# Early-stage classical Hodgkin lymphoma (stage I to II)

Source: https://onco.cc/cancers/early-stage-classical-hodgkin-lymphoma/  
OnCo record `early-stage-classical-hodgkin-lymphoma` (Cancer). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Early-stage classical Hodgkin lymphoma is Hodgkin lymphoma confined to one or two lymph node regions on one side of the diaphragm, one of the most curable cancers, with most patients cured by a short course of ABVD chemotherapy with or without radiotherapy to the involved nodes. Because patients are young, trials now use PET scans after two cycles to give as little treatment as safely possible.

## Summary

Classical Hodgkin lymphoma is a B-cell lymphoma in which the malignant Hodgkin and Reed-Sternberg cells, CD30 and CD15 positive and usually CD20 negative, are outnumbered by a reactive inflammatory background; nodular sclerosis is the commonest subtype in young adults, and PD-L1 amplification at 9p24.1 is near universal. Stage I and II disease is divided into favourable and unfavourable groups by the presence of bulky disease, raised erythrocyte sedimentation rate, B symptoms, three or more nodal sites or extranodal extension, definitions that differ slightly between the German Hodgkin Study Group (GHSG) and the EORTC. Radiotherapy alone cured most patients with early disease from the 1960s, but the second cancers and heart disease it caused decades later drove the shift to combined chemotherapy with smaller radiation fields and lower doses.

GHSG HD10 (New England Journal of Medicine 2010) showed that two cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) with 20 Gy of involved-field radiotherapy was enough for favourable disease, and HD11 and HD14 defined four cycles of chemotherapy (or two escalated BEACOPP plus two ABVD) with 30 Gy for unfavourable disease. Interim PET then became the tool for de-escalation: the RAPID trial (New England Journal of Medicine 2015) and EORTC H10 showed that omitting radiotherapy in patients who were PET-negative after two or three ABVD cycles costs a few percentage points of progression-free survival without a survival difference, and HD16 and HD17 refined which PET-negative patients can safely skip radiotherapy, so today many patients receive chemotherapy alone and the rest involved-site radiotherapy with modern conformal or proton techniques that spare the heart and breasts. Brentuximab vedotin and PD-1 antibodies, established in advanced disease, are moving into early-stage trials: the Children's Oncology Group AHOD2131 trial compares brentuximab vedotin with nivolumab against standard chemotherapy in early-stage high-risk disease in patients from age 5 to 60, and the GHSG HD21 and NIVAHL programmes test PD-1 antibodies with reduced chemotherapy. Fertility preservation, cardiac protection and lifelong survivorship care, including breast screening for women irradiated young, are part of standard management.

## Fields

- Kind: Cancer
- Last checked: 2026-09-18
- Also known as: Limited-stage Hodgkin lymphoma; Stage I to II classical Hodgkin lymphoma; Early favourable and early unfavourable Hodgkin lymphoma; Localised Hodgkin lymphoma
- Tags: subtype-page; haematologic
- Group: haematologic
- Burden: About half of classical Hodgkin lymphoma, typically in young adults with painless neck or mediastinal nodes; cure rates exceed nine in ten, so the modern problem is avoiding late harm from treatment.
- Subtypes: Early favourable classical Hodgkin lymphoma (stage I to II without risk factors; two ABVD and 20 Gy or PET-guided chemotherapy alone); Early unfavourable classical Hodgkin lymphoma (bulk, raised ESR, three or more sites or extranodal extension); Nodular sclerosis classical Hodgkin lymphoma (commonest in young adults, mediastinal); Mixed cellularity classical Hodgkin lymphoma (EBV-positive, children and older adults); Lymphocyte-rich classical Hodgkin lymphoma; Paediatric and adolescent early-stage classical Hodgkin lymphoma (Children's Oncology Group risk groups)
- Biomarkers: Interim FDG-PET after two cycles (Deauville score; guides omission of radiotherapy); CD30 and CD15 on Hodgkin and Reed-Sternberg cells; CD20 usually negative; Bulky disease, erythrocyte sedimentation rate, B symptoms and number of sites (GHSG and EORTC risk factors); EBV status (EBER) in mixed cellularity disease; Baseline metabolic tumour volume (prognostic, research); Circulating tumour DNA (research; PhasED-seq)

## Standard of care

- Staging: FDG-PET/CT with Lugano staging; bone marrow biopsy no longer needed when PET is used; fertility counselling and cardiac baseline. ([FDG PET](https://onco.cc/technologies/fdg-pet/), [Lugano classification / Ann Arbor staging](https://onco.cc/terms/lugano-classification/), [Oncofertility and fertility preservation](https://onco.cc/technologies/fertility-preservation/), [Cardio-oncology](https://onco.cc/technologies/cardio-oncology/))
- Early favourable disease: Two cycles of ABVD with 20 Gy involved-site radiotherapy (HD10); or PET-adapted chemotherapy alone (three ABVD if PET-negative after two, RAPID and H10) accepting a small increase in relapse. ([Doxorubicin](https://onco.cc/drugs/doxorubicin/), [Vinblastine](https://onco.cc/drugs/vinblastine/), [Dacarbazine](https://onco.cc/drugs/dacarbazine/), [ABVD, BEACOPP and BrECADD (Hodgkin lymphoma regimens)](https://onco.cc/terms/abvd-beacopp/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [PET-adapted (response-adapted) therapy](https://onco.cc/technologies/pet-adapted-therapy/), [Deauville five-point scale](https://onco.cc/terms/deauville-score/))
- Early unfavourable disease: Four cycles of ABVD (or two escalated BEACOPP plus two ABVD) with 30 Gy involved-site radiotherapy; radiotherapy omitted in PET-negative patients after HD17. ([Doxorubicin](https://onco.cc/drugs/doxorubicin/), [Vinblastine](https://onco.cc/drugs/vinblastine/), [Dacarbazine](https://onco.cc/drugs/dacarbazine/), [ABVD, BEACOPP and BrECADD (Hodgkin lymphoma regimens)](https://onco.cc/terms/abvd-beacopp/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [PET-adapted (response-adapted) therapy](https://onco.cc/technologies/pet-adapted-therapy/))
- Children and adolescents: Response-adapted Children's Oncology Group regimens with radiotherapy for slow responders; AHOD2131 tests brentuximab vedotin with nivolumab. ([AHOD2131 (COG / NCTN)](https://onco.cc/trials/ahod2131/), [Brentuximab vedotin](https://onco.cc/drugs/brentuximab-vedotin/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Children's Oncology Group (COG)](https://onco.cc/institutions/childrens-oncology-group/))
- Survivorship: Cardiac surveillance, breast screening from eight years after chest radiotherapy in women, thyroid checks and second-cancer awareness for life. ([Cardio-oncology](https://onco.cc/technologies/cardio-oncology/), [Mammography & tomosynthesis](https://onco.cc/technologies/mammography/), [Late effects and survivorship toxicity](https://onco.cc/terms/late-effects/))

## State of the art

- Cure rates above 90 percent make treatment reduction, not intensification, the aim.
- Interim PET lets many patients avoid radiotherapy altogether.
- Brentuximab vedotin and PD-1 antibodies are entering early-stage trials to replace parts of chemotherapy.

## Open problems

- Radiotherapy omission trades a few percent more relapses against late harms that take decades to appear.
- Bleomycin lung toxicity and doxorubicin cardiotoxicity persist even in short regimens.
- Whether PD-1 antibodies can replace chemotherapy in early disease is untested.
- Older patients with early disease tolerate ABVD poorly and have no dedicated standard.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Hodgkin_lymphoma
- GHSG HD10 (NEJM 2010): https://doi.org/10.1056/NEJMoa1000067
- RAPID (NEJM 2015): https://doi.org/10.1056/NEJMoa1408648
- Wikipedia: https://en.wikipedia.org/wiki/Hodgkin_lymphoma

## Connected records

- cancers: [Advanced-stage classical Hodgkin lymphoma (stage III to IV)](https://onco.cc/cancers/advanced-stage-classical-hodgkin-lymphoma/), [Hodgkin lymphoma](https://onco.cc/cancers/hodgkin-lymphoma/), [Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma)](https://onco.cc/cancers/nodular-lymphocyte-predominant-hodgkin-lymphoma/), [Primary mediastinal (thymic) large B-cell lymphoma](https://onco.cc/cancers/primary-mediastinal-b-cell-lymphoma/), [Relapsed and refractory classical Hodgkin lymphoma](https://onco.cc/cancers/relapsed-refractory-hodgkin-lymphoma/)
- technologies: [Cardio-oncology](https://onco.cc/technologies/cardio-oncology/), [ctDNA monitoring in lymphoma (PhasED-seq, clonoSEQ)](https://onco.cc/technologies/ctdna-lymphoma-monitoring/), [FDG PET](https://onco.cc/technologies/fdg-pet/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Mammography & tomosynthesis](https://onco.cc/technologies/mammography/), [Oncofertility and fertility preservation](https://onco.cc/technologies/fertility-preservation/), [PET-adapted (response-adapted) therapy](https://onco.cc/technologies/pet-adapted-therapy/), [Proton therapy](https://onco.cc/technologies/proton-therapy/)
- targets: [CD30](https://onco.cc/targets/cd30/), [PD-1](https://onco.cc/targets/pd1/)
- drugs: [Brentuximab vedotin](https://onco.cc/drugs/brentuximab-vedotin/), [Dacarbazine](https://onco.cc/drugs/dacarbazine/), [Doxorubicin](https://onco.cc/drugs/doxorubicin/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Vinblastine](https://onco.cc/drugs/vinblastine/)
- terms: [ABVD, BEACOPP and BrECADD (Hodgkin lymphoma regimens)](https://onco.cc/terms/abvd-beacopp/), [Deauville five-point scale](https://onco.cc/terms/deauville-score/), [Late effects and survivorship toxicity](https://onco.cc/terms/late-effects/), [Lugano classification / Ann Arbor staging](https://onco.cc/terms/lugano-classification/), [Reed-Sternberg cell](https://onco.cc/terms/reed-sternberg-cell/)
- trials: [AHOD2131 (COG / NCTN)](https://onco.cc/trials/ahod2131/), [Safety and Efficacy of Pembrolizumab (MK-3475) in Children and Young Adults With Classical Hodgkin Lymphoma (MK-3475-667/KEYNOTE-667)](https://onco.cc/trials/nct03407144/)
- key papers: [ECHELON-1: brentuximab vedotin replacing bleomycin in first-line chemotherapy for advanced Hodgkin lymphoma](https://onco.cc/key-papers/paper-echelon-1-brentuximab-avd-nejm-2018/), [GHSG HD10: reduced treatment intensity in early-stage favourable Hodgkin lymphoma](https://onco.cc/key-papers/paper-ghsg-hd10-reduced-intensity-early-hodgkin-nejm-2010/), [RAPID: PET-directed therapy for early-stage Hodgkin lymphoma](https://onco.cc/key-papers/paper-rapid-pet-directed-therapy-early-hodgkin-nejm-2015/)
- institutions: [Children's Oncology Group (COG)](https://onco.cc/institutions/childrens-oncology-group/)

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