How would you manage an in-field small volume recurrence of early-stage favorable Hodgkin Lymphoma treated previously with 2 cycles of ABVD and 20Gy?

An established and extremely successful treatment paradigm for early-stage favorable HL is 2 cycles of ABVD followed by 20 Gy of RT. Assuming the patient is PET negative after chemotherapy, 5-year PFS is expected to be ~93-94% based on HD16. Most recurrences after combined modality therapy (CMT) in this trial were outside the RT field. If a patient did fail within the RT field after 2 cycles ABVD + 20 Gy RT, I would advocate salvage chemotherapy, and if the disease is chemotherapy sensitive, then proceed with high-dose chemotherapy and autologous stem cell transplant. This is concordant with NCCN guidelines.

A more common scenario is a local recurrence when ABVD is given alone. In this circumstance, one may choose to re-wind the clock (star...

I agree with Dr. @Dr. First Last that the lion’s share of patients who relapse after combined modality treatment should proceed with salvage chemotherapy and ASCT if fit.

I would add that it’s important to recognize that patients with early stage favorable HL who relapse after 2 cycles of ABVD and 20 Gy are a unique cohort. The HD10 regimen (2 ABVD, 20 Gy) is a deescalated regimen and relapse after this is not synonymous with aggressive biology. It’s important to note the time to relapse, the extent of disease at the relapse, involvement of extranodal sites, age, fitness, etc, as many low risk patients can be managed with favorable outcomes without high dose chemotherapy/ASCT and treatment should be individualized.

Two recent papers help to...