NCCN Flash Updates: NCCN Guidelines and Templates Updated for Hodgkin Lymphoma
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) , NCCN Radiation Therapy Compendium™, NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), and the NCCN Drugs and Biologics Compendium (NCCN Compendium®) for Hodgkin Lymphoma. These NCCN Guidelines® are currently available as Version 1.2023.
Link directly to the Updates section of the NCCN Guidelines: Hodgkin Lymphoma
- Bullet added: See HODG-E for the Management of CHL in older adults
- Additional Therapy
- Deauville 1-2
- Chemotherapy alone modified: ABVD x 1 cycles (adapted
per from H10F, CALGB)(preferred)
- Combined modality therapy options clarified as follows: ABVD x 2 cycles + ISRT (per GHSG HD16; if ESR <50, no e-lesions, <3 nodal sites per GHSG favorable criteria) or ABVD x 1 cycle (total 3) + ISRT 30 Gy (adapted from RAPID, H10F)
- Deauville 3, Combined modality therapy options revised to include ABVD x 2 cycles (total 4) + ISRT 30 Gy (adapted
perfrom RAPID, H10F)
- Footnote n modified: The degree of abnormality of a Deauville 4 score is quite variable and may influence further therapy. (
eg, If only focally positive on interim FDG-PET it may be feasibleappropriate to continue with 2 more cycles of ABVD and then repeat the FDG-PET scan .) For a Scans that remain positive warrant a biopsy and/or treatment escalation. If a post-chemotherapy PET is only focally positive, consolidation RT utilizing a higher dose may be considered, especially if a biopsy is not feasible. See Principles of Radiation Therapy (HODG-D 2 of 12) throughout the area(s) of initial disease, the consensus is to escalate therapy. (with consideration of biopsy, especially if an easily accessible site). (also in Special considerations box on HODG-4 and HODG-5)
- Footnote o modified: A Deauville 5 score
should prompt re would warrant a biopsy, especially if a readily accessible site, which would thento inform subsequent therapy. If a biopsy is not performed feasible, treatment should be escalated. (also on HODG-6 and HODG-7 and in the Special considerations box on HODG-4 and HODG-5)
- Primary Treatment
- Both ABVD x 2 cycles and Brentuximab vedotin + AVD are now listed as "Preferred Regimens" with a category 1 recommendation
- Restaging recommendations clarified as follows: Restage with FDG-PET/CT after 6 cycles of AVD
- Footnote y modified: An interim FDG-PET/CT after 2 cycles may be helpful in further defining therapy. If performing an interim FDG-PET/CT before completion of 6 cycles, and FDG-PET is positive...
- Footnote ff modified: An FDA-approved biosimilar is an acceptable substitute for rituximab. Rituximab and hyaluronidase human injection for subcutaneous use may be substituted for rituximab after patients have received the first full dose of rituximab by intravenous infusion. (Also on HODG-13, footnote b on HODG-C 2 of 5, HODG-C 3 of 5)
- Interim H&P: Annually
- Annual breast screening modified: Inititate
8-10 y post-therapy, or at age 40 y or 8 y post-therapy, whichever comes first, if chest or axillary radiation.
- Maintenance Therapy, Recommendations modified as follows:
- Deauville 1–3: Observe or Considerbrentuximab vedotin maintenance
for 1 y for patients with high risk of relapse
- Deauville 4: Considerbrentuximab vedotin maintenance
for 1 y for patients with high risk of relapse
- Footnote tt modified: At relapse, rebiopsy should be considered because of risk for transformation, especially if intra-abdominal or splenic disease...
HODG-C (3 of 5)
- Second-Line and Subsequent Therapy
- ESHAP (etoposide, methylprednisolone, high-dose cytarabine, cisplatin) removed as treatment option
- Pembrolizumab: Qualifier removed: for patients not candidates for transplant
- The following regimens were added as options:
- ICE + nivolumab
- ICE + brentuximab vedotin
- R + ESHAP removed as a treatment option
- Heading revised:
Third-Line and SubsequentTherapy for Disease Refractory to at Least 3 Prior Lines of Therapy
- Pembrolizumab removed as a treatment option
- Vinblastine added as a treatment option
- General Guidelines for Checkpoint Inhibitors (CPI) for Relapsed/Refractory CHL
- 3rd bullet modified: Post-allogeneic transplant, patients can receive either nivolumab or pembrolizumab. There are limited data regarding the use of CPI following allogeneic transplantation;
CPI should be used with caution before allogeneic transplantation due to increased risk of GVHD (graft-versus-host disease) and other immunologic complications.If a CPI is used, the transplant regimen will need to be carefully considered.
HODG-D (1 of 12)
- General Principles, 4th bullet modified: ...have been shown to decrease incidental dose to the heart and lungs in many disease presentations. In certain circumstances, the use of protons for mediastinal lymphoma provides dosimetric advantages that may reduce long-term toxicity. The potential advantage of protons is related to the localization of disease within the mediastinum as well as patient gender and age.
HODG-D (2 of 12)
- Involved-Site Radiation Therapy (ISRT): Dose
- 1st bullet, 4th sub-bullet modified: Sites of Deauville 4–5 and partial response to chemotherapy: 36-45 Gy or greater
- Heading revised: ISRT: Volumes
- 3rd bullet modified: For CHL, the pre-chemotherapy or pre-biopsy gross tumor volume (GTV) provides the basis for determining the clinical target volume (CTV).
- 4th bullet modified: For NLPHL,
often treated with RT alone, treatment should extend beyond the PET-positive or CT-enlarged nodes.the CTV will depend on whether treatment consists of RT alone or CMT.
- 4th bullet
- Sub-bullet removed: The CTV definition for treating NLPHL with RT alone will be greater than that used for CHL with similar disease distribution being treated with combined modality therapy.
- Sub-bullet added: ISRT alone: The CTV should be expanded to include potential microscopic disease in the immediate region of the FDG-PET–positive disease
- Sub-bullet added: CMT: Similar to CHL after chemotherapy [treating originally involved lymph node(s) only]
HODG-D (4 of 12)
- Organ at Risk
- Thorax modified: Coronary vessels including the left main, left anterior descending (LAD), left circumflex (LCx), and right coronary artery(RCA)
- Dose Recommendation (1.5–2 Gy/fraction)
- Thorax modified:
Avoid hotspots LAD V15 Gy <10%, Left circumflex V15 Gy <14%, Coronary vessels (total)- Mean <7 Gy, Minimize the maximum dose to individual coronary arteries
- Thorax, bullet added: Major adverse cardiac events
- Footnote d modified: As cardiac toxicity is likely related to dose to specific substructures, it is recommended that these are contoured, constraints are applied, and doses are recorded. Contouring atlases are available. It is recognized that contouring the coronary arteries is challenging given anatomical variations and lung/heart motion. This may warrant designing a planning
organ at riskOAR volume in some patients. Further, it is important to preferentially spare high-doseoverlap with the proximal coronary arteries (left main, proximal LAD). For example, a plan may achieve an LAD V15 Gy <10% but it is not ideal if most of the 15 Gy or higher dose overlap is surrounding the proximal LAD while the distal LAD is spared to meet the volumetric dose goal. Reviewing both dose to the entire coronary tree and the individual components, particularly the proximal vessels, is important.
HODG-D (5 of 12)
- Secondary Malignancies
- Breast, Dose Recommendation modified: Minimize volume >4 Gy (ideally <10%)
HODG-D (9 of 12)
- Lungs, 4th bullet added:
Radiation therapy RT, and possibly some chemotherapy drugs such as alkylating agents, increase the risk of developing lung cancer. The risk increases linearly with dose to the lung. The increased risk is most apparent in smokers, particularly those who continue to use tobacco after diagnosis. In fact, continuing to smoke after thoracic RT multiples the risk of developing lung cancer. Therefore, a concerted effort should be made to help current smokers requiring thoracic RT to stop smoking. Lung cancer screening with low-dose CT may also be appropriate depending upon clinical circumstances including age, pack-year tobacco exposure history, and interval since quitting. See NCCN Guidelines for Lung Cancer Screening
- Breast: New section added.
HODG-E (1 of 2)
- Relapsed or Refractory Diseases, 3rd bullet
- Sub-bullet removed: Second-line, third-line and subsequent therapy options (only for CHL) as listed on Principles of Systemic Therapy for Relapsed or Refractory Disease HODG-C (3 of 5)
- New section added: Abbreviations
NCCN has published updates to the NCCN Chemotherapy Order Templates (NCCN Templates®) for Hodgkin Lymphoma to reflect the currently published NCCN Guidelines for Hodgkin Lymphoma Version 1.2023.
- The following NCCN Templates® have been DELETED:
- HDL10: ESHAP (Etoposide/MethylPREDNISolone/Cytarabine/CISplatin)
- HDL36: ESHAP (Etoposide/MethylPREDNISolone/Cytarabine/CISplatin) + RiTUXimab
For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.
To view the NCCN Guidelines for Patients®, please visit NCCN.org/patientguidelines.
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