin Lymphoma (CHL) Stage IIB

For Classical Hodgkin Lymphoma (CHL) stage IIB, the recommended treatment is four cycles of ABVD chemotherapy followed by 30 Gy involved field (IF) radiotherapy, which provides tumor control and overall survival rates exceeding 85-90% at 5 years. 1

Risk Stratification for Stage IIB

Stage IIB CHL requires careful risk assessment to determine the appropriate treatment approach:

• Standard Stage IIB: Treated as early unfavorable disease
• Stage IIB with large mediastinal mass or extranodal involvement: Treated as advanced disease 1

Treatment Algorithm

For Stage IIB (Early Unfavorable Disease):

1. First-line therapy: 4 cycles of ABVD followed by 30 Gy involved field radiotherapy
   • This combined modality approach achieves 85-90% 5-year overall survival 1
   • Provides superior tumor control compared to radiation therapy alone

For Stage IIB with Bulky Disease or Extranodal Involvement (Advanced Disease):

1. For patients <60 years:

   • Option 1: 8 cycles of escalated BEACOPP (preferred by German Hodgkin Study Group)
   • Option 2: 6-8 cycles of ABVD
   • Overall response rates with BEACOPP escalated reach 96%, with 92% overall survival at 5 years 1

2. For patients ≥60 years:

   • 6-8 cycles of ABVD (BEACOPP avoided due to excessive toxicity) 2
   • Consider radiotherapy for residual masses >1.5 cm after chemotherapy

Response Assessment

• PET/CT scan using Deauville criteria (5-point scale) is essential for response assessment 1
• Interim PET-CT is a good predictor of treatment failure in patients treated with ABVD 2

Treatment Considerations

Efficacy Data

• Combined-modality therapy with ABVD and radiation for stage IIB bulky disease has demonstrated 8-year overall survival rates of 88.8% and relapse-free survival rates of 76.8% 3
• Factors associated with improved outcomes include:
  • Age <40 years
  • ABVD regimen (vs. older MOPP regimen)
  • Radiation dose ≥30.1 Gy 3

Toxicity Management

• Pulmonary toxicity: Monitor for bleomycin-induced pulmonary toxicity, especially in older patients, those with cumulative bleomycin dose, prior lung disease, or pulmonary irradiation 1
• Myelosuppression: Common but typically resolves after treatment completion 1
• Fertility concerns: BEACOPP may cause permanent infertility, while ABVD is less likely to affect fertility 1
• Thyroid function: Annual thyroid function tests for patients receiving neck irradiation 1, 2

Follow-up Recommendations

• Physical examination every 3 months for 2 years, then every 4-6 months for 3 years, then annually 2
• Regular blood counts and imaging studies
• Long-term monitoring for late effects including secondary malignancies and cardiac toxicity 2

Pitfalls to Avoid

• Routine use of growth factors with ABVD is not recommended as it may increase pulmonary toxicity 1
• Avoid undertreatment of stage IIB with bulky disease or extranodal involvement, which should be treated as advanced disease 1
• Ensure adequate radiation dose (≥30 Gy) for optimal outcomes 3
• Be vigilant for late treatment-related side effects, particularly in long-term survivors

In patients with relapsed disease, high-dose chemotherapy followed by autologous stem cell transplantation is the standard approach, with consideration of brentuximab vedotin for patients failing ASCT 1, 2.