VARIANT 2.

25-year-old woman with CS IIA (bilateral neck) NSHL was treated with 4 cycles of ABVD alone and achieved a CR. Two years after completion of treatment, a new 3-cm node was palpated in left neck. (Late nodal relapse after chemotherapy alone.)

Treatment	Rating	Comments
Evidence for relapse or refractory disease
Requires pathologic confirmation	9
Recommended treatment
RT alone	4
Salvage chemotherapy alone	4
Salvage chemotherapy + RT	7
Salvage chemotherapy + SCT	5
Salvage chemotherapy + RT + SCT (CR to salvage chemotherapy)	5
Volume of RT (after CR to chemotherapy)
RT (ISRT) to site of relapse	8
Adjuvant RT to recurrent and all previously untreated nodal sites (TLI)	3
Timing of RT
Primary therapy	3	There are limited data to address this question.
Following salvage chemotherapy, if no SCT	7
After salvage chemotherapy, before SCT (CR to salvage chemotherapy)	6
After SCT	7	Some clinical trials dictate timing of RT
RT dose (CR to salvage chemotherapy)
< 30 Gy	4
30–36 Gy	8
> 36 Gy	4

Rating Scale: 1,2,3 = usually not appropriate; 4,5,6 = may be appropriate; 7,8,9 = usually appropriate.

ABVD = doxorubicin, bleomycin, vinblastine, and dacarbazine; CR = complete response; CS = clinical stage; ISRT = involved-site radiation therapy; NSHL = nodular sclerosis Hodgkin lymphoma; RT = radiation therapy; SCT = stem cell transplantation; TLI = total lymphoid irradiation.