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. 

Sometimes, radiation therapy to an area of disease that remains after chemotherapy might be curative. Using a different combination of chemo drugs is another option. If radiation alone was the initial treatment, using chemo (with or without more radiation) might also be curative.

If HL is still there after these treatments, most doctors would recommend high-dose chemo (and possibly radiation) followed by an autologous stem cell transplant, if it can be done. If cancer still remains after this, an allogeneic stem cell transplant may be an option.

Another option, either instead of or after a stem cell transplant, may be treatment with an immunotherapy drug, such as brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda).

Recurrent or relapsed Hodgkin lymphoma

If HL comes back (recurs) after treatment, further treatment depends on where the lymphoma comes back, on how long it has been since the initial treatment, and on what the initial treatment was. 

If the initial treatment was radiation therapy alone, chemotherapy is usually given for recurrent disease.

If chemotherapy without radiation therapy was used first, and the cancer comes back only in the lymph nodes, radiation to the lymph nodes can be done, with or without more chemo. Chemo with different drugs may be another option. 

Radiation usually cannot be repeated in the same area. If, for example, HL in the chest was treated with radiation and it comes back in the chest, it usually can't be treated with more radiation to the chest. This holds true no matter how long ago the radiation was first given.

If the lymphoma returns after many years, using the same or different chemo drugs (possibly along with radiation) might still cure it. On the other hand, HL that recurs soon after treatment may need more intensive treatment. For example, if the HL has returned within a few months of the original treatment, high-dose chemo (and possibly radiation) followed by an autologous stem cell transplant may be recommended.

If the HL still remains after an autologous transplant, an allogeneic stem cell transplant may be an option. Another option, either instead of or after a stem cell transplant, may be treatment with an immunotherapy drug, such as brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda).