Initial Treatment for Hodgkin Lymphoma
The initial treatment for Hodgkin lymphoma is risk-stratified combined modality therapy, with early-stage favorable disease receiving 2 cycles of ABVD chemotherapy followed by 30 Gy involved-field radiotherapy, early-stage unfavorable disease receiving 4 cycles of ABVD plus 30 Gy involved-field radiotherapy, and advanced-stage disease receiving 6-8 cycles of ABVD (or BEACOPP escalated in patients <60 years) with selective radiotherapy to residual masses. 1
Risk Stratification Framework
Treatment selection depends on proper risk classification using the Cotswolds modification of the Ann Arbor staging system combined with specific risk factors 2:
Early Favorable (Stage I-II without risk factors):
- No large mediastinal mass (≤1/3 horizontal chest diameter)
- ESR <50 with B symptoms or <30 without B symptoms
- Fewer than 3 involved lymph node areas
- No extranodal disease 2
Early Unfavorable (Stage I-II with risk factors):
- Presence of any of the above risk factors 2
Advanced Stage:
- Stage III, IV, or IIb with large mediastinal mass or extranodal involvement 2
Treatment by Risk Group
Early-Stage Favorable Disease
Standard therapy is 2 cycles of ABVD followed by 30 Gy involved-field radiotherapy. 2, 1 This approach is based on the German Hodgkin Study Group HD7 and HD10 trials and EORTC H7F and H8F trials, which demonstrated that 2 cycles of ABVD is non-inferior to 4 cycles when combined with radiotherapy 2. The combined modality approach substantially reduces relapses compared to radiotherapy alone 2.
Important caveat: Chemotherapy-only approaches using 4-6 cycles of ABVD exist as alternatives, but lack robust prospective randomized trial support 2.
Early-Stage Unfavorable Disease
Standard therapy is 4 cycles of ABVD followed by 30 Gy involved-field radiotherapy. 2, 1 This achieves tumor control and overall survival exceeding 85-90% at 5 years 2. The Italian Society of Hematology guidelines confirm that 4 cycles of ABVD plus involved-field radiotherapy represents the standard for limited disease with unfavorable features 2.
For patients under 60 years eligible for more intensive treatment, 2 cycles of BEACOPP escalated followed by 2 cycles of ABVD and 30 Gy involved-field radiotherapy may provide superior freedom from treatment failure 1.
Advanced-Stage Disease
For patients under 60 years, 8 cycles of BEACOPP escalated is the preferred regimen based on superior outcomes. 2 The German Hodgkin Study Group demonstrated that BEACOPP escalated achieves 96% overall response, 88% disease-free survival, and 92% overall survival at 5 years—significantly superior to ABVD's 50-60% long-term cure rates 2.
For patients over 60 years or those unable to tolerate intensive therapy, 6-8 cycles of ABVD is the standard approach due to increased toxicity of BEACOPP in this population. 2, 1
Radiotherapy considerations: Additional radiotherapy to initial tumor bulks or residual disease <2.5 cm after chemotherapy is not generally recommended 2. However, larger residual tumors that are PET-positive should receive consolidation radiotherapy 2.
Special Populations
Lymphocyte-Predominant Hodgkin Lymphoma (LPHL): Stage I LPHL can be treated with involved-field radiotherapy (30 Gy) alone, given its indolent course 2. Rituximab is reserved for relapsed LPHL 2.
ABVD Regimen Components
ABVD consists of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine 2, 3. Vinblastine has demonstrated effectiveness as one of the most effective single agents for Hodgkin's disease and is a key component of combination regimens 3.
Critical Implementation Points
Avoid these pitfalls:
- Do not use extended-field radiotherapy—involved-field radiotherapy at 30 Gy is equally effective with significantly lower toxicity 2
- Do not perform explorative laparotomy or splenectomy for staging—these are no longer recommended 2
- Do not use radiotherapy alone for early-stage disease—combined modality therapy is superior 2
- Ensure proper staging with CT scans of neck, thorax, abdomen, and pelvis, plus bone marrow biopsy in patients with B symptoms, stage III/IV disease, or blood count abnormalities 2
Essential pre-treatment assessments: