All content on this site is intended for healthcare professionals only. By acknowledging this message and accessing the information on this website you are confirming that you are a Healthcare Professional. If you are a patient or carer, please visit the Lymphoma Coalition.
Introducing
Now you can personalise
your Lymphoma Hub experience!
Bookmark content to read later
Select your specific areas of interest
View content recommended for you
Find out moreThe Lymphoma Hub website uses a third-party service provided by Google that dynamically translates web content. Translations are machine generated, so may not be an exact or complete translation, and the Lymphoma Hub cannot guarantee the accuracy of translated content. The Lymphoma Hub and its employees will not be liable for any direct, indirect, or consequential damages (even if foreseeable) resulting from use of the Google Translate feature. For further support with Google Translate, visit Google Translate Help.
The Lymphoma & CLL Hub is an independent medical education platform, sponsored by Beigene and Roche, and supported through educational grants from Bristol Myers Squibb, Ipsen Biopharmaceuticals, Pfizer, and Pharmacyclics LLC, an AbbVie Company and Janssen Biotech, Inc., administered by Janssen Scientific Affairs, LLC View funders.
Bookmark this article
Test your knowledge! Take our quick quiz before and after you read this article to find out if you improved your knowledge. Results help us to improve content and continually provide open-access education.
Hodgkin Lymphoma (HL) is characterized by the presence of Hodgkin and Reed-Sternberg (HRS) cells within a cellular infiltrate of non-malignant inflammatory cells and is classified as nodular lymphocyte predominant HL (NLPHL) or classical HL (cHL). cHL has a further four subtypes: nodular sclerosis, mixed cellularity, lymphocyte-rich, and lymphocyte-depleted. Patients with cHL usually present with painless lymphadenopathy and mediastinal disease. Positron emission tomography (PET)/computerized tomography (CT) staging detects bone marrow involvement in up to 18% patients compared to 5−8% of patients using conventional staging. Systemic symptoms such as drenching night sweats, unexplained fever, and weight loss over 6 months are termed as B symptoms occurring in nearly 25% of patients with cHL. Optimal clinical management of patients with cHL has the potential to improve treatment outcomes and quality of life.
As part of the Lymphoma Hub educational theme on the management of HL, here we provide an overview of the first-line management of cHL based on the recently updated British Society for Haematology guideline by Follows et al.1, published in the British Journal of Haematology.
Patients with a diagnosis of cHL should be assessed prior to treatment (Table 1).
Table 1. Pretreatment evaluation*
Blood evaluation |
Full blood count including HIV, hepatitis B and C, ESR, renal function, liver function, bone profile |
---|---|
Staging |
With PET scan – A bone marrow biopsy usually not required |
Classify early-stage patients as favorable or unfavorable |
|
Advanced staged patients – allocate IPS |
|
Fertility preservation |
Referral for ovarian tissue, oocyte, embryo, or semen cryopreservation should be considered where appropriate to minimize treatment delays |
ESR, erythrocyte sedimentation rate; HIV, human immunodeficiency virus; IPS, International Prognostic Score; PET, positron emission tomography. |
Patients with early-stage disease with adverse features (B symptoms, bulky disease, or multiple nodal sites) have traditionally been managed in the UK with protocols for advanced-stage disease. However, long-term follow-up studies show that these patients have excellent outcomes when treated with early-stage risk-stratified protocols. The pre-treatment evaluation recommended above should determine whether a patient with early-stage disease fits in the favorable or unfavorable category (Table 2). Of note, there is variation in the categorization of mediastinal thoracic ratio; the European Organisation for Research and Treatment of Cancer (EORTC) criteria considers this as >0.35 at T5/6, whereas the UK National Cancer Research Institute (NCRI) and German Hodgkin Study Group (GHSG) consider this to be >0.33.
Table 2. Favorable and unfavorable prognosis*
Favorable prognosis stage I–II HL |
Unfavorable prognosis I–II HL |
||
---|---|---|---|
EORTC |
GHSG |
EORTC |
GHSG |
Presence of one or more of the following: |
|||
No large mediastinal adenopathy |
No large mediastinal adenopathy |
Large mediastinal adenopathy |
Large mediastinal adenopathy† |
ESR <50 without B symptoms |
ESR <50 without B symptoms |
ESR ≥50 without B symptoms |
ESR ≥50 without B symptoms |
ESR <30 with B symptoms |
ESR <30 with B symptoms |
ESR ≥30 with B symptoms |
ESR ≥30 with B symptoms |
Age ≤50 |
No extranodal disease |
Age >50 |
Extranodal disease |
1–3 lymph node sites involved |
1−2 lymph node sites involved |
≥4 lymph node sites involved |
≥3 lymph node sites involved |
EORTC, European Organisation for Research and Treatment of cancer; ESR, erythrocyte sedimentation rate; GHSG, German Hodgkin Study Group; HL Hodgkin lymphoma. |
The recommendations for the management of early-stage favorable disease (Figure 1) are based on the evidence from three landmark studies UK-NCRI RAPID,2 EORTC/LYSA/FIL H10,3 and the GHSG HD164 trials.
In patients with early-stage unfavorable disease who achieve negative iPET, radiotherapy can be safely omitted with no risk to tumor control with an intensive initial chemotherapy approach. These patients can be started early on either escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone (eBEACOPP) or ABVD (Figure 1).
Figure 1. Management of early-stage favorable and unfavorable disease*
ABVD, doxorubicin, bleomycin, vinblastine, dacarbazine; AVD, doxorubicin, vinblastine, dacarbazine; eBEACOPP, escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone; iPET, interim positron emission tomography; PET, positron emission tomography; SOC, standard of care.
*Adapted from Follows et al.1
†Negative iPET defined as Deauville score 1–3.
Initial treatment for adult patients aged ≤60 years with advanced stage cHL should comprise of either two cycles of ABVD or eBEACOPP followed by an iPET scan (Figure 2).
Figure 2. Management of advanced stage disease*
ABVD, doxorubicin, bleomycin, vinblastine, dacarbazine; eBEACOPP, escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisolone; iPET, interim positron emission tomography; SOC, standard of care.
*Adapted from Follows et al.1
†Negative iPET defined as Deauville score 1–3.
The risk of relapse is reduced in early-stage patients treated with ABVD. The internationally recognized standard of care (SOC) for cHL treated with combined-modality therapy is involved-site radiotherapy (ISRT).
Patient’s individual risk profile, and balance between toxicity and efficacy should be considered in the decision about omitting radiotherapy.
The use of PET is crucial in the management of cHL to augment staging and guide therapy. PET scan reports should always include a DS and metabolic response category for response assessment.
Treatment for teenagers and young adults (TYA) may be based on pediatric or adult protocols depending on the center expertise and balance between toxicity and efficacy, and consideration should be given to:
Pregnant patients with cHL should be jointly managed by a specialized obstetric/fetal medicine unit. Standard practice in this population would not be to delay initiation of chemotherapy. However, radiotherapy should be delayed until after delivery if possible.
The comorbidity assessment tool should be used to distinguish between ‘frail’ and ‘non-frail’ patients to establish their fitness to receive combination chemotherapy.
Although cHL is a curable disease, the management of cHL has a significant impact on patients’ quality of life. This guideline on the first-line management of cHL provides an overview of the clinical management of adult patients with cHL. The guideline recommends iPET-guided therapy to reduce treatment-related morbidity and escalating or de-escalating approaches with ABVD and BEACOPP to prevent relapses. The guidance may not be appropriate for all patients with cHL and, therefore, also covers different populations where individual patient circumstances may dictate an alternative approach to their management.
Understanding your specialty helps us to deliver the most relevant and engaging content.
Please spare a moment to share yours.
Please select or type your specialty
Your opinion matters
Subscribe to get the best content related to lymphoma & CLL delivered to your inbox