What are the common treatment options for Hodgkin's lymphoma?

Treatment Options for Hodgkin's Lymphoma

The standard treatment for Hodgkin's lymphoma depends on disease stage and risk factors, with combined modality therapy (chemotherapy plus radiation) being the most effective approach for early-stage disease and chemotherapy alone for advanced disease. 1

Disease Classification and Staging

• Hodgkin's lymphoma is classified into two major subtypes: classical Hodgkin's lymphoma (cHL) and lymphocyte predominant Hodgkin's lymphoma (LPHL) 1
• Staging is based on the Cotswolds classification (modification of Ann Arbor system) and patients are allocated to risk groups based on stage and additional risk factors 1
• Risk groups include: early favorable (stage I-II without risk factors), early unfavorable (stage I-II with risk factors), and advanced (stage III-IV and IIB with large mediastinal mass or extranodal involvement) 1

Treatment by Disease Stage

Early Favorable Disease (Stage I-II without risk factors)

• Standard treatment: 2 cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) followed by 30 Gy involved field (IF) radiotherapy 1
• This combined approach significantly reduces relapse rates compared to radiotherapy alone 1
• Alternative: 4-6 cycles of ABVD chemotherapy alone, though data supporting this approach is limited 1

Early Unfavorable Disease (Stage I-II with risk factors)

• Standard treatment: 4 cycles of ABVD followed by 30 Gy IF radiotherapy 1
• This approach achieves tumor control and overall survival rates exceeding 85-90% at 5 years 1, 2
• For patients with positive interim PET after 2 cycles of ABVD, switching to 2 cycles of BEACOPPescalated before radiotherapy improves outcomes 1

Advanced Disease (Stage III-IV and IIB with bulky disease)

• For patients <60 years: 8 cycles of BEACOPPescalated is recommended by the German Hodgkin Study Group, with superior overall response (96%), disease-free (88%) and overall survival (92%) at 5 years 1
• For patients >60 years or those who cannot tolerate intensive therapy: 6-8 cycles of ABVD due to lower toxicity 1, 3
• Additional radiotherapy is generally not recommended for residual disease <2.5cm but should be considered for larger PET-positive residual tumors 1

Special Populations

• For LPHL: Stage I can be treated with IF radiotherapy (30 Gy) alone; rituximab is an option for relapsed disease 1
• For patients with organ dysfunction (liver disease, kidney injury, cardiomyopathy): modified ABVD without bleomycin followed by involved-site radiotherapy 3
• For pediatric patients: 4 cycles of ABVD for limited disease and 6 cycles for advanced disease, with radiation only for bulky sites or slow early response 4

Relapsed/Refractory Disease

• For younger patients who relapse after combined modality treatment: high-dose chemotherapy (HDCT) and autologous stem-cell transplantation 1
• Salvage regimens include DHAP, ESHAP, ICE, MiniBEAM, or gemcitabine combinations 1
• For patients relapsing after HDCT: gemcitabine alone or in combination as palliative approach 1
• For CD20-positive HL cases (usually LPHL): rituximab has shown effectiveness 1
• For ineligible patients or those who failed high-dose therapy: brentuximab vedotin, immune checkpoint inhibitors, or clinical trials 5

Treatment Regimens

• ABVD: doxorubicin (25 mg/m²), bleomycin (10 mg/m²), vinblastine (6 mg/m²), dacarbazine (375 mg/m²) on days 1 and 15 of a 28-day cycle 1, 6
• BEACOPPescalated: bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone in escalated doses 1

Monitoring and Follow-up

• Response evaluation typically performed after treatment completion and when clinically indicated 1
• Evaluation includes physical examination, laboratory analysis, and CT scans of initially involved areas 1
• PET may help distinguish between active and non-active tissue 1
• Follow-up schedule: every 3 months for first year, every 6 months for years 2-3, then annually 1

Common Pitfalls and Considerations

• Bleomycin should be omitted in patients with compromised pulmonary function or organ dysfunction to avoid pulmonary toxicity 3, 2
• For patients with multiple comorbidities, dose adjustments and modified regimens are necessary to reduce toxicity while maintaining efficacy 3
• Regular cardiac assessment is essential during treatment with anthracycline-containing regimens like ABVD 3
• Women who receive radiotherapy to breast tissue should undergo screening for secondary breast cancer clinically and by mammography after age 40 1