Treatment of early stage favorable and unfavorable Hodgkin lymphoma

Background In early stage classical Hodgkin lymphoma (cHL), reduction of treatment-associated toxicity while maintaining achieved high cure rate remains a major goal. Objectives Evidence-based development of current treatment recommendations for early stage favorable and unfavorable HL. Methods Evaluation of current randomized trials, meta-analyses, and relevant retrospective analyses with regard to tumor control, overall survival, and safety data. Results and conclusions Two cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) and 20 Gy involved-site radiotherapy (IS-RT) are still regarded as standard in early stage favorable HL and are also used in the older patients, unless there are contraindications. Compared to standard treatment, the (18F)fluorodeoxyglucose (FDG) positron emission tomography (PET)-based RT-approach resulted in significantly lower tumor control in the RAPID, H10, and HD16 trials and can therefore only be considered as an individual approach after weighing the benefits and risks of long-term toxicity of RT. In early stage unfavorable HL, two cycles of (escalated(e))BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) followed by two cycles of ABVD (2 + 2) result in significantly higher progression-free survival (PFS) compared to four cycles of ABVD. The HD17 trial showed that 2 + 2 additionally enables a PET-guided RT-approach without impairment of tumor control, i.e., omission of RT in those patients with negative PET after 2 + 2. Therefore, 2 + 2 + PET-guided RT is recommended as the new standard in patients <= 60 years of age. In patients older than 60 years, combined modality treatment (CMT) with two cycles of ABVD followed by two cycles of AVD and 30 Gy IS-RT is still recommended