In which patients with early-stage favorable Hodgkin's lymphoma, if any, would you consider omitting consolidation RT after ABVD chemotherapy?

The GHSG HD16 randomized trial was recently reported at ASH (Abstract 925). Patients with early-stage, favorable HL (per GHSG criteria) were randomized to standard treatment (ABVD X 2 followed by 20 Gy of RT) or a PET-directed approach. If PET negative after 2 cycles (defined as Deauville 1-2), then RT was omitted. Only if the PET-CT was positive (Deauville 3-5) did they get RT.

The primary endpoint was PFS- typical of almost all HL studies. This was a non-inferiority trial with a non-inferiority margin (delta) of 10%. I think most patients will state that an absolute difference in disease control of 9% is NOT non-inferior....but that is a matter for another discussion.

The study was negative. PFS(5) was 93.4% with combined modality therapy...

For early-stage, favorable HL (as defined by the German Hodgkin Study Group), the treatment of choice is 2 cycles of ABVD plus 20 Gy consolidation RT. We know of no studies that have employed 2 cycles of ABVD alone without RT. Whether more cycles of ABVD (4-6) without RT produces equal outcomes with equivalent or less toxicity is controversial. The majority of randomized trials suggest the superiority of combined modality therapy (recently reviewed by us – Kelsey et al., Oncology 2012:26:1182). In short, in our view patients with early-stage, favorable HL should be treated with combined modality therapy.