NCCN Updates Clinical Practice Guidelines for Hodgkin Lymphoma
The National Comprehensive Cancer Network (NCCN) has issued updates to their guidelines for Hodgkin lymphoma, including additions to maintenance therapy options, systemic therapy options, and various treatment algorithms.
In the treatment algorithms for classic Hodgkin lymphoma table, an additional row for clinical stage IA was added, separating the erythrocyte sedimentation rates (< 50 and > 50) and respective guidelines page (HODG-3 or HODG-4, HODG-6) for each row.
In the algorithm for classic stage IA-IIA disease, the primary treatment options were revised. After ABVD x 3 cycles (preference to treat with chemotherapy alone), additional therapy for Deauville 3-4 has been revised to include “consider PET/CT” after ABVD x 1 cycle (total 4) plus ISRT (30 Gy).
The primary treatment algorithm for classic stage III-IV disease no longer includes ABVD x 2 cycles as additional therapy for Deauville 4-5 after initial ABVD x 2 cycles.
In the primary treatment for nodular lymphocyte-predominant Hodgkin lymphoma, observation has been added as an option for CS IIIA and IVA disease.
As for refractory classic Hodgkin lymphoma, multiple changes were made to the second-line therapy options. The maintenance therapy option for those with Deauville 1-3 after high-dose therapy and autologous stem cell rescue (HDT/ASCR) now reads “Observe or Brentuximab vedotin for 1 year for patients with high risk of relapse.” Similarly, maintenance for those with Deauville 4 after HDT/ASCR now reads “Brentuximab vedotin for 1 year for patients with high risk of relapse.” After additional therapy for those with Deauville 5, “Autologous or allogeneic stem cell transplant if response to secondary therapy” was added as an option.
In the suspected relapse algorithm, the second-line therapy pathway after initial stage IA-IIA disease was split to include either “Patients who received abbreviated chemotherapy (3-4 cycles) without RT” and “Patients who received full-course chemotherapy.” Those who received abbreviated chemotherapy now have the options of second-line systemic therapy plus RT, RT alone, or HDT/ASCR plus ISRT. Those who received full-course chemotherapy now have the options of second-line systemic therapy plus RT or HDT/ASCR plus ISRT.
The section on regimens of systemic therapy for relapsed or refractory disease was revised extensively. Removed bullets include:
- The selection of second-line chemotherapy regimens depends on the pattern of relapse and the agents previously used.
- Patients in complete response to second-line therapy have improved outcomes following HDT/ASCR.
- Brentuximab vedotin is a treatment option if HDT/ASCR has failed or at least 2 prior multi-agent chemotherapy regimens have failed.
- Nivolumab is an option for classic Hodgkin lymphoma that has relapse or progressed following HDT/ASCR and post-transplant brentuximab vedotin.
For second-line systemic options of relapsed or refractory disease, gemcitabine plus bendamustine and vinorelbine was added. C-MOPP (cyclophosphamide, vincristine, procarbazine, prednisone), MINE (etoposide, ifosfamide, mesna, and mitoxantrone), and Mini-BEAM (carmustine, cytarabine, etoposide, and melphalan) were all moved to the subsequent systemic therapy options in this section.
In the section for suggested treatment regimens of classic Hodgkin lymphoma in older adults (aged > 60 years), ISRT (30 Gy) was added for stage I-II disease.—Zachary Bessette