Classical Hodgkin's Lymphoma

1. CLASSICAL HODGKIN’S LYMPHOMA:
TREATMENT STRATEGIES
DR ANKIT RAIYANI
Dept. of haematology
SSH, Pune.

2. OVERVIEW OF PRESENTATION
• Staging & risk stratification
• Role of PET scan
• Treatment protocols (First line and second line)
• ABVD protocol and its modifications
• BEACOPP and its modifications
• Newer agents
• Treatment of newly diagnosed HL
• Early stage (Stage I/II) favourable risk
• Early stage unfavourable risk
• Advanced stage disease
• Elderly (> 60 yr) newly diagnosed HL
• Treatment of refractory/relapseed HL

3. ANN ARBOR CLINICAL STAGING

4. RISK STRATIFICATION
Hasenclever D, et al. NEJM, 1998

5. ROLE OF PET SCAN
• 97- 100 % HL are FDG avid
• Preferable to CT for initial staging
• will upstage a minority of patients and aid the interpretation of subsequent PET scan
• PET response should be reported according to Deauville criteria
• 1, 2 should be considered ‘negative’
• 4, 5 considered ‘positive’
• Deauville score 3 should be interpreted according to the clinical context but in many HL patients indicates a good
prognosis with standard treatment.
• Interim PET scan at end of 2 cycles of chemotherapy has greatest prognostic value
• Even overrules the initial IPS risk stratification
• Can guide in escalation or de-escalation of further treatment
• End-of-treatment PET scan positivity:
• Biopsy is advised prior to second-line therapy to confirm residual disease with score 4,5 to exclude false positive
uptake with FDG.

7. TREATMENT PROTOCOLS

8. First line protocols
• ABVD (Adriamycin, Bleomycin, Vinblastin, Dacarbazine) ± ISRT
• Stanford 5 (Adriamycin, Bleomycin, Vinblastin, Vincristine, Meclorethamine, Etoposide, Prednisone)
• BEACOPP (Bleomycin, Etoposide, Adriamycin, Cyclophosphamide, Vincristine, Procarbazine, Prednisone)
•
Second line protocols ± HDT/ASCR

9. NEWER AGENTS
• Brentuximab vedotin
• Antibody-drug conjugate (ADC) directed to the protein CD30
• Approved for relapsed HL
• Potential uses: B-AVD, post ASCT single drug maintenance, single agent palliation in
elderly frail patients
• Adverse effects: peripheral neuropathy, neutropenia
• Nivolumab
• Humanized IgG4 anti-PD-1 monoclonal antibody used to treat cancer.
• Works as a checkpoint inhibitor, blocking a signal that would have prevented
activated T cells from attacking the cancer, thus allowing the immune system to clear
the cancer

10. ABVD PROTOCOL

11. MODIFICATION OF ABVD PROTOCOL

12. STUDY OUTCOME
ABVD AVD ABV AV
Number of
patients
566 571 198 167
FFTF @ 5
years
93% 89% 81% 77%
Gr III/IV
toxicity
33% 26% 28% 26%
Upfront dose reduction not recommended for treatment of cHL with ABVD

14. OUTCOME

15. ADVERSE EVENTS

16. BEACOPP & ESCALATED BEACOPP (NEJM 2003)

17. DISADVANTAGES OF BEACOPP VS ABVD
• Very high rates of severe adverse events
• Very high cost of treatment
• No benefit in 5 yr OS as compared to ABVD
• Reported PFS, OS rates may be difficult to replicate in India
• Benefit in FFTF is balanced by acceptable RR of 2nd line protocol +
HDT/ASCR

18. TREATMENT STRATEGIES

19. TREATMENT OF NEWLY DIAGNOSED HL
• Early stage (Stage I/II) favourable risk
• Early stage unfavourable risk
• Advanced stage disease

20. EARLY STAGE (STAGE I/II) FAVOURABLE
RISK
•ABVD X 2
cycles
Interim
PET scan
Deauville 1-4 ISRT: 20 Gy
Deauville 5 Biopsy
Negative: ISRT 20
Gy
Positive: treat as
refractory disease

21. EARLY STAGE (I/II) UNFAVOURABLE RISK
•ABVD X 4 cycles Restage with PET scan
Deauville 1-3
ABVD X 2 cycles
AVD X 2 cycles
ISRT: 30 Gy
Deauville 4 ABVD X 2 cycles
Restage with PET scan
Deauville 5 Biopsy
Negative: ABVD X 2
cycles AND ISRT 30 - 45
Gy
Positive: treat as
refractory disease

22. ADVANCED STAGE (III/IV) DISEASE
•ABVD X 2
cycles
Restage with
PET scan
Deauville 1-3
AVD X 4
cycles
Deauville 4, 5
ABVD X 4
cycles
Restage with
PET scan
Deauville 1-3
Observe or
ISRT
Deauville 4
ISRT to PET
positive sites
Deauville 5 Biopsy
Negative:
Observe or ISRT
(30 - 45 Gy)
Positive: treat
as refractory
disease

23. ELDERLY (> 60 YR) NEWLY DIAGNOSED HL
•Non-Frail (No
comorbidities)
A(B)VD X 2 cycles Interim PET
Negative (1-3) AVD X 4 cycles
Positive (4-5)
Change protocol
(2nd line/ palliative)
VEPEMB X 6 cycles
± ISRT
PVAG X 6 cycles ±
ISRT
•Frail ( Co
morbidities
)
ChlVPP
VEPEMB
Brentuximab
ISRT
Palliation

24. TREATMENT OF REFRACTORY/RELAPSE (<1 YR) HL
•Biopsy proven
disease
2nd line therapy PET scan
Deauville 1-4
HDT/ASCR if
eligible
Brentuximab
maintenance X 1 yr
ISRT/ Observe
Allogeneic SCT
Deauville 5
ISRT/ Additional
systemic therapy*
Allogeneic SCT
* Brentuximab, Bendamustine

25. CHEMOTHERAPY REGIMENS IN RELAPSED
CLASSICAL HL

26. THANK YOU!!