Initial Treatment for Hodgkin Lymphoma
The initial treatment for Hodgkin lymphoma should be risk-stratified based on disease stage and risk factors, with ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) as the backbone of therapy for most patients, followed by involved field radiation therapy in early-stage disease. 1
Risk Stratification
Patients with Hodgkin lymphoma are classified into three risk groups that determine treatment approach:
- 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 Risk Group
Early Favorable Disease
- Standard treatment: Two cycles of ABVD followed by 30 Gy involved field (IF) radiotherapy 1
- This combined modality approach has demonstrated high cure rates with reduced toxicity compared to more intensive regimens 2
- Chemotherapy plus radiotherapy substantially reduces relapse rates compared to radiotherapy alone 1
Early Unfavorable Disease
- Standard treatment: Four 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
- Extended field radiotherapy or six cycles of chemotherapy have similar efficacy but higher toxicity 1
Advanced Disease
- For patients <60 years: Eight cycles of escalated BEACOPP (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procarbazine, prednisone) is recommended by the German Hodgkin Study Group 1
- BEACOPP escalated has shown 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 in older patients 1
- Additional radiotherapy should be considered for residual PET-positive tumors after chemotherapy 1
Special Considerations
Lymphocyte Predominant Hodgkin Lymphoma (LPHL)
- Stage I LPHL patients can be treated with IF radiotherapy (30 Gy) only 1
- Rituximab is an option for relapsed LPHL 1
Monitoring During Treatment
- PET scanning is increasingly used to guide treatment decisions 1, 3
- Early interim PET may predict treatment failure in advanced HL receiving ABVD 1
Treatment Efficacy and Long-term Outcomes
- Combined modality therapy for early-stage disease achieves cure rates >90% 2
- Advanced-stage disease treated with ABVD alone has long-term cure rates of 50-60% 1
- BEACOPP escalated improves these outcomes significantly in advanced disease 1
Common Pitfalls and Caveats
- Bleomycin pulmonary toxicity requires careful monitoring, especially in older patients 4
- Radiation therapy fields have evolved from extended field to involved field to reduce long-term toxicity 2
- Long-term survivors require monitoring for secondary malignancies and cardiac disease 2
- Vinblastine is FDA-approved for Hodgkin lymphoma and is a critical component of the ABVD regimen 5
Relapsed Disease Management
For patients who relapse after initial therapy: