Linfoma de Hodgkin

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

A ausência ou a presença de critérios de prognóstico específicos determina se o paciente tem doença em estádio inicial favorável ou desfavorável. Os critérios de prognóstico favorável do German Hodgkin Study Group (GHSG) são mais comumente usados nos EUA (taxa de massa mediastinal [TMM] <0.33; velocidade de hemossedimentação [VHS] <50 mm/hora se não houver sintomas B; VHS <30 mm/hora se sintomas B estiverem presentes; envolvimento de ≤2 sítios nodais; e nenhuma doença extranodal; consulte Critérios de diagnóstico).[44]Dhakal S, Advani R, Ballas LK, et al. ACR appropriateness criteria® Hodgkin lymphoma-favorable prognosis stage I and II. Am J Clin Oncol. 2016 Dec;39(6):535-44. http://www.ncbi.nlm.nih.gov/pubmed/27643717?tool=bestpractice.com [50]German Hodgkin Study Group. Disease stages and risk factors. 2019 [internet publication]. https://en.ghsg.org/disease-stages

Pacientes com doença em estádio inicial favorável geralmente recebem dois ciclos iniciais de ABVD (doxorrubicina, bleomicina, vimblastina, dacarbazina) seguidos por uma PET-CT intermediária, para avaliar a resposta metabólica e orientar o tratamento subsequente.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

Uma abordagem de tratamento adaptada à PET é recomendada para todos os pacientes com doença em estádio inicial, pois oferece a oportunidade de equilibrar a eficácia e a toxicidade do tratamento.[5]Eichenauer DA, Aleman BM, André M, et al. Hodgkin lymphoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29(4 suppl):iv19-29. https://www.annalsofoncology.org/article/S0923-7534(19)31690-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29796651?tool=bestpractice.com [33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com ​​[65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [74]Engert A, Plütschow A, Eich HT, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med. 2010 Aug 12;363(7):640-52. https://www.nejm.org/doi/full/10.1056/NEJMoa1000067 http://www.ncbi.nlm.nih.gov/pubmed/20818855?tool=bestpractice.com [75]Aldin A, Umlauff L, Estcourt LJ, et al. Interim PET-results for prognosis in adults with Hodgkin lymphoma: a systematic review and meta-analysis of prognostic factor studies. Cochrane Database Syst Rev. 2020 Jan 13;1(1):CD012643. https://www.doi.org/10.1002/14651858.CD012643.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31930780?tool=bestpractice.com

O tratamento mais eficaz da doença em estádio inicial é a terapia de modalidade combinada, que compreende quimioterapia combinada (por exemplo, ABVD) seguida de radioterapia.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [55]Noordijk EM, Carde P, Dupouy N, et al. Combined-modality therapy for clinical stage I or II Hodgkin's lymphoma: long-term results of the European Organisation for Research and Treatment of Cancer H7 randomized controlled trials. J Clin Oncol. 2006 Jul 1;24(19):3128-35. https://ascopubs.org/doi/full/10.1200/jco.2005.05.2746 http://www.ncbi.nlm.nih.gov/pubmed/16754934?tool=bestpractice.com [56]Press OW, LeBlanc M, Lichter AS, et al. Phase III randomized intergroup trial of subtotal lymphoid irradiation versus doxorubicin, vinblastine, and subtotal lymphoid irradiation for stage IA to IIA Hodgkin's disease. J Clin Oncol. 2001 Nov 15;19(22):4238-44. http://www.ncbi.nlm.nih.gov/pubmed/11709567?tool=bestpractice.com [57]Specht L, Gray RG, Clarke MJ, et al. Influence of more extensive radiotherapy and adjuvant chemotherapy on long-term outcome of early-stage Hodgkin's disease: a meta-analysis of 23 randomized trials involving 3,888 patients. International Hodgkin's Disease Collaborative Group. J Clin Oncol. 1998 Mar;16(3):830-43. http://www.ncbi.nlm.nih.gov/pubmed/9508163?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [59]Fermé C, Thomas J, Brice P, et al. ABVD or BEACOPP(baseline) along with involved-field radiotherapy in early-stage Hodgkin lymphoma with risk factors: results of the European Organisation for Research and Treatment of Cancer (EORTC)-Groupe d'Étude des Lymphomes de l'Adulte (GELA) H9-U intergroup randomised trial. Eur J Cancer. 2017 Aug;81:45-55. http://www.ncbi.nlm.nih.gov/pubmed/28601705?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [61]Fuchs M, Goergen H, Kobe C, et al. Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international, randomized phase III HD16 trial by the German Hodgkin Study Group. J Clin Oncol. 2019 Nov 1;37(31):2835-45. https://www.doi.org/10.1200/JCO.19.00964 http://www.ncbi.nlm.nih.gov/pubmed/31498753?tool=bestpractice.com ​

Uma abordagem apenas com quimioterapia pode ser considerada se for preferível evitar a radioterapia (por exemplo, por causa da idade do paciente, sexo, história familiar de câncer ou doença cardíaca, comorbidades, sítios de envolvimento).[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [62]Connors JM. The case for chemotherapy alone for limited-stage Hodgkin's lymphoma. Oncologist. 2012;17(8):1011-3. http://theoncologist.alphamedpress.org/content/17/8/1011.long http://www.ncbi.nlm.nih.gov/pubmed/22807512?tool=bestpractice.com [63]Hill-Kayser CE, Plastaras JP, Tochner Z, et al. The case for combined-modality therapy for limited-stage Hodgkin's disease. Oncologist. 2012;17(8):1006-10. http://theoncologist.alphamedpress.org/content/17/8/1006.long http://www.ncbi.nlm.nih.gov/pubmed/22807513?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com ​ A decisão de omitir a radioterapia deve envolver a opinião especializada de uma equipe multidisciplinar e discussão com o paciente sobre riscos e benefícios. A quimioterapia isolada está associada a uma taxa ligeiramente menor de controle do tumor e a uma maior taxa de recidiva em comparação com a terapia de modalidade combinada, mas as taxas de sobrevida são semelhantes.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [67]Raemaekers JM, André MP, Federico M, et al. Omitting radiotherapy in early positron emission tomography-negative stage I/II Hodgkin lymphoma is associated with an increased risk of early relapse: clinical results of the preplanned interim analysis of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2014 Apr 20;32(12):1188-94. https://ascopubs.org/doi/full/10.1200/jco.2013.51.9298 http://www.ncbi.nlm.nih.gov/pubmed/24637998?tool=bestpractice.com [68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com ​[69]Hay AE, Klimm B, Chen BE, et al. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol. 2013 Dec;24(12):3065-9. https://www.doi.org/10.1093/annonc/mdt389 http://www.ncbi.nlm.nih.gov/pubmed/24121121?tool=bestpractice.com [ ] How does positron emission tomography-adapted therapy as first-line treatment affect outcomes in people with early-stage Hodgkin lymphoma?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.758/fullMostre-me a resposta

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

A ausência ou a presença de critérios de prognóstico específicos determina se o paciente tem doença em estádio inicial favorável ou desfavorável. Os critérios de prognóstico favorável do German Hodgkin Study Group (GHSG) são mais comumente usados nos EUA (taxa de massa mediastinal [TMM] <0.33; velocidade de hemossedimentação [VHS] <50 mm/hora se não houver sintomas B; VHS <30 mm/hora se sintomas B estiverem presentes; envolvimento de ≤2 sítios nodais; e nenhuma doença extranodal; consulte Critérios de diagnóstico).[44]Dhakal S, Advani R, Ballas LK, et al. ACR appropriateness criteria® Hodgkin lymphoma-favorable prognosis stage I and II. Am J Clin Oncol. 2016 Dec;39(6):535-44. http://www.ncbi.nlm.nih.gov/pubmed/27643717?tool=bestpractice.com [50]German Hodgkin Study Group. Disease stages and risk factors. 2019 [internet publication]. https://en.ghsg.org/disease-stages ​

Pacientes com doença em estádio inicial favorável geralmente recebem dois ciclos iniciais de ABVD (doxorrubicina, bleomicina, vimblastina, dacarbazina) seguidos por uma PET-CT intermediária, para avaliar a resposta metabólica e orientar o tratamento subsequente.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

Uma abordagem de tratamento adaptada à PET é recomendada para todos os pacientes com doença em estádio inicial, pois oferece a oportunidade de equilibrar a eficácia e a toxicidade do tratamento.[5]Eichenauer DA, Aleman BM, André M, et al. Hodgkin lymphoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29(4 suppl):iv19-29. https://www.annalsofoncology.org/article/S0923-7534(19)31690-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29796651?tool=bestpractice.com [33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [74]Engert A, Plütschow A, Eich HT, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med. 2010 Aug 12;363(7):640-52. https://www.nejm.org/doi/full/10.1056/NEJMoa1000067 http://www.ncbi.nlm.nih.gov/pubmed/20818855?tool=bestpractice.com [75]Aldin A, Umlauff L, Estcourt LJ, et al. Interim PET-results for prognosis in adults with Hodgkin lymphoma: a systematic review and meta-analysis of prognostic factor studies. Cochrane Database Syst Rev. 2020 Jan 13;1(1):CD012643. https://www.doi.org/10.1002/14651858.CD012643.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31930780?tool=bestpractice.com

O tratamento mais eficaz da doença em estádio inicial é a terapia de modalidade combinada, que compreende quimioterapia combinada (por exemplo, ABVD) seguida de radioterapia.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [55]Noordijk EM, Carde P, Dupouy N, et al. Combined-modality therapy for clinical stage I or II Hodgkin's lymphoma: long-term results of the European Organisation for Research and Treatment of Cancer H7 randomized controlled trials. J Clin Oncol. 2006 Jul 1;24(19):3128-35. https://ascopubs.org/doi/full/10.1200/jco.2005.05.2746 http://www.ncbi.nlm.nih.gov/pubmed/16754934?tool=bestpractice.com [56]Press OW, LeBlanc M, Lichter AS, et al. Phase III randomized intergroup trial of subtotal lymphoid irradiation versus doxorubicin, vinblastine, and subtotal lymphoid irradiation for stage IA to IIA Hodgkin's disease. J Clin Oncol. 2001 Nov 15;19(22):4238-44. http://www.ncbi.nlm.nih.gov/pubmed/11709567?tool=bestpractice.com [57]Specht L, Gray RG, Clarke MJ, et al. Influence of more extensive radiotherapy and adjuvant chemotherapy on long-term outcome of early-stage Hodgkin's disease: a meta-analysis of 23 randomized trials involving 3,888 patients. International Hodgkin's Disease Collaborative Group. J Clin Oncol. 1998 Mar;16(3):830-43. http://www.ncbi.nlm.nih.gov/pubmed/9508163?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [59]Fermé C, Thomas J, Brice P, et al. ABVD or BEACOPP(baseline) along with involved-field radiotherapy in early-stage Hodgkin lymphoma with risk factors: results of the European Organisation for Research and Treatment of Cancer (EORTC)-Groupe d'Étude des Lymphomes de l'Adulte (GELA) H9-U intergroup randomised trial. Eur J Cancer. 2017 Aug;81:45-55. http://www.ncbi.nlm.nih.gov/pubmed/28601705?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [61]Fuchs M, Goergen H, Kobe C, et al. Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international, randomized phase III HD16 trial by the German Hodgkin Study Group. J Clin Oncol. 2019 Nov 1;37(31):2835-45. https://www.doi.org/10.1200/JCO.19.00964 http://www.ncbi.nlm.nih.gov/pubmed/31498753?tool=bestpractice.com

Uma abordagem apenas com quimioterapia pode ser considerada se for preferível evitar a radioterapia (por exemplo, por causa da idade do paciente, sexo, história familiar de câncer ou doença cardíaca, comorbidades, sítios de envolvimento).[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [62]Connors JM. The case for chemotherapy alone for limited-stage Hodgkin's lymphoma. Oncologist. 2012;17(8):1011-3. http://theoncologist.alphamedpress.org/content/17/8/1011.long http://www.ncbi.nlm.nih.gov/pubmed/22807512?tool=bestpractice.com [63]Hill-Kayser CE, Plastaras JP, Tochner Z, et al. The case for combined-modality therapy for limited-stage Hodgkin's disease. Oncologist. 2012;17(8):1006-10. http://theoncologist.alphamedpress.org/content/17/8/1006.long http://www.ncbi.nlm.nih.gov/pubmed/22807513?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com ​ A decisão de omitir a radioterapia deve envolver a opinião especializada de uma equipe multidisciplinar e discussão com o paciente sobre riscos e benefícios. A quimioterapia isolada está associada a uma taxa ligeiramente menor de controle do tumor e a uma maior taxa de recidiva em comparação com a terapia de modalidade combinada, mas as taxas de sobrevida são semelhantes.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [67]Raemaekers JM, André MP, Federico M, et al. Omitting radiotherapy in early positron emission tomography-negative stage I/II Hodgkin lymphoma is associated with an increased risk of early relapse: clinical results of the preplanned interim analysis of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2014 Apr 20;32(12):1188-94. https://ascopubs.org/doi/full/10.1200/jco.2013.51.9298 http://www.ncbi.nlm.nih.gov/pubmed/24637998?tool=bestpractice.com [68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com ​[69]Hay AE, Klimm B, Chen BE, et al. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol. 2013 Dec;24(12):3065-9. https://www.doi.org/10.1093/annonc/mdt389 http://www.ncbi.nlm.nih.gov/pubmed/24121121?tool=bestpractice.com [ ] How does positron emission tomography-adapted therapy as first-line treatment affect outcomes in people with early-stage Hodgkin lymphoma?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.758/fullMostre-me a resposta

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

A ausência ou a presença de critérios de prognóstico específicos determina se o paciente tem doença em estádio inicial favorável ou desfavorável. Os critérios de prognóstico favorável do German Hodgkin Study Group (GHSG) são mais comumente usados nos EUA (taxa de massa mediastinal [TMM] <0.33; velocidade de hemossedimentação [VHS] <50 mm/hora se não houver sintomas B; VHS <30 mm/hora se sintomas B estiverem presentes; envolvimento de ≤2 sítios nodais; e nenhuma doença extranodal; consulte Critérios de diagnóstico).[44]Dhakal S, Advani R, Ballas LK, et al. ACR appropriateness criteria® Hodgkin lymphoma-favorable prognosis stage I and II. Am J Clin Oncol. 2016 Dec;39(6):535-44. http://www.ncbi.nlm.nih.gov/pubmed/27643717?tool=bestpractice.com [50]German Hodgkin Study Group. Disease stages and risk factors. 2019 [internet publication]. https://en.ghsg.org/disease-stages

Pacientes com doença em estádio inicial desfavorável geralmente recebem dois ciclos iniciais de ABVD (doxorrubicina, bleomicina, vimblastina, dacarbazina) seguidos por uma PET-CT intermediária, para avaliar a resposta metabólica e orientar o tratamento subsequente.

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

Uma abordagem de tratamento adaptada à PET é recomendada para todos os pacientes com doença em estádio inicial, pois oferece a oportunidade de equilibrar a eficácia e a toxicidade do tratamento.[5]Eichenauer DA, Aleman BM, André M, et al. Hodgkin lymphoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29(4 suppl):iv19-29. https://www.annalsofoncology.org/article/S0923-7534(19)31690-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29796651?tool=bestpractice.com [33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [74]Engert A, Plütschow A, Eich HT, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med. 2010 Aug 12;363(7):640-52. https://www.nejm.org/doi/full/10.1056/NEJMoa1000067 http://www.ncbi.nlm.nih.gov/pubmed/20818855?tool=bestpractice.com [75]Aldin A, Umlauff L, Estcourt LJ, et al. Interim PET-results for prognosis in adults with Hodgkin lymphoma: a systematic review and meta-analysis of prognostic factor studies. Cochrane Database Syst Rev. 2020 Jan 13;1(1):CD012643. https://www.doi.org/10.1002/14651858.CD012643.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31930780?tool=bestpractice.com

O tratamento mais eficaz da doença em estádio inicial é a terapia de modalidade combinada, que compreende quimioterapia combinada (por exemplo, ABVD) seguida de radioterapia.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [55]Noordijk EM, Carde P, Dupouy N, et al. Combined-modality therapy for clinical stage I or II Hodgkin's lymphoma: long-term results of the European Organisation for Research and Treatment of Cancer H7 randomized controlled trials. J Clin Oncol. 2006 Jul 1;24(19):3128-35. https://ascopubs.org/doi/full/10.1200/jco.2005.05.2746 http://www.ncbi.nlm.nih.gov/pubmed/16754934?tool=bestpractice.com [56]Press OW, LeBlanc M, Lichter AS, et al. Phase III randomized intergroup trial of subtotal lymphoid irradiation versus doxorubicin, vinblastine, and subtotal lymphoid irradiation for stage IA to IIA Hodgkin's disease. J Clin Oncol. 2001 Nov 15;19(22):4238-44. http://www.ncbi.nlm.nih.gov/pubmed/11709567?tool=bestpractice.com [57]Specht L, Gray RG, Clarke MJ, et al. Influence of more extensive radiotherapy and adjuvant chemotherapy on long-term outcome of early-stage Hodgkin's disease: a meta-analysis of 23 randomized trials involving 3,888 patients. International Hodgkin's Disease Collaborative Group. J Clin Oncol. 1998 Mar;16(3):830-43. http://www.ncbi.nlm.nih.gov/pubmed/9508163?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [59]Fermé C, Thomas J, Brice P, et al. ABVD or BEACOPP(baseline) along with involved-field radiotherapy in early-stage Hodgkin lymphoma with risk factors: results of the European Organisation for Research and Treatment of Cancer (EORTC)-Groupe d'Étude des Lymphomes de l'Adulte (GELA) H9-U intergroup randomised trial. Eur J Cancer. 2017 Aug;81:45-55. http://www.ncbi.nlm.nih.gov/pubmed/28601705?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [61]Fuchs M, Goergen H, Kobe C, et al. Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international, randomized phase III HD16 trial by the German Hodgkin Study Group. J Clin Oncol. 2019 Nov 1;37(31):2835-45. https://www.doi.org/10.1200/JCO.19.00964 http://www.ncbi.nlm.nih.gov/pubmed/31498753?tool=bestpractice.com

Uma abordagem apenas com quimioterapia pode ser considerada se for preferível evitar a radioterapia (por exemplo, por causa da idade do paciente, sexo, história familiar de câncer ou doença cardíaca, comorbidades, sítios de envolvimento).[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [62]Connors JM. The case for chemotherapy alone for limited-stage Hodgkin's lymphoma. Oncologist. 2012;17(8):1011-3. http://theoncologist.alphamedpress.org/content/17/8/1011.long http://www.ncbi.nlm.nih.gov/pubmed/22807512?tool=bestpractice.com [63]Hill-Kayser CE, Plastaras JP, Tochner Z, et al. The case for combined-modality therapy for limited-stage Hodgkin's disease. Oncologist. 2012;17(8):1006-10. http://theoncologist.alphamedpress.org/content/17/8/1006.long http://www.ncbi.nlm.nih.gov/pubmed/22807513?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com ​ A decisão de omitir a radioterapia deve envolver a opinião especializada de uma equipe multidisciplinar e discussão com o paciente sobre riscos e benefícios. A quimioterapia isolada está associada a uma taxa ligeiramente menor de controle do tumor e a uma maior taxa de recidiva em comparação com a terapia de modalidade combinada, mas as taxas de sobrevida são semelhantes.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [67]Raemaekers JM, André MP, Federico M, et al. Omitting radiotherapy in early positron emission tomography-negative stage I/II Hodgkin lymphoma is associated with an increased risk of early relapse: clinical results of the preplanned interim analysis of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2014 Apr 20;32(12):1188-94. https://ascopubs.org/doi/full/10.1200/jco.2013.51.9298 http://www.ncbi.nlm.nih.gov/pubmed/24637998?tool=bestpractice.com [68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com ​[69]Hay AE, Klimm B, Chen BE, et al. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol. 2013 Dec;24(12):3065-9. https://www.doi.org/10.1093/annonc/mdt389 http://www.ncbi.nlm.nih.gov/pubmed/24121121?tool=bestpractice.com [ ] How does positron emission tomography-adapted therapy as first-line treatment affect outcomes in people with early-stage Hodgkin lymphoma?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.758/fullMostre-me a resposta

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

A ausência ou a presença de critérios de prognóstico específicos determina se o paciente tem doença em estádio inicial favorável ou desfavorável. Os critérios de prognóstico favorável do German Hodgkin Study Group (GHSG) são mais comumente usados nos EUA (taxa de massa mediastinal [TMM] <0.33; velocidade de hemossedimentação [VHS] <50 mm/hora se não houver sintomas B; VHS <30 mm/hora se sintomas B estiverem presentes; envolvimento de ≤2 sítios nodais; e nenhuma doença extranodal; consulte Critérios de diagnóstico).[44]Dhakal S, Advani R, Ballas LK, et al. ACR appropriateness criteria® Hodgkin lymphoma-favorable prognosis stage I and II. Am J Clin Oncol. 2016 Dec;39(6):535-44. http://www.ncbi.nlm.nih.gov/pubmed/27643717?tool=bestpractice.com [50]German Hodgkin Study Group. Disease stages and risk factors. 2019 [internet publication]. https://en.ghsg.org/disease-stages

Pacientes com doença em estádio inicial desfavorável geralmente recebem dois ciclos iniciais de ABVD (doxorrubicina, bleomicina, vimblastina, dacarbazina) seguidos por uma PET-CT intermediária, para avaliar a resposta metabólica e orientar o tratamento subsequente.

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

Uma abordagem de tratamento adaptada à PET é recomendada para todos os pacientes com doença em estádio inicial, pois oferece a oportunidade de equilibrar a eficácia e a toxicidade do tratamento.[5]Eichenauer DA, Aleman BM, André M, et al. Hodgkin lymphoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29(4 suppl):iv19-29. https://www.annalsofoncology.org/article/S0923-7534(19)31690-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29796651?tool=bestpractice.com [33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com ​​​[66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [74]Engert A, Plütschow A, Eich HT, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med. 2010 Aug 12;363(7):640-52. https://www.nejm.org/doi/full/10.1056/NEJMoa1000067 http://www.ncbi.nlm.nih.gov/pubmed/20818855?tool=bestpractice.com [75]Aldin A, Umlauff L, Estcourt LJ, et al. Interim PET-results for prognosis in adults with Hodgkin lymphoma: a systematic review and meta-analysis of prognostic factor studies. Cochrane Database Syst Rev. 2020 Jan 13;1(1):CD012643. https://www.doi.org/10.1002/14651858.CD012643.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31930780?tool=bestpractice.com

O tratamento mais eficaz da doença em estádio inicial é a terapia de modalidade combinada, que compreende quimioterapia combinada (por exemplo, ABVD) seguida de radioterapia.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [55]Noordijk EM, Carde P, Dupouy N, et al. Combined-modality therapy for clinical stage I or II Hodgkin's lymphoma: long-term results of the European Organisation for Research and Treatment of Cancer H7 randomized controlled trials. J Clin Oncol. 2006 Jul 1;24(19):3128-35. https://ascopubs.org/doi/full/10.1200/jco.2005.05.2746 http://www.ncbi.nlm.nih.gov/pubmed/16754934?tool=bestpractice.com [56]Press OW, LeBlanc M, Lichter AS, et al. Phase III randomized intergroup trial of subtotal lymphoid irradiation versus doxorubicin, vinblastine, and subtotal lymphoid irradiation for stage IA to IIA Hodgkin's disease. J Clin Oncol. 2001 Nov 15;19(22):4238-44. http://www.ncbi.nlm.nih.gov/pubmed/11709567?tool=bestpractice.com [57]Specht L, Gray RG, Clarke MJ, et al. Influence of more extensive radiotherapy and adjuvant chemotherapy on long-term outcome of early-stage Hodgkin's disease: a meta-analysis of 23 randomized trials involving 3,888 patients. International Hodgkin's Disease Collaborative Group. J Clin Oncol. 1998 Mar;16(3):830-43. http://www.ncbi.nlm.nih.gov/pubmed/9508163?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [59]Fermé C, Thomas J, Brice P, et al. ABVD or BEACOPP(baseline) along with involved-field radiotherapy in early-stage Hodgkin lymphoma with risk factors: results of the European Organisation for Research and Treatment of Cancer (EORTC)-Groupe d'Étude des Lymphomes de l'Adulte (GELA) H9-U intergroup randomised trial. Eur J Cancer. 2017 Aug;81:45-55. http://www.ncbi.nlm.nih.gov/pubmed/28601705?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [61]Fuchs M, Goergen H, Kobe C, et al. Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international, randomized phase III HD16 trial by the German Hodgkin Study Group. J Clin Oncol. 2019 Nov 1;37(31):2835-45. https://www.doi.org/10.1200/JCO.19.00964 http://www.ncbi.nlm.nih.gov/pubmed/31498753?tool=bestpractice.com ​

Uma abordagem apenas com quimioterapia pode ser considerada se for preferível evitar a radioterapia (por exemplo, por causa da idade do paciente, sexo, história familiar de câncer ou doença cardíaca, comorbidades, sítios de envolvimento).[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [62]Connors JM. The case for chemotherapy alone for limited-stage Hodgkin's lymphoma. Oncologist. 2012;17(8):1011-3. http://theoncologist.alphamedpress.org/content/17/8/1011.long http://www.ncbi.nlm.nih.gov/pubmed/22807512?tool=bestpractice.com [63]Hill-Kayser CE, Plastaras JP, Tochner Z, et al. The case for combined-modality therapy for limited-stage Hodgkin's disease. Oncologist. 2012;17(8):1006-10. http://theoncologist.alphamedpress.org/content/17/8/1006.long http://www.ncbi.nlm.nih.gov/pubmed/22807513?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com ​ A decisão de omitir a radioterapia deve envolver a opinião especializada de uma equipe multidisciplinar e discussão com o paciente sobre riscos e benefícios. A quimioterapia isolada está associada a uma taxa ligeiramente menor de controle do tumor e a uma maior taxa de recidiva em comparação com a terapia de modalidade combinada, mas as taxas de sobrevida são semelhantes.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [67]Raemaekers JM, André MP, Federico M, et al. Omitting radiotherapy in early positron emission tomography-negative stage I/II Hodgkin lymphoma is associated with an increased risk of early relapse: clinical results of the preplanned interim analysis of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2014 Apr 20;32(12):1188-94. https://ascopubs.org/doi/full/10.1200/jco.2013.51.9298 http://www.ncbi.nlm.nih.gov/pubmed/24637998?tool=bestpractice.com [68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com ​[69]Hay AE, Klimm B, Chen BE, et al. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol. 2013 Dec;24(12):3065-9. https://www.doi.org/10.1093/annonc/mdt389 http://www.ncbi.nlm.nih.gov/pubmed/24121121?tool=bestpractice.com [ ] How does positron emission tomography-adapted therapy as first-line treatment affect outcomes in people with early-stage Hodgkin lymphoma?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.758/fullMostre-me a resposta

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

A ausência ou a presença de critérios de prognóstico específicos determina se o paciente tem doença em estádio inicial favorável ou desfavorável. Os critérios de prognóstico favorável do German Hodgkin Study Group (GHSG) são mais comumente usados nos EUA (taxa de massa mediastinal [TMM] <0.33; velocidade de hemossedimentação [VHS] <50 mm/hora se não houver sintomas B; VHS <30 mm/hora se sintomas B estiverem presentes; envolvimento de ≤2 sítios nodais; e nenhuma doença extranodal; consulte Critérios de diagnóstico).[44]Dhakal S, Advani R, Ballas LK, et al. ACR appropriateness criteria® Hodgkin lymphoma-favorable prognosis stage I and II. Am J Clin Oncol. 2016 Dec;39(6):535-44. http://www.ncbi.nlm.nih.gov/pubmed/27643717?tool=bestpractice.com [50]German Hodgkin Study Group. Disease stages and risk factors. 2019 [internet publication]. https://en.ghsg.org/disease-stages

Pacientes com doença em estádio inicial desfavorável geralmente recebem dois ciclos iniciais de ABVD (doxorrubicina, bleomicina, vimblastina, dacarbazina) seguidos por uma PET-CT intermediária, para avaliar a resposta metabólica e orientar o tratamento subsequente.

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

Uma abordagem de tratamento adaptada à PET é recomendada para todos os pacientes com doença em estádio inicial, pois oferece a oportunidade de equilibrar a eficácia e a toxicidade do tratamento.[5]Eichenauer DA, Aleman BM, André M, et al. Hodgkin lymphoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29(4 suppl):iv19-29. https://www.annalsofoncology.org/article/S0923-7534(19)31690-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29796651?tool=bestpractice.com [33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com ​​​[65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [74]Engert A, Plütschow A, Eich HT, et al. Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma. N Engl J Med. 2010 Aug 12;363(7):640-52. https://www.nejm.org/doi/full/10.1056/NEJMoa1000067 http://www.ncbi.nlm.nih.gov/pubmed/20818855?tool=bestpractice.com [75]Aldin A, Umlauff L, Estcourt LJ, et al. Interim PET-results for prognosis in adults with Hodgkin lymphoma: a systematic review and meta-analysis of prognostic factor studies. Cochrane Database Syst Rev. 2020 Jan 13;1(1):CD012643. https://www.doi.org/10.1002/14651858.CD012643.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31930780?tool=bestpractice.com

O tratamento mais eficaz da doença em estádio inicial é a terapia de modalidade combinada, que compreende quimioterapia combinada (por exemplo, ABVD) seguida de radioterapia.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [54]Eich HT, Diehl V, Görgen H, et al. Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial. J Clin Oncol. 2010 Sep 20;28(27):4199-206. http://www.ncbi.nlm.nih.gov/pubmed/20713848?tool=bestpractice.com [55]Noordijk EM, Carde P, Dupouy N, et al. Combined-modality therapy for clinical stage I or II Hodgkin's lymphoma: long-term results of the European Organisation for Research and Treatment of Cancer H7 randomized controlled trials. J Clin Oncol. 2006 Jul 1;24(19):3128-35. https://ascopubs.org/doi/full/10.1200/jco.2005.05.2746 http://www.ncbi.nlm.nih.gov/pubmed/16754934?tool=bestpractice.com [56]Press OW, LeBlanc M, Lichter AS, et al. Phase III randomized intergroup trial of subtotal lymphoid irradiation versus doxorubicin, vinblastine, and subtotal lymphoid irradiation for stage IA to IIA Hodgkin's disease. J Clin Oncol. 2001 Nov 15;19(22):4238-44. http://www.ncbi.nlm.nih.gov/pubmed/11709567?tool=bestpractice.com [57]Specht L, Gray RG, Clarke MJ, et al. Influence of more extensive radiotherapy and adjuvant chemotherapy on long-term outcome of early-stage Hodgkin's disease: a meta-analysis of 23 randomized trials involving 3,888 patients. International Hodgkin's Disease Collaborative Group. J Clin Oncol. 1998 Mar;16(3):830-43. http://www.ncbi.nlm.nih.gov/pubmed/9508163?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [59]Fermé C, Thomas J, Brice P, et al. ABVD or BEACOPP(baseline) along with involved-field radiotherapy in early-stage Hodgkin lymphoma with risk factors: results of the European Organisation for Research and Treatment of Cancer (EORTC)-Groupe d'Étude des Lymphomes de l'Adulte (GELA) H9-U intergroup randomised trial. Eur J Cancer. 2017 Aug;81:45-55. http://www.ncbi.nlm.nih.gov/pubmed/28601705?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [61]Fuchs M, Goergen H, Kobe C, et al. Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international, randomized phase III HD16 trial by the German Hodgkin Study Group. J Clin Oncol. 2019 Nov 1;37(31):2835-45. https://www.doi.org/10.1200/JCO.19.00964 http://www.ncbi.nlm.nih.gov/pubmed/31498753?tool=bestpractice.com ​

Uma abordagem apenas com quimioterapia pode ser considerada se for preferível evitar a radioterapia (por exemplo, por causa da idade do paciente, sexo, história familiar de câncer ou doença cardíaca, comorbidades, sítios de envolvimento).[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [62]Connors JM. The case for chemotherapy alone for limited-stage Hodgkin's lymphoma. Oncologist. 2012;17(8):1011-3. http://theoncologist.alphamedpress.org/content/17/8/1011.long http://www.ncbi.nlm.nih.gov/pubmed/22807512?tool=bestpractice.com [63]Hill-Kayser CE, Plastaras JP, Tochner Z, et al. The case for combined-modality therapy for limited-stage Hodgkin's disease. Oncologist. 2012;17(8):1006-10. http://theoncologist.alphamedpress.org/content/17/8/1006.long http://www.ncbi.nlm.nih.gov/pubmed/22807513?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [65]Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015 Apr 23;372(17):1598-607. https://www.nejm.org/doi/full/10.1056/NEJMoa1408648 http://www.ncbi.nlm.nih.gov/pubmed/25901426?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com ​ A decisão de omitir a radioterapia deve envolver a opinião especializada de uma equipe multidisciplinar e discussão com o paciente sobre riscos e benefícios. A quimioterapia isolada está associada a uma taxa ligeiramente menor de controle do tumor e a uma maior taxa de recidiva em comparação com a terapia de modalidade combinada, mas as taxas de sobrevida são semelhantes.[51]Meyer RM, Gospodarowicz MK, Connors JM, et al. Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005 Jul 20;23(21):4634-42. https://ascopubs.org/doi/full/10.1200/jco.2005.09.085 http://www.ncbi.nlm.nih.gov/pubmed/15837968?tool=bestpractice.com [52]Straus DJ, Portlock CS, Qin J, et al. Results of a prospective randomized clinical trial of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by radiation therapy (RT) versus ABVD alone for stages I, II, and IIIA nonbulky Hodgkin disease. Blood. 2004 Dec 1;104(12):3483-9. http://www.bloodjournal.org/content/104/12/3483.full http://www.ncbi.nlm.nih.gov/pubmed/15315964?tool=bestpractice.com [53]Blank O, von Tresckow B, Monsef I, et al. Chemotherapy alone versus chemotherapy plus radiotherapy for adults with early stage Hodgkin lymphoma. Cochrane Database Syst Rev. 2017 Apr 27;(4):CD007110. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007110.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/28447341?tool=bestpractice.com [58]Nachman JB, Sposto R, Herzog P, et al; Children's Cancer Group. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol. 2002 Sep 15;20(18):3765-71. http://www.ncbi.nlm.nih.gov/pubmed/12228196?tool=bestpractice.com [60]André MPE, Girinsky T, Federico M, et al. Early positron emission tomography response-adapted treatment in stage I and II Hodgkin lymphoma: final results of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2017 Jun 1;35(16):1786-94. https://www.doi.org/10.1200/JCO.2016.68.6394 http://www.ncbi.nlm.nih.gov/pubmed/28291393?tool=bestpractice.com [64]Meyer RM, Gospodarowicz MK, Connors JM, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2;366(5):399-408. https://www.nejm.org/doi/full/10.1056/NEJMoa1111961 http://www.ncbi.nlm.nih.gov/pubmed/22149921?tool=bestpractice.com [66]Straus DJ, Jung SH, Pitcher B, et al. CALGB 50604: risk-adapted treatment of nonbulky early-stage Hodgkin lymphoma based on interim PET. Blood. 2018 Sep 6;132(10):1013-21. https://www.doi.org/10.1182/blood-2018-01-827246 http://www.ncbi.nlm.nih.gov/pubmed/30049811?tool=bestpractice.com [67]Raemaekers JM, André MP, Federico M, et al. Omitting radiotherapy in early positron emission tomography-negative stage I/II Hodgkin lymphoma is associated with an increased risk of early relapse: clinical results of the preplanned interim analysis of the randomized EORTC/LYSA/FIL H10 trial. J Clin Oncol. 2014 Apr 20;32(12):1188-94. https://ascopubs.org/doi/full/10.1200/jco.2013.51.9298 http://www.ncbi.nlm.nih.gov/pubmed/24637998?tool=bestpractice.com [68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com ​[69]Hay AE, Klimm B, Chen BE, et al. An individual patient-data comparison of combined modality therapy and ABVD alone for patients with limited-stage Hodgkin lymphoma. Ann Oncol. 2013 Dec;24(12):3065-9. https://www.doi.org/10.1093/annonc/mdt389 http://www.ncbi.nlm.nih.gov/pubmed/24121121?tool=bestpractice.com [ ] How does positron emission tomography-adapted therapy as first-line treatment affect outcomes in people with early-stage Hodgkin lymphoma?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.758/fullMostre-me a resposta

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

O ABVD é um tratamento inicial preferencial para pacientes com doença em estádio avançado.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com

Uma abordagem de tratamento adaptada à PET pode ser usada em pacientes com doença em estádio avançado para orientar as decisões de tratamento em relação ao escalonamento ou desescalonamento da quimioterapia.[68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com [94]Borchmann P, Goergen H, Kobe C, et al. PET-guided treatment in patients with advanced-stage Hodgkin's lymphoma (HD18): final results of an open-label, international, randomised phase 3 trial by the German Hodgkin Study Group. Lancet. 2017 Dec 23;390(10114):2790-802. http://www.ncbi.nlm.nih.gov/pubmed/29061295?tool=bestpractice.com [95]Casasnovas RO, Bouabdallah R, Brice P, et al. PET-adapted treatment for newly diagnosed advanced Hodgkin lymphoma (AHL2011): a randomised, multicentre, non-inferiority, phase 3 study. Lancet Oncol. 2019 Feb;20(2):202-15. http://www.ncbi.nlm.nih.gov/pubmed/30658935?tool=bestpractice.com [96]Kreissl S, Goergen H, Buehnen I, et al. PET-guided eBEACOPP treatment of advanced-stage Hodgkin lymphoma (HD18): follow-up analysis of an international, open-label, randomised, phase 3 trial. Lancet Haematol. 2021 Jun;8(6):e398-409. http://www.ncbi.nlm.nih.gov/pubmed/34048679?tool=bestpractice.com

Pacientes com doença em estádio avançado destinados à terapia de indução padrão com quimioterapia com ABVD geralmente recebem dois ciclos iniciais de ABVD, seguidos por uma PET-CT intermediária, para avaliar a resposta metabólica e orientar o tratamento subsequente.[68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.

O objetivo do tratamento de todos os pacientes com LH é a cura, minimizando o risco de toxicidade e complicações em longo prazo.

Uma abordagem de tratamento adaptada à PET pode ser usada em pacientes com doença em estádio avançado para orientar as decisões de tratamento em relação ao escalonamento ou desescalonamento da quimioterapia.[68]Johnson P, Federico M, Kirkwood A, et al. Adapted treatment guided by interim PET-CT scan in advanced Hodgkin's lymphoma. N Engl J Med. 2016 Jun 23;374(25):2419-29. https://www.nejm.org/doi/full/10.1056/NEJMoa1510093 http://www.ncbi.nlm.nih.gov/pubmed/27332902?tool=bestpractice.com [94]Borchmann P, Goergen H, Kobe C, et al. PET-guided treatment in patients with advanced-stage Hodgkin's lymphoma (HD18): final results of an open-label, international, randomised phase 3 trial by the German Hodgkin Study Group. Lancet. 2017 Dec 23;390(10114):2790-802. http://www.ncbi.nlm.nih.gov/pubmed/29061295?tool=bestpractice.com [95]Casasnovas RO, Bouabdallah R, Brice P, et al. PET-adapted treatment for newly diagnosed advanced Hodgkin lymphoma (AHL2011): a randomised, multicentre, non-inferiority, phase 3 study. Lancet Oncol. 2019 Feb;20(2):202-15. http://www.ncbi.nlm.nih.gov/pubmed/30658935?tool=bestpractice.com [96]Kreissl S, Goergen H, Buehnen I, et al. PET-guided eBEACOPP treatment of advanced-stage Hodgkin lymphoma (HD18): follow-up analysis of an international, open-label, randomised, phase 3 trial. Lancet Haematol. 2021 Jun;8(6):e398-409. http://www.ncbi.nlm.nih.gov/pubmed/34048679?tool=bestpractice.com

Determinados pacientes com doença avançada (por exemplo, aqueles com International Prognostic Score [IPS] ≥4 e idade <60 anos) podem ser adequados para quimioterapia de indução intensiva inicial, compreendendo dois ciclos iniciais de BEACOPP escalonado (bleomicina, etoposídeo, doxorrubicina, ciclofosfamida, vincristina, procarbazina, prednisolona), seguidos de PET-CT intermediária para avaliar a resposta metabólica e orientar o tratamento subsequente.[94]Borchmann P, Goergen H, Kobe C, et al. PET-guided treatment in patients with advanced-stage Hodgkin's lymphoma (HD18): final results of an open-label, international, randomised phase 3 trial by the German Hodgkin Study Group. Lancet. 2017 Dec 23;390(10114):2790-802. http://www.ncbi.nlm.nih.gov/pubmed/29061295?tool=bestpractice.com [95]Casasnovas RO, Bouabdallah R, Brice P, et al. PET-adapted treatment for newly diagnosed advanced Hodgkin lymphoma (AHL2011): a randomised, multicentre, non-inferiority, phase 3 study. Lancet Oncol. 2019 Feb;20(2):202-15. http://www.ncbi.nlm.nih.gov/pubmed/30658935?tool=bestpractice.com

A resposta metabólica é determinada pelos critérios de Deauville, que atribui um escore de 1 a 5 com base na captação da fluordesoxiglucose (FDG) nos sítios envolvidos.[40]Barrington SF, Mikhaeel NG, Kostakoglu L, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014 Sep 20;32(27):3048-58. https://ascopubs.org/doi/10.1200/JCO.2013.53.5229 http://www.ncbi.nlm.nih.gov/pubmed/25113771?tool=bestpractice.com

Pacientes com escore de Deauville de 1 a 3 (isto é, PET-CT negativa) são considerados como tendo resposta metabólica completa. Pacientes com escore de Deauville de 4 ou 5 (isto é, PET-CT positiva) são considerados como tendo resposta metabólica parcial (consulte Critérios de diagnóstico).

O LH em pacientes idosos (com idade >60 anos) está associado a desfechos piores e maior toxicidade e mortalidade relacionadas ao tratamento, em comparação com pacientes mais jovens.[47]Jagadeesh D, Diefenbach C, Evens AM. XII. Hodgkin lymphoma in older patients: challenges and opportunities to improve outcomes. Hematol Oncol. 2013 Jun;31 Suppl 1:69-75. https://onlinelibrary.wiley.com/doi/10.1002/hon.2070 http://www.ncbi.nlm.nih.gov/pubmed/23775654?tool=bestpractice.com [48]Böll B, Görgen H, Fuchs M, et al. ABVD in older patients with early-stage Hodgkin lymphoma treated within the German Hodgkin Study Group HD10 and HD11 trials. J Clin Oncol. 2013 Apr 20;31(12):1522-9. https://ascopubs.org/doi/10.1200/JCO.2012.45.4181?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed http://www.ncbi.nlm.nih.gov/pubmed/23509310?tool=bestpractice.com [49]Ballova V, Rüffer JU, Haverkamp H, et al. A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly). Ann Oncol. 2005 Jan;16(1):124-31. https://www.annalsofoncology.org/article/S0923-7534(19)41646-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/15598949?tool=bestpractice.com ​​​​​ Esquemas de tratamento alternativos podem ser considerados para pacientes com >60 anos ou com baixa capacidade funcional ou comorbidades substanciais. A bleomicina deve ser usada com cautela; os esquemas padrão podem ser adaptados de modo a remover a bleomicina ou restringir seu uso a apenas dois ciclos.[33]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Consulte o protocolo clínico e de diretrizes terapêuticas local para obter mais informações sobre dosagens.