VARIANT 3.

25-year-old woman with CS IIIA (neck, mediastinum, and para-aortic) NSHL was treated with 6 cycles of ABVD alone and achieved a CR. Six months after completion of treatment, a new 3-cm node was palpated in left neck. (Early nodal relapse after chemotherapy alone.)

Treatment	Rating	Comments
Evidence for relapse or refractory disease
Requires pathologic confirmation	9
Recommended treatment
RT alone	2
Salvage chemotherapy alone	3
Salvage chemotherapy + RT	5
Salvage chemotherapy + SCT	7
Salvage chemotherapy + RT + SCT (CR to salvage chemotherapy)	8
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	In this scenario, TLI is not referring to conditioning for SCT Consider whether it is appropriate to use TLI as adjuvant therapy.
Timing of RT
Primary therapy	2
Following salvage chemotherapy, if no SCT	7
After salvage chemotherapy, before SCT (CR to salvage chemotherapy)	7
After SCT	7
RT dose (CR to salvage chemotherapy)
< 30 Gy	4
30–36 Gy	8
> 36 Gy	5

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.