What are the initial treatment options for Hodgkin lymphoma?

Initial Treatment Options for Hodgkin Lymphoma

The initial treatment for Hodgkin lymphoma should be tailored according to disease stage and risk factors, with ABVD chemotherapy forming the backbone of most treatment regimens across all stages. 1

Risk Stratification

Treatment selection depends on proper risk stratification into three main groups:

• Early favorable risk group: Stage I and II without risk factors 2, 1
• Early unfavorable risk group: Stage I and II with risk factors (large mediastinal mass, extranodal disease, elevated ESR, or ≥3 involved lymph node areas) 2, 1
• Advanced risk group: Stage III, IV, and IIB with large mediastinal mass or extranodal involvement 2, 1

Treatment by Risk Group

Early Favorable Disease

• Standard treatment: Combined modality therapy with 2 cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) followed by 30 Gy involved-field radiotherapy (IF-RT) 2, 1
• This approach has been validated by the German Hodgkin Study Group HD7/HD10 trials and EORTC H7F/H8F trials 2
• Two cycles of ABVD is not inferior to four cycles when combined with 30 Gy IF-RT 2
• Alternative approach: Chemotherapy alone with 4-6 cycles of ABVD, though data from randomized trials supporting this is limited 2

Early Unfavorable Disease

• Standard treatment: 4 cycles of ABVD followed by 30 Gy IF-RT 2, 1
• This approach achieves tumor control and overall survival rates exceeding 85-90% at 5 years 2
• For patients under 60 years eligible for more intensive treatment, 2 cycles of BEACOPPescalated followed by 2 cycles of ABVD and 30 Gy IF-RT may provide superior freedom from treatment failure 1
• Extended field radiotherapy or 6 cycles of chemotherapy have similar efficacy but higher toxicity 2, 3

Advanced Disease (Stage III-IV)

• Standard treatment options:
  • 6-8 cycles of ABVD with radiotherapy limited to residual masses 2, 1
  • For patients <60 years: 8 cycles of BEACOPPescalated followed by radiation to residual disease >1.5 cm 2, 1
• The German Hodgkin Study Group considers BEACOPPescalated standard for patients <60 years due to superior overall response (96%), disease-free (88%), and overall survival (92%) at 5 years 2
• For elderly patients (>60 years): 6-8 cycles of ABVD due to higher toxicity of BEACOPP 2, 1

Special Considerations

Nodular Lymphocyte-Predominant Hodgkin Lymphoma (NLPHL)

• Stage I NLPHL can be treated with involved-field radiotherapy (30 Gy) alone 2
• Rituximab is an option for relapsed NLPHL 2

Response Assessment

• PET/CT is essential for response assessment using the Deauville criteria 1
• Additional radiotherapy should be considered for PET-positive residual tumors after chemotherapy 2

Treatment Toxicity Considerations

• Bleomycin pulmonary toxicity is more common with longer ABVD regimens (31% with 6 cycles vs 20% with 4 cycles) 3
• Fertility preservation should be offered to young patients prior to treatment 1
• Long-term follow-up is crucial due to potential late effects of treatment 1

Relapsed/Refractory Disease

• High-dose chemotherapy followed by autologous stem cell transplantation is the standard of care 1
• Salvage regimens include DHAP, IGEV, or ICE to reduce tumor burden before transplant 1
• Brentuximab vedotin has shown encouraging results in relapsed/refractory disease 1, 4