VARIANT 4.

25-year-old woman with CS IIIAX (neck, bulky mediastinum, upper para-aortic) NSHL was treated with ABVD × 6 and IFRT (30 Gy to the mediastinum).Three years after completion of therapy, chest CT showed new mediastinal adenopathy with bilateral lung nodules. (Possible late relapse after combined-modality therapy.)

Treatment	Rating	Comments
Evidence for relapse or refractory disease
Requires pathologic confirmation	9
Recommended treatment
RT alone	1
Salvage chemotherapy alone	4
Salvage chemotherapy + RT	3
Salvage chemotherapy + SCT	8
Salvage chemotherapy + RT + SCT (CR to salvage chemotherapy)	5
Volume of RT (after CR to chemotherapy)
RT (ISRT) to mediastinum	5
Adjuvant RT to recurrent and all previously untreated nodal sites (TLI)	3
Timing of RT
Primary therapy	2
Following salvage chemotherapy, if no SCT	5	This option is indicated if there is a CR to salvage chemotherapy.
After salvage chemotherapy, before SCT (CR to salvage chemotherapy)	6
After SCT	7
RT dose to mediastinum (CR to salvage chemotherapy)
< 30 Gy	6
30–36 Gy	6
> 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; CT = computed tomography; IFRT = involved-field radiation therapy; ISRT = involved-site radiation therapy; NSHL = nodular sclerosis Hodgkin lymphoma; RT = radiation therapy; SCT = stem cell transplantation; TLI = total lymphoid irradiation.