Full Blood Count with ESR

Renal Function 

Liver Function

Bone Profile

Testing HIV & Hepatitis B/C

PET Scan 

CT Scan with Contrast

Cryopreservation of Ovarian Tissue, oocyte, embryo or semen

In female prophylactic use of gonadotrophin-releasing hormone analougs.

Blood evaluation including HIV, hepatitis B and C serology.

PET staging is recommended. A bone-marrow biopsy is usually not required.

Early-stage patients should be classified as favorable or unfavorable.

Advanced-stage patients should be allocated an IPS.

Patients should be offered fertility preservation/counselling where appropriate 

Standard of care for patients with early favorable disease is to start with two cycles of ABVD followed by an interim PET scan.

For early favorable disease and a negative interim PET scan, standard of care is a total of 2–3cycles of ABVD followed by radiotherapy.

A negative interim PET scan, it may be appropriate to omit radiotherapy following discussion with a radiation oncologist. These patients should receive a total of three or four cycles of ABVD.

A standard of care is two cycles of eBEACOPP and two cycles of ABVD followed by a PET. With a positive scan, patients should be offered radiotherapy.

An alternative standard is two cycles of ABVD followed by interim PET. If iPET-negative, patients have 1–2 further cycles of ABVD with radiotherapy or complete a total of six cycles of chemotherapy with the last four being AVD without radiotherapy

For early-stage disease with a positive PET scan after two cycles of ABVD, consider two cycles of eBEACOPP followed by radiotherapy.

DS1–3 is considered complete metabolic response.

Standard treatment for patients with stage III/IV HL is combination chemotherapy.

patients starting with ABVD, approximately two-thirds will not require dose intensification. 

The rest will require intensification either after iPET2 or following a later relapse.

Another approach when starting with ABVD is to replace the bleomycin with brentuximab vedotin (BV) as per the ECHELON1.

There is a trail BV-AVD vs ABVD where shows only 4.9% improvement in two year modified PFS in BV-AVD group.

eBEACOPP is more effective but has higher rates of significant toxicities than ABVD.

The eBEACOPP regimen was developed by the GHSG and has evolved through a series of large randomized trials  to remove consolidation radiotherapy for most patients and progressively reduce the number of treatment cycles.

After receiving two cycles of eBEACOPP if iPET is negative the patient should receive either a total of four or six to eight cycles of eBEACOPP.

An alternative de-escalation strategy is the AHL2011 approach. 

In this trial,  iPET-negative patients in the experimental arm were de-intensified to four cycles of ABVD.

iPET-negative patients treated in this way had a five-year PFS of 85.7%, which was same as the standard arm of six cycles of eBEACOPP.

eBEACOPP with a dacarbazine substitution, the so-called eBEACOPDac regimen.

Substituting dacarbazine for procarbazine as part of consolidation chemotherapy does not compromise event-free survival & suggest similar efficacy.

Reduced gonadotoxicity,

Reduced neutropenia 

Reduced red-cell transfusion requirements,

Reduced acute admissions to hospital and 

Earlier restarting of menstrual periods post chemotherapy .

Withdraw of radiotherapy depends upon individual risk profile & acceptable balance between toxicity & efficacy

Dose for Favorable Early stage disease 20 Gy & for others 30 Gy but for partial response boost to 36-45 Gy.

Involved-site radiotherapy is standard care for HL treatment

Radiotherapy reduces the risk of relapse in early-stage Patients treated with ABVD.

Radiotherapy should be given in early stage disease both favorable & unfavorable group if iPET positive (DS 4-5).

When radiotherapy is delivered as consolidation for advanced-stage patients post chemotherapy it is usually given just to the PET-positive residual mass (including any contiguous PET-negative residuum) rather than as ISRT.

Compared with ABVD, pediatrics regimens include corticosteroids, have a higher initial dose intensity but lower cumulative dose of anthracycline, and increased exposure to vinca alkaloids.

Long-terms risks of organ toxicity, secondary cancer & impact on fertility should be discussed with the patient

Referral to a fertility specialist should always be offered 

Patients should be jointly managed with feto-maternal unit.

Maternal health should be 1st priority & therapeutic termination may be needed in few cases.

Delaying commencement of chemotherapy is best standard practice & should be done with caution. 

If therapy required- ABVD is preferred 

ABVD may be used in all three trimester but chemotherapy should be avoided in 1st trimester if possible.

Radiotherapy should be delayed until after delivery.

Elderly patient should be assessed for fitness & should distinguish 'frail' from 'non-frail' patients.

Frail patient should avoided anthracycline-based combination therapy & ChIVVP may be appropriate.

Alternative to anthracycline containing regimen including CHOP & ACOPP 

Non-Frail patients should be offered anthracycline based combination chemotherapy with or without radiotherapy aiming complete remission

They can also offered ABVD Regimen but use of bleomycin should be limited as it may cause lung toxicity. So AVD is preferred 

ABVD is limited to three cycles.

PET response should be reported according to DS and metabolic response categories.

DS 1, 2 and 3 should be considered as a CMR (1B).

iPET-positive patients should have an end-of-treatment PET to determine response status .

Biopsy or interval imaging is advised to confirm residual disease with DS 4 or 5 prior to second-line therapy .

Standard PET reconstructions (e.g. OSEM) are recommended for reporting.

Second cancers like Increased risk of breast cancer & thyroid cancer

Cardiovascular events i.e myocardial infraction, angina pectoris, CCF, valvular disease.

Hypothyroidism 

Pulmonary toxicity including pulmonary fibrosis, pneumonitis, ARDS.

Reduced fertility, in female early menopause 

Psychological effects like chronic fatiguability, anxiety, depression.

Usually followed up for at least two years following first-line therapy.

Women treated with radiotherapy to breast tissue under the age of 36 years should be offered breast screening starting eight years after radiotherapy or at age 25, whichever is later.

Patients treated with radiotherapy to the neck and upper  mediastinum should have regular thyroid function tests.

Follow-up discussions about the impact of treatment on their fertility and/or menopausal status.

Patients should receive irradiated blood products for lifelong.

Further optimize first-line treatment in all stages of Hodgkin lymphoma 

  Minimizing treatment-related adverse effects and maintaining treatment efficacy.