Current Updated Guidelines for Management of Classical Hodgkin Lymphoma

Initial Workup and Staging

The National Comprehensive Cancer Network recommends a complete blood count with differential to assess for cytopenias, as well as serum albumin and LDH as prognostic markers and indicators of tumor burden in patients with classical Hodgkin lymphoma 2
Erythrocyte sedimentation rate (ESR) is used for risk stratification in patients with classical Hodgkin lymphoma 2
HBV, HCV, and HIV serology are essential in patients with classical Hodgkin lymphoma, as these infections impact treatment decisions 2
A pregnancy test is necessary in women of fertile age before therapy initiation for classical Hodgkin lymphoma 2
CT scan of neck, chest, abdomen, and pelvis is used for volumetric assessment and identification of bulky disease in patients with classical Hodgkin lymphoma 3, 4
FDG-PET or CT-PET scan is strongly recommended for accurate baseline staging and is necessary for PET-aided response assessment during treatment in patients with classical Hodgkin lymphoma 5, 2
Monolateral bone marrow biopsy should be performed in patients with B symptoms and/or stage III/IV disease and/or blood count abnormalities 5

The American Society of Clinical Oncology recommends combined modality therapy with ABVD chemotherapy followed by involved-field radiotherapy for early-stage disease, and full-term ABVD chemotherapy for advanced-stage disease, with PET/CT-based response assessment using the Deauville 5-point scale to guide treatment decisions in patients with classical Hodgkin lymphoma 1
Combined modality therapy with ABVD chemotherapy followed by involved-field radiotherapy is the standard approach for early-stage disease, as radiotherapy alone has been definitively shown to be inferior with significantly worse freedom from progression 2, 5
Full-term chemotherapy with ABVD is recommended for advanced-stage disease, with brentuximab vedotin plus AVD emerging as a standard of care in 2025 2
Adjuvant radiotherapy in patients without initial bulk who achieved complete remission is not recommended, as this increases toxicity without survival benefit 2

Early evaluation of response with FDG-PET scan after 2-4 cycles of chemotherapy is recommended to guide treatment modifications in patients with classical Hodgkin lymphoma 2, 6
Response is assessed using the Deauville 5-point scale, with scores 1-3 considered PET-negative in patients with classical Hodgkin lymphoma 1
Never use radiotherapy alone for early-stage disease, as combined modality therapy has proven superior survival outcomes with 3-year progression-free survival of 93% versus 70% with radiotherapy alone 2, 5

High-dose chemotherapy followed by autologous hematopoietic stem cell transplant is the standard of care for patients younger than 60-65 years with relapsed or refractory disease, achieving 3-year event-free survival of 53% compared to 10% with conventional-dose therapy 7, 2
Non-cross-resistant regimens such as IGEV, DHAP, or ICE should be used for debulking before autologous transplant in patients with relapsed or refractory classical Hodgkin lymphoma 7
Allogeneic stem cell transplant with reduced-intensity conditioning is recommended in patients relapsing after autologous transplant 7

Reproductive counseling must be offered immediately to all patients of reproductive age before any treatment initiation, as chemotherapy and radiotherapy cause permanent fertility damage in patients with classical Hodgkin lymphoma 6, 4, 8
Fertility preservation measures should be taken before the initiation of therapy in patients with classical Hodgkin lymphoma 8

Long-term follow-up after completion of treatment is essential to determine potential long-term effects, including second cancers and cardiovascular disease in patients with classical Hodgkin lymphoma 1
The 5-year overall survival for classical Hodgkin lymphoma now approaches 90%, with permanent remission rates of 80-90% in adolescents and young adults 6