Classic Hodgkin Lymphoma: Treatment

Classic Hodgkin Lymphoma: overview

This algorithm organizes treatment of classic Hodgkin lymphoma by stage and risk group. Early-stage favorable disease is treated with combined modality therapy, two cycles of ABVD plus involved-site radiotherapy (HD10). Early-stage unfavorable disease receives four cycles of ABVD plus involved-site radiotherapy (HD11). For advanced-stage disease, the chart shows brentuximab vedotin plus AVD (ECHELON-1) and nivolumab plus AVD (S1826). In the site's summaries, ECHELON-1 improved modified PFS and, on long-term follow-up, OS versus ABVD while eliminating bleomycin, and S1826 showed improved PFS with nivolumab plus AVD over brentuximab plus AVD with better tolerability.

For relapsed or refractory disease, chemosensitive relapse is treated with salvage chemotherapy followed by autologous stem cell transplant. Brentuximab vedotin is used as post-transplant maintenance (AETHERA), which reduced the risk of progression in high-risk patients without a significant OS benefit. Nivolumab or pembrolizumab is the immunotherapy option, supported by KEYNOTE-204, in which pembrolizumab improved PFS over brentuximab vedotin (HR 0.65).

Trials behind this algorithm

HD10 (GHSG) Engert A et al, NEJM, 2010; PMID: 20818855
HD11 (GHSG) Eich HT et al, JCO, 2010; PMID: 20713848
ECHELON-1 Connors JM et al, NEJM, 2018; PMID: 29224502
S1826 Herrera AF et al, NEJM, 2024; PMID: 39413375
AETHERA Moskowitz CH et al, Blood, 2018; PMID: 30266774
KEYNOTE-204 Kuruvilla J et al, Lancet Oncol, 2021; PMID: 33721562

Background reading: Hodgkin lymphoma board review notes.

Classic Hodgkin Lymphoma: the algorithm in words

Starting point: Classic Hodgkin lymphoma. Full background: Hodgkin lymphoma notes.

Early-stage favorable (first-line): Combined-modality: ABVD ×2 + ISRT (HD10).
Early-stage unfavorable (first-line): Combined-modality: ABVD ×4 + ISRT (HD11).
Advanced-stage (first-line): BV-based: Brentuximab + AVD (ECHELON-1); IO-based: Nivolumab + AVD (S1826).
Relapsed / refractory (second-line): Salvage: Salvage chemo → autologous SCT (chemosensitive relapse); Maintenance: Brentuximab vedotin (AETHERA); IO: Nivolumab / pembrolizumab (KEYNOTE-204).