ACR Appropriateness Criteria s Hodgkin Lymphoma—Unfavorable Clinical Stage I and II

: These guidelines review the historical evolution of treatment for early-stage Hodgkin lymphoma (HL) with current standards that rely on prognostic factors to risk stratify and direct current treatment schemes that includes differentiation of favorable and unfavorable presentations. The major clinical trials for unfavorable early-stage HL are reviewed. Patients in this heterogenous subgroup of classic HL are best managed with sequential chemotherapy and radiotherapy. The role of imaging response assessment as a means to modify therapy is a strategy under investigation. Tailoring the radiation treatment volume and radiation dose prescription along with selective use of modern conformal techniques is expected to help reduce long-term toxicities. Many patients are well served receiving involved-site radiotherapy to 30Gy after appropriate systemic therapy intensity; but, there are nuances for which some variations in the chemotherapy and radiotherapy speciﬁcs are appropriately individualized. Following a dis- cussion of the current evidence-based treatment algorithms, several different example cases are reviewed to help physicians make appro- priate treatment decisions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for speciﬁc clinical conditions that are reviewed every 3 years by a multi-disciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modiﬁed Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evi- dence is lacking or not deﬁnitive, expert opinion may be used to rec-ommend imaging or treatment. BEACOPPesc-contain-ing 2 +2 arm, with a difference of 7.2% (95% CI, 3.8%-10.5%; 94.8% vs. 87.7%), but no differences in OS. 55 A subgroup analysis suggested that a bulky mediastinal mass and an ele- vated ESR continued to predict a higher relapse rate. The use of BEACOPPesc was associated with higher acute toxicity, particularly with myelosuppression and a related 0.52% acute death rate; the ABVD (cid:3) 4 arm had no acute deaths. A higher adriamycin, bleomycin, vincristine, etoposide, cyclophosphamide, and prednisone; BEACOPP, bleomycin, etoposide, adriamycin, cyclo- phosphamide, vincristine, procarbazine, and prednisone; ESR, erythrocyte sedimentation rate; MOPP, mechlorethamine, vincristine, procarbazine, and prednisone; NSHL, nodular sclerosis Hodgkin lymphoma; PET, positron emission tomography; RT, radiation therapy. therapeutic sequence have 8- to 10-year OS rates of 21% to 27%, with FFTF on the order of 16%. 67,71 However, if patients are PET negative going into an autotransplant, results are improved. One study showed that progression-free survival of the PET-negative group of lymphoma patients after conventional-dose chemo- therapy followed by high-dose chemotherapy salvage was 72% versus 23% for the PET-positive group. 72 Primary refractory disease has been generally categorized as high risk relative to patients relapsing >12 months after ﬁrst remission; as such,