Next Treatment for Relapsed Hodgkin Lymphoma After ABVD
For this 14-year-old girl with Hodgkin lymphoma relapsed after ABVD, the next treatment should be 2-3 cycles of platinum-based salvage chemotherapy (DHAP, ICE, or IGEV) followed by high-dose chemotherapy with autologous stem cell transplantation (ASCT). 1, 2
Immediate Next Steps
Confirm True Relapse
- Obtain histological confirmation via biopsy before proceeding with salvage therapy, particularly if progression occurs in new sites, to rule out misdiagnosis or transformation 3
- This is mandatory before any salvage treatment begins 3
Salvage Chemotherapy Regimen Selection
Choose one of the following platinum-based regimens: 1, 2
- DHAP (dexamethasone/high-dose ara-C/cisplatin) - particularly recommended since she was previously treated with ABVD and the cumulative doxorubicin dose makes cardiac toxicity a concern 2
- ICE (ifosfamide/carboplatin/etoposide) - equally effective alternative 1, 2
- IGEV (ifosfamide/gemcitabine/vinorelbine) - demonstrates good activity with low toxicity profile 1, 2
Administer 2-3 cycles of the chosen salvage regimen to reduce tumor burden and mobilize stem cells prior to transplantation 1, 2
Critical Treatment Goals
- The primary goal is achieving FDG-PET negativity (Deauville score ≤3), which defines chemosensitivity and dramatically impacts post-ASCT outcomes 2, 3
- Chemosensitive disease (at minimum partial response) is required to proceed to transplantation 3
Definitive Treatment: High-Dose Chemotherapy with ASCT
If salvage chemotherapy achieves chemosensitive disease, proceed immediately to high-dose chemotherapy followed by ASCT - this is the treatment of choice for relapsed Hodgkin lymphoma and offers the only potentially curative option 1, 3
Evidence Supporting This Approach
- Randomized trials demonstrate 3-year event-free survival of 53-55% with ASCT versus only 10-34% with conventional chemotherapy alone 3, 4
- Five-year failure-free survival reaches 40-45% with ASCT 5, 6
- ASCT significantly improves freedom from treatment failure (55% at 3 years) compared to continued conventional chemotherapy (34%) 4
Post-ASCT Management
After ASCT, administer brentuximab vedotin consolidation - this is now standard for high-risk patients, which includes relapsed disease 3
If Residual Disease Persists
- Consider radiotherapy to residual nodal disease after salvage therapy if chemosensitive but with residual masses 2
Regimens to AVOID in This Patient
Do NOT use the following: 2
- BEACOPPescalated as salvage therapy - risk of exceeding critical cumulative anthracycline dose (she already received doxorubicin in ABVD), significant hematologic toxicity, and potential impairment of stem cell mobilization 2
- Mini-BEAM or Dexa-BEAM - associated with significant toxic mortality 2
- Dose-intensive sequential chemotherapy - does not improve prognosis compared to standard DHAP-based salvage 2
Special Considerations for Adolescent Patient
Age-Appropriate Factors
- At 14 years old, she is well within the age range for aggressive salvage therapy and ASCT (guidelines specify patients up to 60 years) 1
- Reproductive counseling is mandatory before salvage treatment because chemotherapy can cause permanent fertility damage 7
- Pre-treatment cardiac and pulmonary function tests are required to identify patients at increased risk of complications 7
Prognosis
- Despite relapse, the prognosis remains favorable with appropriate salvage therapy and ASCT 7
- Achieving PET-negative status after salvage chemotherapy is the most important prognostic factor for post-transplant success 2, 3
If Refractory to Salvage Chemotherapy
If she fails to achieve chemosensitive disease after salvage chemotherapy, consider: 3