Hodgkin Lymphoma Clinical Practice Guidelines (NCCN, 2020)

National Comprehensive Cancer Network

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

July 30, 2020

The guideline update on Hodgkin lymphoma was released in June 2020 by the National Comprehensive Cancer Network.[1]

Diagnosis, Workup, and Staging

The workup for Hodgkin lymphoma (HL) should include the following:

  • A thorough history, including determination of B symptoms

  • Physical examination, including all lymphoid regions, spleen, and liver

  • Standard laboratory tests (complete blood count, differential, platelets, erythrocyte sedimentation rate [ESR], serum lactate dehydrogenase, albumin, and liver and renal function tests)

  • Positron emission tomography (PET)/computed tomography (CT) scan (skull base to midthigh or vertex to feet in selected cases)

  • Diagnostic contrast-enhanced CT (neck, chest, abdomen, and pelvis). At minimum, diagnostic CT scans should include involved areas identified as abnormal on PET scan.

  • Posterior-anterior and lateral chest X-rays are encouraged in selected cases for patients with large mediastinal mass.

  • Excisional lymph node biopsy recommended; core needle biopsy may be adequate if diagnostic

  • Immunohistochemistry evaluation (CD3, CD15, CD20, CD30, CD45, CD79a, and PAX5)

Staging is based on the Ann Arbor staging system. PET scans are considered essential for initial staging and for evaluating residual masses at the end of treatment.

Treatment of Classical Hodgkin Lymphoma

Recommended therapy for classical HL begins with two cycles of ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, dacarbazine) followed by interim restaging with PET. Subsequent therapy recommendations vary according to the following:

  • Disease stage

  • Risk classification (favorable or unfavorable, non-bulky or bulky)

  • Deauville score

  • For some cases of stage I-II disease, whether there is a preference for combined modality therapy or chemotherapy alone

Subsequent treatment may include further cycles of ABVD, AVD, or BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine [Oncovin], procarbazine, prednisone), in most cases with involved-site radiation therapy (ISRT). Biopsy is recommended in patients with stage III-IV disease who have a Deauville score of 5.

Older patients

Enrollment in a clinical trial, when available, is recommended for patients older than 60 years with classical HL. Otherwise, the following regimens should be considered, in order to lessen or minimize toxicity, although they have not been proven to improve disease outcomes in older patients.

Stage I-II favorable disease options are as follows:

  • ABVD (preferred) or AVD, followed by ISRT

  • CHOP (cyclophosphamide, doxorubicin [hydroxydaunomycin], vincristine [Oncovin], prednisolone) with ISRT

  • VEPEMB (vinblastine, cyclophosphamide, procarbazine, prednisone, etoposide, mitoxantrone, bleomycin) with or without ISRT

Stage I–II unfavorable or stage III–IV disease options are as follows:

  • ABVD plus brentuximab vedotin lead in followed by AVD and brentuximab vedotin maintenance

  • Brentuximab vedotin plus dacarbazine (DTIC)

  • CHOP

  • PVAG (prednisone, vinblastine, doxorubicin, gemcitabine)

  • VEPEMB with or without ISRT

Relapsed or refractory classical Hodgkin lymphoma

Second-line systemic therapy followed by response assessment with PET is recommended for all patients. Other options include the following:

  • Further cytoreduction and high-dose therapy with autologous stem cell rescue (HDT/ASCR), with RT if not previously given

  • RT or systemic therapy with or without RT

  • Conventional-dose second-line systemic therapy may precede HDT/ASCR

  • RT should be strongly considered for selected sites of relapse that have not been previously irradiated. In radiation-naïve patients, total lymphoid irradiation may be an appropriate component of HDT/ASCR.

For more information, see Hodgkin Lymphoma. For more Clinical Practice Guidelines, please go to Guidelines.

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