Treating Classic Hodgkin Lymphoma by Stage

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07/09/23

Treating Classic Hodgkin Lymphoma, by Stage
This section sums up the treatment options for Hodgkin lymphoma (HL) in adults, based on the stage of cancer. Treatment of the disease in children is slightly different from the treatment for adults. Some of these differences are discussed in Treating Hodgkin Lymphoma in Children. For teens with HL who are fully grown, the treatment is usually the same as that for an adult.

Treatment options depend on many factors, including:

The type of HL
The stage (extent) of the HL
Whether or not the disease is bulky (large)
Whether the disease is causing B symptoms
Results of blood tests and other lab tests
A person’s age
A person’s overall health
Personal preferences
Based on these factors, a person’s treatment might be a little different from the general outline below.

Most experts agree that treatment in a clinical trial should be considered for HL that is resistant to treatment or comes back (relapses) after treatment.

Stages IA and IIA, favorable
This group includes HL that is only on one side of the diaphragm (above or below) and that doesn’t have any unfavorable factors. For example:

It's not bulky
HL is in less than 3 different lymph node areas
It doesn’t cause any of the B symptoms
The ESR (erythrocyte sedimentation rate) is not elevated
Treatment for many patients is chemotherapy (usually 2 to 4 cycles of the ABVD regimen), followed by radiation to the initial site of the disease (involved site radiation therapy, or ISRT). Another option is chemotherapy alone (usually for 3 to 6 cycles) in selected patients.

Doctors often order a PET/CT scan after a few courses of chemo to see how well the treatment is working and to determine how much more treatment (if any) is needed.

If a person can’t have chemotherapy because of other health issues, radiation therapy alone may be an option.

For those who don’t respond to treatment, chemo using different drugs or high-dose chemo (and possibly radiation) followed by a stem cell transplant may be recommended. Treatment with an immunotherapy drug such as brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda) might be another option.

Stages I and II, unfavorable
This group includes HL that is only on one side of the diaphragm (above or below), but has 1 or more of these risk factors:

It's bulky (the tumor is large)
HL is in 3 or more different areas of lymph nodes
There's cancer outside the lymph nodes (called extranodal involvement)
It's causing B symptoms
The ESR (erythrocyte sedimentation rate) is high
Treatment is generally more intense than that for favorable disease. It typically starts with chemotherapy (usually with the ABVD regimen for 4 to 6 cycles or other regimens such as 3 cycles of Stanford V).

PET/CT scans are often done after several cycles of chemo to see if (and how much) more treatment is needed. This is often followed by more, and maybe different, chemo. Radiation therapy (involved field radiation therapy, or IFRT) is usually given to the sites of the tumor at this point, especially if it was bulky disease.

For those who don’t respond to treatment, chemo using different drugs or high-dose chemo (and possibly radiation) followed by a stem cell transplant may be recommended. Treatment with an immunotherapy drug such as brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda) might be another option.

Stages III and IV
This includes HL that is both above and below the diaphragm and/or has spread widely through one or more organs outside the lymph system.

Doctors generally treat these stages with chemotherapy using more intense regimens than that used for earlier stages. The ABVD regimen (for at least 6 cycles) is often used, but some doctors favor more intense treatment with the Stanford V regimen for 3 cycles, or up to 8 cycles of the BEACOPP regimen if there are several unfavorable prognostic factors. Another option for some people might be chemo plus the drug brentuximab vedotin (Adcetris).

PET/CT scans might be used during or after chemo to assess how much more treatment you need. Depending on the results of the scans, more chemo may be given. Radiation therapy may be given after chemo, especially if there were any large tumor areas.

For those whose HL doesn’t respond to treatment, chemo using different drugs or high-dose chemo (and possibly radiation) followed by a stem cell transplant may be recommended. Treatment with an immunotherapy drug such as brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda) might be another option.

Resistant or refractory Hodgkin lymphoma
Treatment for HL should remove all traces of the lymphoma. After treatment, the doctor will do tests such as PET/CT scans to look for any signs of HL. If HL is still there, most experts think that more of the same treatment is unlikely to cure it.