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 used for adults. Some of the differences in treating adults and children 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 Hodgkin disease
- The stage (extent) of the Hodgkin disease
- Whether or not the disease is bulky (large)
- Whether the disease is causing certain symptoms (known as B symptoms)
- Results of blood and other lab tests
- A person’s age
- A person’s general health
Based on these factors, a person’s treatment might be a little different from the general outline below.
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 is not bulky
- It is not in several different lymph node areas
- It doesn’t cause any of the B symptoms
- It doesn’t cause an elevated erythrocyte sedimentation rate (ESR)
Treatment for most patients is chemotherapy (usually 2 to 4 cycles of the ABVD regimen or 8 weeks of the Stanford V regimen), followed by radiation to the initial site of the disease. Another option is chemotherapy alone (usually for 4 or 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, chemotherapy using different drugs or high-dose chemotherapy (and possibly radiation) followed by a stem cell transplant may be recommended. Treatment with the monoclonal antibody brentuximab vedotin (Adcetris) may be another option. If this isn’t helpful, the immunotherapy drug nivolumab (Opdivo) might be useful.
Stages I and II, unfavorable
This group includes HD that is only on one side of the diaphragm (above or below), but that is bulky, is in several different areas, is causing any of the B symptoms, and/or is causing an elevated erythrocyte sedimentation rate (ESR).
Treatment is generally more intense than that for favorable disease. It typically starts with chemotherapy (usually ABVD for 4 to 6 cycles or other regimens such as Stanford V for 12 weeks).
PET/CT scans are often done after several cycles of chemo to determine how much more treatment you need. This is often followed by more chemo. Radiation therapy is typically given to the sites of the tumor at this point, especially if it was bulky.
For those who don’t respond to treatment, chemotherapy using different drugs or high-dose chemotherapy (and possibly radiation) followed by a stem cell transplant may be recommended. Treatment with the monoclonal antibody brentuximab vedotin may be another option. If this isn’t helpful, the immunotherapy drug nivolumab (Opdivo) might be useful.
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 what is used for earlier stages. Although ABVD (for at least 6 cycles) can be used, some doctors favor more intense treatment with the Stanford V regimen for 12 weeks, or even the BEACOPP regimen if there are several unfavorable prognostic factors.
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 chemotherapy (and possibly radiation) followed by a stem cell transplant may be recommended. Treatment with the monoclonal antibody brentuximab vedotin may be another option. If this isn’t helpful, an immunotherapy drug such as nivolumab (Opdivo) or pembrolizumab (Keytruda) might be useful.
Resistant Hodgkin disease
Treatment for HL should remove all traces of the lymphoma. Once initial treatment is complete, 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 may be 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 a combination of 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 the monoclonal antibody brentuximab vedotin (Adcetris). If this isn’t helpful, the immunotherapy drug nivolumab (Opdivo) might be useful.
Recurrent or relapsed Hodgkin disease
If HL comes back 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 chemotherapy without radiation therapy was used first, and the cancer comes back only in the lymph nodes, the patient could receive radiation therapy to the lymph nodes 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 cannot 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 several years, then using the same or different chemo drugs (possibly along with radiation) might still cure it. On the other hand, patients whose HL 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 the monoclonal antibody brentuximab vedotin (Adcetris). If this isn’t helpful, the immunotherapy drug such as nivolumab (Opdivo) or pembrolizumab (Keytruda) might be useful.
The treatment information given here is not official policy of the American Cancer Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor. Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.
Bartlett NL, Foyil KV. Chapter 105: Hodgkin lymphoma. In: Niederhuber JE, Armitage JO, Dorshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa. Elsevier: 2014.
National Cancer Institute. Physician Data Query (PDQ). Adult Hodgkin Lymphoma Treatment. 2016. Accessed at www.cancer.gov/types/lymphoma/hp/adult-hodgkin-treatment-pdq on April 20, 2016.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Hodgkin Lymphoma. Version 2.2016. Accessed at www.nccn.org/professionals/physician_gls/pdf/hodgkins.pdf on April 20, 2016.
Ramchandren R. Advances in the treatment of relapsed or refractory Hodgkin’s lymphoma. Oncologist. 2012;17:367−376.
Younes A, Carbone A, Johnson P, Dabaja B, Ansell S, Kuruvilla J. Chapter 102: Hodgkin’s lymphoma. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015.
Last Medical Review: February 10, 2017 Last Revised: March 29, 2017
- Chemotherapy for Hodgkin Lymphoma
- Radiation Therapy for Hodgkin Lymphoma
- Immunotherapy for Hodgkin Lymphoma
- High-dose Chemotherapy and Stem Cell Transplant for Hodgkin Lymphoma
- Treating Classic Hodgkin Lymphoma, by Stage
- Treating Nodular Lymphocyte Predominant Hodgkin Lymphoma (NLPHL)
- Treating Hodgkin Lymphoma in Children
- Treating Hodgkin Lymphoma in Pregnancy