Is ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) an appropriate systemic therapy for a patient with Hodgkin lymphoma confined to the abdominal wall after surgical resection?

ABVD is Not Standard for Isolated Abdominal Wall Hodgkin Lymphoma Post-Resection

For Hodgkin lymphoma confined to the abdominal wall after surgical resection, ABVD chemotherapy is appropriate as systemic therapy, but the treatment approach should be guided by formal staging, risk stratification, and whether complete resection was achieved.

Critical Initial Assessment Required

Before determining ABVD appropriateness, complete staging workup is mandatory:

• Contrast-enhanced CT of neck, chest, and abdomen to exclude occult nodal disease 1
• PET/CT scanning for accurate disease extent assessment, as isolated extranodal presentation is uncommon in Hodgkin lymphoma 1
• Bone marrow biopsy if PET shows multifocal skeletal lesions or cytopenias are present 1
• Full blood count, ESR, and blood chemistry including LDH and albumin for risk stratification 1

Treatment Decision Algorithm

If Truly Stage IE Disease (Isolated Extranodal Site)

Limited-stage favorable disease (single extranodal site, no risk factors):

• 2-4 cycles of ABVD followed by 20-30 Gy involved-site radiotherapy is the standard approach 1, 2
• The ESMO guidelines specifically recommend 2-4 cycles of ABVD plus 20-30 Gy IFRT for limited stages 1
• Expected complete response rates of 82-94% with 5-year progression-free survival >90% 2

If unfavorable features present (bulky disease >5cm, elevated ESR, multiple extranodal sites):

• 4-6 cycles of ABVD followed by 30 Gy involved-site radiotherapy 1, 3
• The HD11 trial validated 4 cycles of ABVD plus IFRT for early unfavorable disease with 6-year overall survival of 100% 3

If Post-Resection Status is Complete

• Chemotherapy is still indicated even after complete surgical resection, as surgery alone is not curative for Hodgkin lymphoma 1
• The standard remains systemic chemotherapy with ABVD to address microscopic disease 1
• Consolidative radiotherapy to the resection bed at 30-36 Gy after complete remission from chemotherapy 1

ABVD Regimen Specifics

The standard ABVD dosing is 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
• Cycle repeats every 28 days

Critical Pre-Treatment Evaluations

Before initiating ABVD 1:

• Echocardiography to establish baseline ejection fraction for doxorubicin cardiotoxicity monitoring
• Pulmonary function tests including DLCO for bleomycin toxicity risk assessment
• Pregnancy test in women of childbearing age
• Fertility preservation counseling and consideration of sperm/oocyte cryopreservation before alkylating agent exposure

Common Pitfalls to Avoid

• Do not use G-CSF prophylaxis with ABVD, as it increases bleomycin pulmonary toxicity without survival benefit 2, 4
• Do not confuse vincristine with vinblastine - ABVD uses vinblastine, not vincristine 2
• Do not assume isolated extranodal disease without complete staging - most apparent "isolated" presentations have occult nodal involvement 1
• Do not omit systemic therapy based on complete surgical resection - surgery is not definitive treatment for Hodgkin lymphoma 1

Expected Outcomes

With appropriate ABVD-based treatment 2, 5:

• Complete response rates: 82-94% for early-stage disease
• 5-year overall survival: 96-100% for stage I-II disease
• 5-year progression-free survival: 84-90% for limited-stage disease
• Relapse rate: 10-16% with salvage options including high-dose chemotherapy and autologous stem cell transplantation

Monitoring During Treatment

• Pulmonary function testing if bleomycin cumulative dose exceeds 200 units/m² or respiratory symptoms develop 1
• Echocardiography if cumulative doxorubicin dose approaches 300 mg/m² 4
• Interim PET/CT after 2-4 cycles to assess treatment response, though treatment modification based on interim PET remains investigational 1