Table 2.
Treatment recommendations according to available level of resources.
| Disease Stage | Level of Available Resources | |||
|---|---|---|---|---|
| Basic | Core | Enhanced | Maximal | |
| Undetermined Stage | Six Cycles of ABVD Chemotderapy | - | - | - |
| Limited stage | - | Six cycles of ABVD or CMT * with 2–4 cycles of ABVD chemotherapy and 20–30 Gy IFRT/ISRT (number of ABVD chemotherapy cycles and radiotherapy dose depending on risk group) |
CMT as defined in the core level setting - two cycles of ABVD followed by two cycles of escalated BEACOPP ** and 30 Gy IFRT/ISRT as a possible alternative for intermediate stage |
Two cycles of ABVD with interim PET-CT, intensification with two cycles of escalated BEACOPP ** + 30 Gy ISRT if interim PET positive, one additional cycle of ABVD + 20 Gy ISRT if interim PET negative |
| Advanced | 6 cycles of ABVD chemotherapy | 6 cycles of ABVD chemotherapy | - 6 cycles of escalated BEACOPP ** as an alternative to 6 to 8 cycles of ABVD chemotherapy - Complementary radiotherapy for initial bulky or residual disease or >2.5cm PET + residual disease (if treated with escalated BEACOPP **) |
2 cycles of ABVD chemotherapy and interim PET-CT - If PET positive, consider treatment intensification - 2 cycles of escalated BEACOPP ** as an alternative initial therapy, if PET negative, restrict chemotherapy to 2 additional escalated BEACOPP ** or 4 cycles of ABVD, complementary radiotherapy as outlined in the enhanced level setting |
| Relapsed/Refractory disease | Referral to primary care center for ASCT if possible | Referral to primary care center for ASCT if possible - Palliative single agent gemcitabine, bendamustine or vinblastine chemotherapy |
High dose chemotherapy followed by ASCT if age/comorbidities permits - Brentuximab vedotin as consolidation after ASCT, if relapse after ASCT or if progression after 2 prior lines of chemotherapy - PD-1 inhibitors nivolumab or pembrolizumab if progression after ASCT and/or prior brentuximab vedotin |
Allogeneic SCT if progression after ASCT to be considered |
* Combined Modality Treatment, to be preferred to chemotherapy alone in limited stage disease when appropriate staging resources and radiotherapy are available. ** Escalated BEACOPP should not be given to patients over the age of 60 years. CMT—combined modality treatment; IFRT—involved field radiotherapy/ISRT—involved site radiotherapy; ASCT—autologous stem cell transplantation; PD—progressive disease.