Initial Management of Hodgkin Lymphoma
The initial management of Hodgkin lymphoma requires comprehensive staging workup followed by risk-stratified combined modality therapy, with ABVD chemotherapy plus involved-field radiotherapy for early-stage disease and full-course ABVD for advanced-stage disease. 1, 2
Initial Workup and Staging
Mandatory Laboratory Evaluations
The following tests must be performed before initiating therapy 1:
- Complete blood count with differential to assess for cytopenias 1, 3
- Serum albumin and LDH as prognostic markers and indicators of tumor burden 1, 3
- Erythrocyte sedimentation rate (ESR) for risk stratification 1
- HBV, HCV, and HIV serology as these infections impact treatment decisions 1, 3
- Pregnancy test in women of fertile age before therapy initiation 1
- Comprehensive metabolic panel including liver and kidney function 3
Required Imaging Studies
CT scan of the neck, thorax, abdomen, and pelvis is mandatory for volumetric assessment and staging 1, 3. Standard chest X-ray with calculation of mass-to-thorax diameter ratio is necessary to define bulky mediastinal involvement 1.
FDG-PET or CT-PET is strongly recommended (though not absolutely mandatory) for baseline assessment, as it is essential for PET-guided response evaluation during treatment 1. When available, combined CT-PET is preferred over standard FDG-PET 1.
Selective Procedures
Bone marrow biopsy should be performed in patients with B symptoms (fever >38°C, night sweats, weight loss >10% body weight), stage III/IV disease, or blood count abnormalities 1.
Cardiac and Fertility Assessment
Bidimensional ultrasound evaluation of left ventricular ejection fraction is required before anthracycline-based therapy 1. This is simpler and less expensive than angio-scintigraphy for detecting cardiac dysfunction 1.
All fertile patients must receive reproductive counseling before therapy initiation 1. Male patients should be offered sperm cryopreservation 1. Female patients should be offered estro-progestinic therapy to reduce amenorrhea risk and consider oocyte/ovary tissue cryopreservation 1, 4.
Additional Assessments for Radiation Candidates
For patients who will receive neck irradiation, thyroid function tests (TSH, FT3, FT4) and dental care are mandatory 1.
First-Line Treatment Strategy
Early-Stage Disease (Stages I-II)
Combined modality therapy with ABVD chemotherapy followed by involved-field radiotherapy (30 Gy) is the standard approach 1. The number of ABVD courses depends on risk category 1:
- Favorable early-stage: 2-4 courses of ABVD followed by involved-field RT 1
- Unfavorable early-stage: 4-6 courses of ABVD followed by involved-field RT 1
This combined approach has demonstrated superior 5-year freedom from progression (93% vs 70%) compared to radiotherapy alone 1. Radiotherapy alone is no longer recommended based on multiple randomized trials including SWOG, GHSG HD7, and EORTC H7/H8 studies 1.
Advanced-Stage Disease (Stages III-IV)
Full-term chemotherapy with ABVD (typically 6-8 courses) is recommended 1. Adjuvant radiotherapy is NOT recommended in patients without initial bulky disease who achieve complete remission 1.
For younger patients with advanced disease and high-risk features, escalated BEACOPP regimens may be considered, though ABVD remains standard 1. However, in elderly patients, chemotherapy regimens more intensive than ABVD are not recommended due to toxicity concerns 1.
Response Assessment
Early evaluation of response with FDG-PET scan is recommended to guide treatment modifications 1. PET-guided therapy allows for treatment adaptation based on metabolic response 2, 5, 6.
Relapsed or Refractory Disease
High-dose chemotherapy followed by autologous hematopoietic stem cell transplant is the standard of care for patients with relapsed or refractory disease 1, 7, 8, 2.
For patients who relapse after autologous transplant, options include 1, 2, 5:
- Allogeneic transplant (recommended for post-autologous transplant relapse) 1
- Brentuximab vedotin (now standard therapy) 7, 8, 2
- PD-1 blockade with checkpoint inhibitors 2, 5, 6
- Non-myeloablative allogeneic stem cell transplant 7, 8, 2
- Clinical trial participation 7, 8
Critical Pitfalls to Avoid
Do not use radiotherapy alone for early-stage disease, as combined modality therapy has proven superior survival outcomes 1. Do not add adjuvant radiotherapy to patients with advanced disease who achieve complete remission without initial bulk, as this increases toxicity without survival benefit 1.
Do not delay fertility counseling until after treatment initiation—gonadal function preservation measures must be implemented before therapy starts 1. Women should adopt effective contraception to avoid pregnancies for three years after chemotherapy completion 1.
For patients previously treated with chest radiation before age 30, exercise extreme caution with estrogen supplementation due to significantly elevated breast cancer risk (up to 29% cumulative risk by age 55) 4.