![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Hodgkin´s Disease---unfavorable clinical stage I and II.

#### BIBLIOGRAPHIC SOURCE(S)

Mendenhall NP, Chang D, Hoppe RT, Ng A, Colman M, Constine LS, Deming
RL, Morris DE, Wolkov HB, Yahalom J, Chauvenet AR, Hudson MM, Winter JN,
Expert Panel on Radiation Oncology-Hodgkin\'s Disease. Hodgkin\'s
disease - unfavorable clinical stage I and II. \[online publication\].
Reston (VA): American College of Radiology (ACR); 2006. 10 p. \[43
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
Expert Panel on Radiation Oncology. Hodgkin\'s disease unfavorable
clinical stage I and II. American College of Radiology. Appropriateness
Criteria. Reston (VA): American College of Radiology (ACR); 2000. 10 p.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hodgkin\'s disease -- unfavorable clinical stage I and II

#### GUIDELINE CATEGORY

Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Hematology\
Internal Medicine\
Oncology\
Radiation Oncology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of treatment procedures for patients
with unfavorable clinical stage I and II Hodgkin\'s disease

#### TARGET POPULATION

Patients with unfavorable clinical stage I and II Hodgkin\'s disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Radiation therapy

    -   Involved field radiation therapy (IFRT)

    -   Extended field RT (EFRT)

    -   Subtotal lymphoid irradiation (STLI)

    -   Total lymphoid irradiation (TLI)

    -   STLI/TLI plus spleen

    -   Mantle

    -   Mediastinum/bilateral hila/bilateral supraclavicular

2.  Chemotherapy

3.  Combination therapy

    -   Chemotherapy plus IFRT

    -   Chemotherapy plus EFRT

    -   Chemotherapy plus STLI/TLI

4.  Biopsy

5.  Observation

#### MAJOR OUTCOMES CONSIDERED

-   Utility of positron emission tomography (PET)

-   Impact of prognostic factors

-   Relapse-free and overall survival rate

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Hodgkin\'s Disease \-- Unfavorable Clinical Stage
I and II**

**Variant 1: 26-year-old male; CS IIB NSHD; supradiaphragmatic, no bulky
disease; fevers  \>38 degrees C and drenching night sweats.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  4-6 months           8                    
  chemotherapy plus                        
  involved field RT                        
  (IFRT)                                   

  4-6 months           6                   Limited data. Relapse rates may be
  chemotherapy only                        higher, but survival may be the
                                           same.

  4-6 months           2                    
  chemotherapy plus                        
  extended field RT                        
  (EFRT)                                   

  Radiation alone,     1                    
  subtotal lymphoid                        
  irradiation (STLI)                       

  4-6 months           1                    
  chemotherapy plus                        
  STLI                                     

  Radiation alone,     1                    
  involved field                           

  **Radiation                              
  Dose/Combined                            
  Modality (4 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        8                   Emerging data suggest that 20 Gy
                                           is insufficient.

  31-36 Gy IFRT        4                    

  \>36-40 Gy IFRT      2                    

  \>40 Gy IFRT         1                    

  **Radiation                              
  Dose/Combined                            
  Modality (6 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        8                    

  31-36 Gy IFRT        2                    

  \>36-40 Gy IFRT      2                    

  \>40 Gy IFRT         1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: 26-year-old male; CS IIB NSHD; supradiaphragmatic, bulky
disease 10 cm in the neck; marrow uninvolved; fevers \>38 degrees C and
drenching night sweats.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  4-6 months           8                    
  chemotherapy plus                        
  involved field RT                        
  (IFRT)                                   

  4-6 months           1                    
  chemotherapy plus                        
  STLI/TLI                                 

  4-6 months           1                    
  chemotherapy only                        

  Radiation alone,     1                    
  STLI/TLI plus spleen                     

  Radiation alone,     1                    
  mantle                                   

  **Radiation                              
  Dose/Combined                            
  Modality (4 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        6                   Limited data. Relapse rates may be
                                           higher, but survival may be the
                                           same.

  31-36 Gy IFRT        8                    

  \>36-40 Gy IFRT      4                    

  \>40 Gy IFRT         1                    

  **Radiation                              
  Dose/Combined                            
  Modality (6 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        8                   Data on\<30 Gy are limited.

  31-36 Gy IFRT        6                    

  \>36-40 Gy IFRT      3                    

  \>40 Gy IFRT         1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: 26-year-old male; CS IIA NSHD. MTR=0.38 (ratio at T5-6).
MMR=0.31 (ratio at maximum intrathoracic diameter).**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  4-6 months           8                    
  chemotherapy plus                        
  involved field RT                        
  (IFRT)                                   

  Radiation alone,     1                    
  STLI/TLI plus spleen                     

  Radiation alone,     1                    
  mantle                                   

  4-6 months           1                    
  chemotherapy plus                        
  STLI/TLI                                 

  4-6 months           1                    
  chemotherapy only                        

  **Radiation                              
  Dose/Combined                            
  Modality (4 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        6                    

  31-36 Gy IFRT        8                    

  \>36-40 Gy IFRT      4                    

  \>40 Gy IFRT         1                    

  Boost mediastinum    8                    
  dose to 36 Gy                            

  Boost mediastinum    6                   If the mediastinum is boosted \>36
  dose to 40 Gy                            Gy, careful consideration should
                                           be given to using a \"shrinking
                                           field\" technique.

  Boost mediastinum    1                   If the mediastinum is boosted \>36
  dose to 44 Gy                            Gy, careful consideration should
                                           be given to using a \"shrinking
                                           field\" technique.

  **Radiation                              
  Dose/Combined                            
  Modality (6 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        8                    

  31-36 Gy IFRT        6                    

  \>36-40 Gy IFRT      3                    

  \>40 Gy IFRT         1                    

  Boost mediastinum    8                    
  dose to 36 Gy                            

  Boost mediastinum    5                   If the mediastinum is boosted \>36
  dose to 40 Gy                            Gy, careful consideration should
                                           be given to using a \"shrinking
                                           field\" technique.

  Boost mediastinum    1                   If the mediastinum is boosted \>36
  dose to 44 Gy                            Gy, careful consideration should
                                           be given to using a \"shrinking
                                           field\" technique.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: 26-year-old male; CS IIA NSHD. MTR=0.45. MMR=0.38.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  4-6 months           8                    
  chemotherapy plus                        
  involved field RT                        
  (IFRT)                                   

  Radiation alone,     1                    
  mantle                                   

  Radiation alone,     1                    
  STLI/TLI plus spleen                     

  4-6 months           1                    
  chemotherapy plus                        
  STLI/TLI                                 

  **Radiation                              
  Dose/Combined                            
  Modality (4 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        4                    

  31-36 Gy IFRT        8                    

  \>36-40 Gy IFRT      4                    

  \>40 Gy IFRT         1                    

  Boost mediastinum    8                    
  dose to 36 Gy                            

  Boost mediastinum    6                    
  dose to 40 Gy                            

  Boost mediastinum    1                    
  dose to 44 Gy                            

  **Radiation                              
  Dose/Combined                            
  Modality (6 months                       
  conventional chemo                       
  and good response)**                     

  20-30 Gy IFRT        8                    

  31-36 Gy IFRT        6                    

  \>36-40 Gy IFRT      3                    

  \>40 Gy IFRT         1                    

  Boost mediastinum    8                    
  dose to 36 Gy                            

  Boost mediastinum    4                    
  dose to 40 Gy                            

  Boost mediastinum    1                    
  dose to 44 Gy                            

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: 26-year-old female; CS IIA NSHD involving mediastinum and
left supraclavicular. MMR=0.38. Good response on CT to 6 months of
conventional chemotherapy, PET negative.**

  ------------------------------------------------------------------------------
  **Treatment**           **Appropriateness   **Comments**
                          Rating**            
  ----------------------- ------------------- ----------------------------------
  **Radiotherapy Volume**                     

  Involved field          8                    

  Mediastinum/bilateral   8                    
  hila/bilateral                              
  supraclavicular                             

  Full mantle             1                    

  STLI plus spleen        1                    

  **Radiation                                 
  Dose/Combined Modality                      
  (6 months conventional                      
  chemo and good                              
  response)**                                 

  20-30 Gy IFRT           8                    

  31-36 Gy IFRT           6                    

  \>36-40 Gy IFRT         3                    

  \>40 Gy IFRT            1                    

  Boost mediastinum dose  8                    
  to 36 Gy                                    

  Boost mediastinum dose  3                    
  to 40 Gy                                    

  Boost mediastinum dose  1                    
  to 44 Gy                                    

  **Mediastinal Volume**                      

  Treat post-chemo volume 8                   If there is no lung extension, the
  only (laterally)                            width of the postchemo RT field
                                              may correspond to the post-chemo
                                              extent of disease; however, the
                                              superior-inferior extent of the
                                              field should encompass the initial
                                              extent of disease.

  Treat pre-chemo volume  1                   If there is no lung extension, the
  to 10-15 Gy, then                           width of the postchemo RT field
  shrink                                      may correspond to the post-chemo
                                              extent of disease; however, the
                                              superior-inferior extent of the
                                              field should encompass the initial
                                              extent of disease.

  Inferior margin 2 cm    8                    
  below pre-chemo volume                      

  Inferior margin 2 cm    1                    
  below post-chemo volume                     

  Inferior margin 5 cm    1                    
  below post-chemo volume                     

  Inferior margin         1                    
  approximately at                            
  diaphragm                                   

  Inferior margin 5 cm    1                    
  below pre-chemo volume                      

  ***Appropriateness                          
  Criteria Scale*\                            
  1 2 3 4 5 6 7 8 9\                          
  1 = Least appropriate 9                     
  = Most appropriate**                        
  ------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 6: 26-year-old female; CS IIA NSHD involving mediastinum and
left supraclavicular; MMR=0.38. Completion of chemo for 6 months and
IFRT with complete response but residual PET scan avidity in the
mediastinum 2 months later.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  Observe and rescan   8                    
  in 2-3 months                            

  Observe and rescan   4                    
  in 6 months                              

  Biopsy now           4                    

  Salvage chemo with   2                    
  ESHAP or other                           
  salvage regimen and                      
  expectation of auto                      
  transplant without                       
  any radiation                            
  without biopsy.                          

  Salvage chemo with   1                    
  ESHAP or other                           
  salvage regimen and                      
  expectation of auto                      
  transplant with                          
  mediastinal RT                           
  without biopsy.                          

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 7: 26-year-old male; CS IIB NSHD; supradiaphragmatic, no bulky
disease. PET scan shows an additional focus of activity at the splenic
hilum not visible on CT.**

  ---------------------------------------------------------------------------
  **Treatment**        **Appropriateness   **Comments**
                       Rating**            
  -------------------- ------------------- ----------------------------------
  4-6 cycles chemo and No consensus        Residual PET activity after
  IFRT to all sites of                     treatment with chemo is associated
  disease seen on CT                       with a worse prognosis. It is
  and PET                                  unclear, however, what adjustments
                                           to treatment need to be made in
                                           this scenario.

  4-6 cycles chemo and No consensus        Residual PET activity after
  IFRT to all sites of                     treatment with chemo is associated
  disease seen on CT                       with a worse prognosis. It is
  only                                     unclear, however, what adjustments
                                           to treatment need to be made in
                                           this scenario.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Summary of Literature Review**

Despite the excellent predictive value of the Ann Arbor staging system
for Hodgkin\'s disease, it has been shown that certain presentations of
stage I-II may be associated with a distinctly worse freedom from
progression when initial treatment is with irradiation alone. More
intensive management approaches are indicated for some of these
patients. Numerous analyses have evaluated the impact of prognostic
factors in stage I-II disease in order to identify patients who benefit
from more intensive therapy. Prognostic factors identified in these
analyses include the number of involved lymphoid regions, the size of
individual nodes, the extent of mediastinal disease, patient gender and
age, the presence of B symptoms or pruritus, histology, and erythrocyte
sedimentation rate (ESR). A pooled analysis of patients with localized
disease from the GELA H8 and H9 trials confirmed that age \>45 years,
male sex, hemoglobin \<10.5 g/dL, lymphocytes \<600/microL, B symptoms
with elevated ESR, and extranodal sites significantly correlated with
survival rate. Overall tumor burden was shown to correlate well with
prognosis.

In the United States there has been general consensus that two of these
factors in stage I-II Hodgkin\'s disease should influence management
decisions. The first is constitutional (B) symptoms \-- unexplained
fevers, drenching night sweats, or significant weight loss as clearly
defined in the Ann Arbor staging classification system. The presence of
B symptoms is correlated with a higher likelihood of systemic disease,
including occult subdiaphragmatic disease, detectable only by staging
laparotomy and splenectomy. Evidence suggests that fevers and weight
loss have more prognostic significance than night sweats alone.

The second prognostic factor that should influence treatment selection
is the presence of large mediastinal adenopathy or bulky disease in non
mediastinal sites. Several retrospective series have shown very strong
correlation between mediastinal mass size and prognosis for patients
treated with irradiation alone or chemotherapy alone. These series
suggest that patients who present with large mediastinal adenopathy can
be treated more effectively with combined modality therapy when freedom
from relapse or freedom from treatment failure is the endpoint.

Appropriate evaluation for patients with unfavorable early stage disease
includes computed tomography (CT) scanning, blood studies, and bone
marrow biopsy, but no longer requires laparotomy. Positron emission
tomography (PET) has been incorporated into the workup because of its
sensitivity in detecting subclinical disease, further obviating the need
for pathologic staging. One study found that patients with early stage
disease who were upstaged to stage III or IV by PET had worse outcomes,
suggesting a need to incorporate PET into the staging procedure and
management decisions.

Treatment of patients with unfavorable stage I-II Hodgkin\'s lymphoma
with radiation or chemotherapy alone is not recommended due to the high
risk of relapse. Data from a variety of studies using different criteria
for risk stratification consistently demonstrate a benefit for freedom
from disease progression with the addition of consolidative irradiation
after chemotherapy but, as of yet, no improvement in survival. In a
Spanish series of patients treated with adriamycin, bleomycin,
vinblastine, and dacarbazine (ABVD), using consolidative radiation
therapy only for patients with bulky disease or an incomplete response
to chemotherapy, progression-free and overall survival rates at 7 years
were 76% and 92%, respectively, in patients with bulky mediastinal
disease and 82% and 94% in patients with B symptoms. In the NCIC/ECOG
trial, which excluded patients with bulky disease and B symptoms, but
included patients with other unfavorable features such as male gender,
four or more sites of involvement, age 40 years or older, and elevated
erythrocyte sedimentation rate (ESR), freedom from disease progression
was superior in patients treated with combined modality therapy,
although survival was the same. A trial in patients with non-bulky IA/B,
IIA/B, and IIIA disease showed no benefit to extended field radiation
therapy (EFRT) following 6 cycles of ABVD vs. ABVD alone, but was
powered to detect only a benefit of at least 20%. A recent meta-analysis
has shown superior overall and progression-free survival with combined
modality therapy for both early-stage and advanced-stage disease.
Patients treated with combined modality therapy for stage I-II
Hodgkin\'s disease with large mediastinal adenopathy can expect
five-year survival and freedom-from-relapse rates of at least 85% to
90%.

Trials have not demonstrated a benefit of irradiating radiographically
uninvolved sites when at least 4 cycles of chemotherapy are given. Thus,
involved field radiation therapy (IFRT) should be the standard treatment
volume, when at least four cycles of chemotherapy are given. The value
of including PET positive sites that are radiographically negative in
the radiation field is unknown.

Emerging data suggest that combined-modality therapy with reduced
radiation treatment volumes will reduce the risk of long-term
complications, specifically second malignancies.

In the setting of planned combined modality therapy for patients with
large mediastinal adenopathy or bulky disease, treatment is initiated
with chemotherapy in order to reduce the size of the mass to be
irradiated, as well as to treat all occult sites of disease. Shrinkage
of the mass with initial chemotherapy permits the use of more generous
lung blocks, thereby providing additional protection for the lungs.
Following chemotherapy, treatment is administered to involved or
slightly extended fields that generally include the mediastinum and
bilateral hilar and supraclavicular regions. The initial lateral extent
of mediastinal disease should not be treated, unless there was known
extranodal disease extension into the pulmonary parenchyma or chest
wall. Irradiation of the pre-chemotherapy volume may result in excessive
pulmonary toxicity.

A randomized study of radiation dose in combined modality therapy
conducted by the German Hodgkin\'s Study Group has demonstrated no
difference in outcome between radiation doses of 20 Gy and 40 Gy to
sites without bulky disease. A recent interim analysis of the German
Hodgkin\'s trial HD11 comparing 20 Gy vs. 30 Gy of IFRT after 4 cycles
of chemotherapy for early unfavorable patients showed little difference
in 3-year freedom from treatment failure (90% vs. 87%) and overall
survival (97% vs. 97%), although follow-up is limited. In combined
modality programs for bulky mediastinal disease, a dose of ≥36 Gy has
commonly been used, although there is little evidence to define the
optimal dose. One study showed in combined modality therapy that doses
of \>30 Gy were not needed for tumors ≤6 cm. However, the high in-field
relapse rate of 26% in larger tumors (\>9 cm) treated with combined
modality therapy using radiation doses of ≤35 Gy suggests a possible
role for higher doses. Response to chemotherapy may serve as an
additional factor influencing dose.

Chemotherapy regimens differ across studies, and the optimal type or
duration of systemic treatment is not known. Most studies have used
anthracycline-based chemotherapy, usually adriamycin. The EORTC H6U
trial found superior freedom from progression with 6 cycles of ABVD as
compared with 6 cycles of mechlorethamine, vincristine, procarbazine,
and prednisone (MOPP). The use of less intensive chemotherapy in
patients with unfavorable-prognosis disease has been associated with
significantly inferior treatment outcomes; in the EORTC H7U trial
comparing 6 cycles of epirubicin, bleomycin, vinblastine, and prednisone
(EBVP) to 6 cycles of MOPP/ABVD followed by IFRT, patients on the EBVP
arm had an inferior 6-year event-free survival rate (68% vs. 90%).
Preliminary results from the GHSG HD11 and the EORTC H9U trials, both
comparing 4 cycles of bleomycin, etoposide, doxorubicin,
cyclophosphamide, vincristine, prednisone, and procarbazine (BEACOPP)
with 4 to 6 cycles of ABVD, showed no significant failure-free or
overall survival benefit to the use of BEACOPP.

A common clinical problem following completion of therapy for patients
with a large mediastinal mass is residual abnormality on chest
radiograph or chest CT scan. In fact, despite the overall excellent
prognosis for these patients, the majority will have residual
abnormalities secondary to sclerosis or fibrosis of previously involved
nodes. In general, these patients may be followed closely, provided
there is no evidence of progressive radiographic abnormality.

PET is emerging as a potentially useful tool in evaluating residual
radiographic abnormality. Studies have reported that it has superior
sensitivity, specificity, and predictive value compared to CT in the
post-treatment setting, and PET evaluation of a patient\'s response to
therapy may serve as an important prognostic factor. Additionally, PET
response during chemotherapy may serve as an early predictor of
treatment success, allowing risk-adapted therapy by intensifying
treatment for higher-risk patients. It is unknown whether risk-adapted
therapy based on early response criteria, including PET findings will
result in better outcomes.

**Abbreviations**

-   C, Celsius

-   CS, clinical stage

-   CT, computed tomography

-   EFRT, extended field radiation therapy

-   ESHAP, etoposide, cisplatin, cytarabine, and methylprednisolone

-   IFRT, involved field radiation therapy

-   MMR, mediastinal mass ratio

-   MTR, median time to relapse

-   NSHD, nodular sclerosing Hodgkin\'s disease

-   PET, positron emission tomography

-   RT, radiation therapy

-   STLI, subtotal lymphoid irradiation

-   TLI, total lymphoid irradiation

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate treatment procedures for patients with
unfavorable clinical stage I and II Hodgkin\'s disease

#### POTENTIAL HARMS

Toxicity associated with chemo and radiation therapy

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Mendenhall NP, Chang D, Hoppe RT, Ng A, Colman M, Constine LS, Deming
RL, Morris DE, Wolkov HB, Yahalom J, Chauvenet AR, Hudson MM, Winter JN,
Expert Panel on Radiation Oncology-Hodgkin\'s Disease. Hodgkin\'s
disease - unfavorable clinical stage I and II. \[online publication\].
Reston (VA): American College of Radiology (ACR); 2006. 10 p. \[43
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Radiation
Oncology--Hodgkin\'s Disease

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Nancy P. Mendenhall, MD; Daniel Chang, MD; Richard T.
Hoppe, MD; Andrea Ng, MD; Martin Colman, MD; Louis S. Constine, MD;
Richard L. Deming, MD; David Eric Morris, MD; Harvey B. Wolkov, MD;
Joachim Yahalom, MD; Allen R. Chauvenet, MD; Melissa M. Hudson, MD; Jane
N. Winter, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
Expert Panel on Radiation Oncology. Hodgkin\'s disease unfavorable
clinical stage I and II. American College of Radiology. Appropriateness
Criteria. Reston (VA): American College of Radiology (ACR); 2000. 10 p.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHodgkinsWorkGroup/HodgkinsDisease151UnfavorableClinicalStageIandIIDoc3.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on May 16, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008