International Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 10, 2018

In This Article

Hodgkin Lymphoma

European Society for Medical Oncology


The presence of Hodgkin and Reed/Sternberg (HRS) cells is disease-defining in classical HL (cHL); the detection of lymphocyte-predominant (LP) cells is required for the diagnosis of nodular lymphocyte-predominant HL (NLPHL).

Staging and risk assessment

Chest x-ray and a contrast-enhanced CT scan of neck, chest, and abdomen are mandatory.

A baseline PET should be conducted if this diagnostic tool is available.

A bone marrow biopsy is not indicated in patients undergoing PET–CT evaluation but must be carried out if PET–CT is not available.

Full blood cell count, ESR testing, and blood chemistry analysis are obligatory. Screening for HBV, HCV, and HIV is compulsory.

Staging is carried out according to the Ann Arbor classification, and patients are allocated to one of three categories (limited, intermediate, or advanced stage).

After staging examinations are completed, HL patients are allocated to distinct risk groups depending on their clinical stage and the presence of clinical risk factors.

Cardiac and pulmonary function tests should be carried out before the start of treatment.

Reproductive counseling and consideration of sperm banking, oocyte collection, or ovarian tissue cryopreservation should be offered to patients of reproductive age before treatment.

Treatment of HL

HL patients should be treated within clinical trial protocols whenever possible.

Limited-stage disease

Combined-modality treatment consisting of brief chemotherapy (ChT) followed by radiotherapy (RT) has been shown to result in superior tumor control compared with RT alone.

Two or three cycles of ABVD followed by conventionally fractionated RT represent the standard of care for limited-stage HL.

Involved-site radiotherapy (ISRT) is recommended instead of involved-field RT (IFRT) after ChT in limited stages.

Intermediate-stage disease

Four cycles of ABVD followed by conventionally fractionated RT at 30 Gy are widely considered standard of care for intermediate-stage HL. Two cycles of BEACOPPesc followed by two cycles of ABVD and RT at 30 Gy can be proposed to the patients ≤60 years who are eligible for a more intensive treatment.

ISRT is recommended instead of IFRT after ChT in intermediate stages.

Limited- and intermediate-stage disease

ChT alone may be offered to the individual patients when the late risk of delivering RT is thought to outweigh the short-term benefit of improved disease control.

Patients with a positive interim PET after two cycles of ABVD should be treated with two cycles of BEACOPPesc before ISRT.

Bleomycin should not be given for more than two cycles in patients >60 years.

Advanced-stage disease

Advanced-stage HL is usually treated with ChT alone. Additional RT is confined to the patients with residual disease after ChT.

Patients ≤60 years are treated with either ABVD (six cycles) or BEACOPPesc (four to six cycles), optionally followed by localized RT.

After two cycles of ABVD, the omission of bleomycin in cycles 3–6 in the case of a negative interim PET should be considered, especially in elderly patients and those at an increased risk for lung toxicity.

Patients with advanced HL who have a positive interim PET after two cycles of ABVD could switch from ABVD to BEACOPPesc.

After two cycles of BEACOPPesc, PET-negative patients can safely receive only two more cycles compared with PET-positive patients who need four more cycles.

RT can be restricted to the patients with PET-positive residual lymphoma ≥2.5 cm after four or six cycles of BEACOPPesc.

The BEACOPP regimen should not be given to patients >60 years.

ABVD-based ChT represents the standard of care for older HL patients who are fit enough for multi-agent ChT. Bleomycin should be discontinued after the second ChT cycle in this patient group.

Relapsed disease

For most patients with refractory or relapsed HL, the treatment of choice consists of high-dose ChT (HDCT) followed by autologous stem cell transplantation (ASCT).

High-risk patients may benefit from tandem ASCT.

Consolidating treatment with brentuximab vedotin following HDCT and ASCT is recommended in patients presenting with defined poor-risk factors.

DHAP, IGEV or ICE can be given before HDCT and ASCT.

In some patients, single-agent brentuximab vedotin may be sufficient as salvage therapy before HDCT and ASCT.

Achieving a negative PET should be the goal of salvage therapy irrespective of the applied protocol.

RT before HDCT and ASCT may be discussed in patients with single PET-positive lymph nodes after salvage therapy.

Single-agent brentuximab vedotin represents an option in patients failing ASCT.

Nivolumab and pembrolizumab are approved for the treatment of patients with disease recurrence after HDCT followed by ASCT and brentuximab vedotin therapy.

Allogeneic SCT represents a potentially curative treatment option for patients failing HDCT followed by ASCT. This approach should be considered and discussed in young, chemosensitive patients in good general condition after careful evaluation of the risk–benefit ratio.

Gemcitabine-based palliative ChT and/or regional RT are recommended in patients with multiple relapses who have no other treatment options.



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