Treating Classic Hodgkin Lymphoma, by Stage

This information sums up treatment options for classic Hodgkin lymphoma (cHL) in adults, based on the stage of cancer.

Your treatment might be a little different from the general outline below. Your options will depend on many things, including:

• The type and stage (extent) of your cancer
• If the disease is bulky (large)
• If it is causing B symptoms
• The results of blood tests and other lab tests
• Your age, overall health, and personal preferences

Most experts agree that treatment in a clinical trial should be considered for Hodgkin lymphoma that is resistant to treatment or comes back (relapses) after treatment.

Note: Treating Hodgkin lymphoma in children is slightly different from treating it in adults. Some of these differences are discussed in Treating Hodgkin Lymphoma in Children. For teens who are fully grown, treatment is usually the same as for adults.

Stages IA and IIA, favorable

This group includes Hodgkin lymphoma that is only on one side of the diaphragm (above or below) and doesn’t have any unfavorable factors. For example:

• It's not bulky
• It is in 3 or less different areas of lymph nodes
• It doesn’t cause any of the B symptoms
• The ESR (erythrocyte sedimentation rate) is not elevated

For some people, treatment is chemotherapy followed by radiation. Chemo is usually 2 to 4 cycles of the ABVD regimen. Involved site radiation therapy (ISRT) is given to the initial site of the disease.

Chemo alone is another option for some people, usually for 3 to 6 cycles.

Doctors often order a PET/CT scan after a few courses of chemo to see how well the treatment is working and determine how much more treatment, if any, is needed.

If you can’t have chemotherapy because of other health issues, radiation therapy alone may be an option.

If your lymphoma doesn’t respond to treatment, doctors may recommend using different chemo (such as high-dose chemo) and possibly radiation, followed by a stem cell transplant

Immunotherapy with brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda) might be another option. 

Stages I and II, unfavorable

This group includes Hodgkin lymphoma that is only on one side of the diaphragm (above or below) but has one or more of these risk factors:

• It's bulky (the tumor is large)
• It is in more than 3 different areas of lymph nodes
• It's causing B symptoms
• The ESR (erythrocyte sedimentation rate) is high – 50 or greater

Treatment is generally more intense than for favorable disease. It typically starts with chemotherapy, such as the ABVD regimen for 4 to 6 cycles. PET/CT scans are often done after several cycles of chemo to see if more treatment is needed, and if so, how much.

This is often followed by more, and maybe different, chemo. Radiation therapy (ISRT) may be given to the sites of the tumor, especially if it was bulky disease.

If your lymphoma doesn’t respond to treatment, doctors may recommend different chemo drugs or high-dose chemo, and possibly radiation, followed by a stem cell transplant.

Immunotherapy with brentuximab vedotin (Adcetris), nivolumab (Opdivo), or pembrolizumab (Keytruda) might be another option.

Stages III and IV

This includes Hodgkin lymphoma 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 more intense chemotherapy regimens than those used for earlier stages.

Depending on your age, health, and other factors, some of the more common chemo options include:

• Nivolumab (Opdivo) plus AVD
• The BrECADD chemo regimen
• The BV-AVD chemo regimen
• The ABVD chemo regimen

For more on the chemo drugs used in these regimens, see Chemotherapy for Hodgkin Lymphoma.

You might have PET/CT scans during or after chemo to assess how much more treatment you need. Depending on the results of the scans, you might get more chemo. You might get radiation therapy after chemo, especially if you had any large tumor areas.

If your lymphoma doesn’t respond to treatment, doctors may recommend different chemo drugs or high-dose chemo, and possibly radiation, followed by a stem cell transplant.

Immunotherapy with brentuximab vedotin, nivolumab, or pembrolizumab (Keytruda) in combination with other chemo might be another option.

Resistant or refractory Hodgkin lymphoma

Treatment for Hodgkin lymphoma should remove all traces of the lymphoma. After treatment, your cancer care team will do tests such as PET/CT scans to look for any signs of lymphoma.

If Hodgkin lymphoma is still there after initial treatment, 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 cure the lymphoma.
• Using a different combination of chemo drugs is another option.
• If radiation alone was the initial treatment, chemo given with or without more radiation might also cure it.

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

Immunotherapy can be part of the treatment used to get the lymphoma under control before an autologous stem cell transplant. This involves treatment with immunotherapy drugs such as nivolumab (Opdivo) or pembrolizumab (Keytruda).

Recurrent or relapsed Hodgkin lymphoma

If Hodgkin lymphoma comes back (recurs) after treatment, further treatment depends on:

• Where the lymphoma recurs
• How long it’s been since the initial treatment
• 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 can’t be repeated in the same area. For example, if Hodgkin lymphoma 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 radiation was first given.

If the lymphoma returns after many years, it might still be cured with the same or different chemo drugs, possibly along with radiation.

If Hodgkin lymphoma recurs soon after treatment, more intensive treatment may be needed. For example, if it returns within a few months, additional chemo with or without immunotherapy followed by an autologous stem cell transplant may be recommended.

If Hodgkin lymphoma remains after an autologous transplant, an allogeneic stem cell transplant may be an option. Treatment with an immunotherapy drug such as nivolumab (Opdivo) or pembrolizumab (Keytruda) may be another option, either instead of or after a stem cell transplant.