Frontline Therapy for Classical Hodgkin Lymphoma by Stage and Prognostic Factors

Abstract

Hodgkin lymphoma is a highly curable malignancy in early and advanced stages. Most patients are diagnosed in their teens or twenties and are expected to live decades beyond their treatment. Therefore, the toxicity of treatment must be balanced with the goal of cure. Thus, treatment has been refined through prognostic models and positron emission tomography-computed tomography (PET-CT)-directed therapy. Stratification by prognostic models defines groups of patients with favorable characteristics who may be treated with less intensive therapy upfront, including fewer cycles of chemotherapy, lower doses of radiation, or omission of radiation altogether. Alternatively, high-risk patients may be assigned to a more aggressive initial approach. The modern use of interim PET-CT allows further tailoring of treatment by response.

Keywords: Hodgkin lymphoma; PET directed; advanced stage; early favorable; early unfavorable; prognosis.

Figure 1.

Treatment Schema: Early Favorable Hodgkin Lymphoma. ^aPatients without response should have a biopsy. If biopsy is positive, consider transitioning to a salvage regimen. ^bThis approach is based on the RAPID-UK study, but not a preferred approach. Patients with Deauville score of 4 to 5 should have a biopsy and consider transitioning to escalated BEACOPP if negative or a salvage regimen and autologous transplant if biopsy is positive. ^cRadiation with smaller fields, including involved site irradiation (ISRT) or involved nodal irradiation (INRT). ^dRadiation dose varies based on PET response and bulky versus nonbulky disease. GHSG indicates German Hodgkin Study Group; EORTC, European Organization for the Research and Treatment of Cancer; NCCN, National Comprehensive Cancer Network; CMT, combination modality therapy; RT, radiation therapy; escBEACOPP, escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone; ABVD, doxorubicin, bleomycin, vinblastine, dacarbazine; Rx, treatment.

Figure 2.

Treatment Schema: Early Unfavorable (non-bulky) Hodgkin Lymphoma. ^aPatients without response should have a biopsy. If biopsy is positive, consider transitioning to a salvage regimen. ^bReimage after 2 cycles of escBEACOPP to ensure response; if no response, consider changing to a salvage regimen. ^cRadiation techniques with smaller fields including involved site irradiation (ISRT) or involved nodal irradiation (INRT) are preferred. ABVD indicates doxorubicin, bleomycin, vinblastine, dacarbazine; CMT: combination modality therapy; escBEACOPP: escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone; ESR, erythrocyte sedimentation rate; PET-CT, positron emission tomography-computed tomography; RT: radiation therapy; Rx: treatment.

Figure 3.

Treatment Schema: Early Unfavorable (bulky) Hodgkin Lymphoma. ^aPatients without response should have a biopsy. If biopsy is positive, consider transitioning to a salvage regimen. ^bReimage after 2 cycles of escBEACOPP to ensure response; if no response, consider changing to a salvage regimen. ^cRadiation techniques with smaller fields including involved site irradiation (ISRT) or involved nodal irradiation (INRT) are preferred. ^dBulky disease sites may receive 30 to 36 Gy of RT. ABVD indicates doxorubicin, bleomycin, vinblastine, dacarbazine; CMT: combination modality therapy; escBEACOPP: escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone; PET-CT, positron emission tomography-computed tomography; RT: radiation therapy; Rx: treatment.

Figure 4.

Treatment Schema: Advanced Stage Hodgkin Lymphoma. ^aPatients with concern for progression should have a biopsy. If biopsy is positive, consider transitioning to a salvage regimen. ^bInterim PET-CT after 2 cycles of escBEACOPP to ensure response. If no response, consider transitioning to salvage regimen. ^cRadiation techniques with smaller fields including involved site irradiation (ISRT) or involved nodal irradiation (INRT) are preferred. ^dRadiation to initially bulky site or with Deauville score of 4 to 5 after completion of chemotherapy. ^eConsider omitting bleomycin for elderly patients, or those with pulmonary comorbidities, or patients at risk for bleomycin lung toxicity. ABVD indicates doxorubicin, bleomycin, vinblastine, dacarbazine; escBEACOPP, escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone; IPS, International Prognostic Score; PET-CT, positron emission tomography-computed tomography; RT, radiation therapy; Rx, treatment. **Consideration for escalated BEACOPP in patients

Figure 5.

Treatment Schema: Elderly Hodgkin Lymphoma. ^aBleomycin may be omitted from initially in patients at risk for bleomycin lung toxicity. ^bRe-image after 2 cycles to assess response. Patients without response should have a biopsy. If biopsy is positive, consider transitioning to a salvage regimen with safety and efficacy in the elderly such as brentuximab vedotin or PD-1 inhibitors. Use of BEACOPP generally not recommended in this population. ^cRadiation techniques with smaller fields including involved site irradiation (ISRT) or involved nodal irradiation (INRT) are preferred. ^dPatients who receive bleomycin initially and achieve a CR after 2 cycles, may omit bleomycin from future cycles.