Recommendations for the treatment of Hodgkin lymphoma

This review outlined the current recommended treatment options for different stages of Hodgkin Lymphoma as well as highlighted promising new experimental drugs.

Hodgkin Lymphoma (HL) is generally considered a curable disease. Over 90% of patients diagnosed with early stage favorable HL will be cured. However, there some patients will not respond to first line treatment. Additionally, some patients who are cured of HL will experience treatment related illnesses later in life, such as heart disease.

HL is most common in adolescents and young adults aged 15 to 34 and people over the age of 60. Treatment intensity varies by age group.

This review comes from the National Clinical Trials Network on lymphoid malignancies. It outlines current treatment protocols for different stages of HL and highlights new treatments that appear promising.

First-line therapy generally involves chemotherapy and radiation therapy. ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) is a standard chemotherapy combination used in HL. BEACOPP (bleomycin, etoposide, adriamycin, cyclophosphamide, oncovin, procarbazine, and prednisone) is also often used. Involved field radiation therapy (IFRT; 20 or 30 Gy) is also a standard option. The combinations of these treatments depends on the stage and risk level of the disease.

Patients diagnosed with early stage favorable HL (stage I-IIA) have two standard treatment options. One treatment involves 3–6 cycles of ABVD alone. The other option is a combined treatment involving a smaller number of chemotherapy cycles followed by 20 Gy IFRT. One study found a small improvement in progression free survival (time from treatment to disease progression) for patients treated with CMT. Patients experienced a 3.8% increase in progression free survival. There was no difference in overall survival (time from treatment until death from any cause).

Patients with Stage I-II unfavorable, non-bulky HL present with smaller tumors but with other risk factors, such symptoms like night sweats, fever, or weight loss, or lymphoma in distant lymph nodes or organs. Standard treatment options for these patients include 3–6 cycles of ABVD, ABVD plus 30Gy IFRT, or a combination of ABVD, BEACOPP, and IFRT. Patients with bulky disease (larger tumors) should be treated with 4–6 cycles of ABVD followed by 30 Gy IFRT.

For patients with advanced stage disease, ABVD and/or escalated BEACOPP have shown to be effective.

PET/CT scans are often used during staging and to measure treatment response. Patients shown to have persistent advanced HL with a positive positron emission tomography (PET) scan show improvement when their treatment is increased from ABVD to escalated BEACOPP. One study found no difference in progression free survival between PET positive and PET negative patients when treatment is escalated for PET positive patients. This indicates that escalating therapy is effective for patients with a positive PET scan and advanced stage disease.

Younger patients often receive less intense treatment because of the potential risk for future treatment-related illness, especially heart failure.

If first-line chemotherapy is unsuccessful, additional second-line therapy and autologous stem cell transplantation (the patient’s own stem cells) are used. These treatments are not as standardized as first-line therapy. There are some experimental medications that have shown to be effective. Some of these new treatments include brentuximab vedotin (BV), nivolumab, ipilumumab, prembrolizumab, bendamustine, and mTOR inhibitors. BV was shown to improve time to disease progression after stem cell transplantation, but was associated with increased side effects.

Current clinical trials are mainly focusing on the addition of brentuximab vedotin into the standard chemotherapy regimen. Other trials are examining the effectiveness of escalating or reducing BEACOPP based on PET scans. Nivolumab (a treatment that stimulates the immune system) has shown to be effective. One study has found a 6 month progression free survival rate of 77%. Future trials will most likely focus on biological therapy, including BV, nivolumab, and pembrolizumab. 

This study reviewed the current standard treatment regimens for patients with HL as well as new experimental treatments currently being studied. 

The new medications work in different ways to manage HL. They are meant to be taken with other already established therapies. Talk to your doctor to about these new medications, their side effects, and any potential benefit they may have to your treatment.