Treatment Options for Hodgkin's Lymphoma
The treatment of Hodgkin's lymphoma is primarily based on risk stratification, with combined modality therapy (chemotherapy plus radiation) being the standard approach for most patients, tailored according to disease stage and risk factors. 1
Risk Stratification
Hodgkin's lymphoma treatment is determined by classifying patients into risk groups:
- Early favorable risk group: Stage I and II without risk factors 1
- Early unfavorable risk group: Stage I and II with risk factors (large mediastinal mass, extranodal disease, elevated ESR, ≥3 involved lymph node areas) 1
- Advanced risk group: Stage III, IV, and IIB with large mediastinal mass or extranodal involvement 1
Treatment by Disease Stage
Early Favorable Disease
- Standard treatment: Two cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) followed by 30 Gy involved field (IF) radiotherapy 1
- This approach has been validated by the German Hodgkin Study Group (GHSG) HD7 and HD10 trials and EORTC trials H7F and H8F 1
- Alternative: Four to six cycles of ABVD alone for selected patients, though data from large randomized trials supporting this approach is limited 1
Early Unfavorable Disease
- Standard treatment: Four cycles of ABVD followed by 30 Gy IF radiotherapy 1
- This regimen provides tumor control and overall survival exceeding 85-90% at 5 years 1
- Extended field radiotherapy or six cycles of chemotherapy are similarly effective but more toxic 1
- Recent data shows excellent outcomes with 4 cycles of ABVD followed by involved-site radiation therapy (ISRT), even for patients with bulky disease 2
Advanced Disease
- For patients <60 years: Eight cycles of escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) is recommended by the German Hodgkin Study Group 1
- Provides superior overall response (96%), disease-free survival (88%), and overall survival (92%) at 5 years 1
- For patients >60 years: Six to eight cycles of ABVD due to higher toxicity of BEACOPP 1
- Additional radiotherapy is not generally recommended for residual disease <2.5 cm 1
- PET-positive larger residual tumors after chemotherapy should receive additional radiotherapy 1
Lymphocyte Predominant Hodgkin Lymphoma (LPHL)
- Stage I LPHL: Involved field radiotherapy (30 Gy) alone 1
- Rituximab is an option for relapsed LPHL due to CD20 positivity 1, 3
Treatment of Relapsed Disease
- Standard approach for younger patients: 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 with palliative intent 1
- Chemotherapy-sensitive younger patients with suitable donors may be considered for allogeneic transplantation (experimental) 1
- Brentuximab vedotin is effective for patients ineligible for high-dose therapy or those who have failed autologous stem cell transplant 4
Special Considerations
- For patients with multiple comorbidities: Consider modified ABVD without bleomycin followed by involved-site radiotherapy 3
- For patients with severe organ dysfunction: Single-agent therapy with brentuximab vedotin may be considered 3
- For pediatric patients: Four cycles of ABVD for limited disease and six cycles for advanced disease, with radiation (20-21 Gy) only to sites of bulky disease or slow early response 5
Response Evaluation and Follow-up
- Response evaluation typically occurs after treatment completion 1
- Evaluation includes physical examination, laboratory analysis, and CT scans of initially involved areas 1
- PET-CT is valuable for distinguishing between active and non-active tissue 1
- Follow-up schedule: Every 3 months for the first year, every 6 months for years 2-3, then annually 1
- Women who received radiotherapy to breast tissue should undergo mammography screening after age 40 1