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Advanced Favorable Hodgkin Lymphoma

    Drug combinations described in this section:

    • ABVD: doxorubicin plus bleomycin plus vinblastine plus dacarbazine.
    • CEC: cyclophosphamide plus lomustine plus vindesine plus melphalan plus prednisone plus epidoxorubicin plus vincristine plus procarbazine plus vinblastine plus bleomycin.
    • MOPP: mechlorethamine plus vincristine plus procarbazine plus prednisone.
    • MOPP/ABV hybrid: mechlorethamine plus vincristine plus procarbazine plus prednisone/doxorubicin plus bleomycin plus vinblastine.
    • Stanford V: doxorubicin plus vinblastine plus mechlorethamine plus etoposide plus vincristine plus bleomycin plus prednisone.
    • MOPPEBVCAD: mechlorethamine plus vincristine plus procarbazine plus prednisone plus epidoxorubicin plus bleomycin plus vinblastine plus lomustine plus doxorubicin plus vindesine.

    Patients are designated as having advanced favorable Hodgkin lymphoma (HL) if they have clinical stage III or stage IV disease and three or fewer risk factors on the International Prognostic Index for HL, which corresponds to a freedom-from-progression at greater than 60% at 5 years with combination chemotherapy.[1]

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    ABVD therapy for 6 to 8 months is as effective as 12 months of MOPP alternating with ABVD, and both are superior to MOPP alone in terms of failure-free survival (FFS) (50% vs. 36% with a 14-year median follow-up; P = .03).[2,3][Level of evidence: 1iiA] The Intergroup trial comparing ABVD with MOPP/ABV hybrid showed equivalent efficacy in FFS and overall survival (OS), but increased toxic effects in the hybrid arm, especially from second malignancies.[4][Level of evidence: 1iiA]

    A prospective, randomized study, from the Medical Research Council (MRC) (MRC-UKLG-LY09), of 807 patients compared ABVD with two multidrug regimens also incorporating etoposide, chlorambucil, vincristine, and procarbazine. With 52 months' median follow-up, the 3-year event-free survival was 75% (confidence interval [CI], 71%–79%) for all three regimens, and 88% to 90% OS (CI, 84%–93%) for all three regimens, but there were significantly fewer toxic effects with ABVD.[5][Level of evidence: 1iiA]

    A prospective, randomized study of 331 patients compared ABVD with escalated BEACOPP, along with a planned autologous stem cell transplantation after reinduction chemotherapy for relapsed or resistant disease. With 61 months' median follow-up, although 7-year freedom from first progression favored escalated BEACOPP (73% vs. 85%, P = .004), 7-year OS was not statistically different (84% vs. 89%, P = .39).[6][Level of evidence: 1iiA] Escalated BEACOPP is associated with increased rates of myelodysplasia and acute myelogenous leukemia (3%–4%).[7] Stanford V is an alternative drug combination with mandated radiation consolidation for most patients and survival rates comparable to those with ABVD.[8,9][Level of evidence: 1iiA]

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