Treatment for Localized Hodgkin's Lymphoma Confined to the Abdominal Wall
For a patient with Hodgkin's lymphoma isolated to the abdominal wall with no other sites of metastasis, the recommended treatment is 4 cycles of ABVD chemotherapy followed by 30 Gy involved-site radiotherapy (ISRT), as this represents intermediate-stage unfavorable disease due to extranodal involvement. 1
Why This is Intermediate-Stage Unfavorable Disease
The presence of an isolated abdominal wall mass constitutes extranodal disease, which is a critical risk factor that automatically upgrades the patient from early favorable to intermediate-stage unfavorable disease, regardless of the Ann Arbor stage. 1 Extranodal involvement is specifically listed as a risk factor that moves patients from limited stage to intermediate stage treatment groups according to the German Hodgkin Study Group (GHSG) classification. 2, 1
Required Staging Workup Before Treatment
Before initiating therapy, complete the following staging evaluation:
- Contrast-enhanced CT scan of neck, chest, and abdomen to confirm no other sites of involvement 1
- PET-CT for accurate initial staging when available 1
- Bone marrow biopsy to exclude marrow involvement 1
- Full blood count, ESR, and blood chemistry including liver enzymes, LDH, and albumin 2
- Baseline cardiac evaluation with ECG and echocardiography to assess left ventricular ejection fraction before doxorubicin exposure 2, 3
- Pulmonary function testing to establish baseline before bleomycin exposure 2, 3
- Reproductive counseling and fertility preservation options for patients of reproductive age 2, 3
Standard Treatment Protocol
Chemotherapy Regimen
Administer 4 cycles of ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine) given every 2 weeks: 2, 1
- Doxorubicin 25 mg/m² IV on days 1 and 15
- Bleomycin 10 mg/m² IV on days 1 and 15
- Vinblastine 6 mg/m² IV on days 1 and 15
- Dacarbazine 375 mg/m² IV on days 1 and 15
- Recycle on day 29 2
Consolidation Radiotherapy
Following chemotherapy, deliver 30 Gy involved-site radiotherapy (ISRT) to the abdominal wall. 2, 1 The current ILROG guidelines recommend ISRT after chemotherapy in limited stages, which represents smaller radiation fields compared to older involved-field techniques. 2
Alternative Intensive Approach for Younger Patients
For patients under 60 years old who are candidates for more intensive treatment, consider 2 cycles of BEACOPPescalated followed by 2 cycles of ABVD and 30 Gy ISRT. 2, 1, 4 This intensified approach demonstrated superior freedom from treatment failure compared to 4 cycles of ABVD in the GHSG HD14 trial, with a 7.2% improvement at 5 years. 4 However, this comes with increased acute toxicity, though no overall differences in treatment-related mortality or secondary malignancies were observed. 4
PET-Adapted Treatment Considerations
Interim PET scanning after 2 cycles allows for treatment optimization, though this approach cannot yet be considered standard practice. 2, 3 If interim PET is negative (Deauville score ≤2), some protocols continue with standard therapy, while positive interim PET may warrant escalation to BEACOPPescalated. 2, 3 However, available data consistently demonstrate a progression-free survival advantage for patients treated with combined-modality approaches despite negative interim PET. 2
Expected Outcomes
With appropriate treatment, patients with intermediate-stage Hodgkin lymphoma achieve:
Post-Treatment Surveillance
- PET-CT at treatment completion to confirm complete remission 1
- Long-term follow-up for late effects including secondary malignancies and cardiovascular disease 1
- Monitoring for bleomycin pulmonary toxicity and doxorubicin cardiotoxicity 3, 5
Critical Pitfall to Avoid
Do not treat this as early favorable disease with only 2 cycles of ABVD plus radiotherapy. 2, 3 The extranodal location automatically classifies this as intermediate-stage unfavorable disease requiring 4 cycles of chemotherapy, not 2. 1 Undertreatment would compromise the excellent cure rates achievable with appropriate therapy.