Hodgkin and Non-Hodgkin Lymphoma Management
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Direct answer
The pathology report splits lymphoma into two algorithm families: Hodgkin lymphoma, where ABVD remains the backbone with interim PET steering de-escalation or escalation, and the non-Hodgkin group, where DLBCL takes R-CHOP for six cycles unless it is double-hit, indolent histologies are watched or treated with rituximab-based chemoimmunotherapy, and Burkitt demands immediate intensive regimens with tumour lysis precautions. Relapsed chemosensitive Hodgkin and DLBCL go to salvage chemotherapy then autologous transplant, with brentuximab, checkpoint inhibitors and CAR-T reshaping what follows. Before any rituximab is given, hepatitis B serology is mandatory — reactivation under anti-CD20 therapy is a preventable fatal complication and a standing exam question.
What you must remember
- Immunophenotype anchors diagnosis: classic Hodgkin Reed-Sternberg cells are CD30 and CD15 positive, CD45 negative; nodular lymphocyte-predominant Hodgkin is CD20 positive, CD15 and CD30 negative, and is treated with rituximab-containing regimens like indolent lymphoma.
- ABVD with interim PET: after two cycles, Deauville 1–3 continues ABVD; Deauville 4–5 escalates (RATHL escalated to BEACOPP). Deauville 3 means continue — not escalate — and that distinction is tested.
- Brentuximab vedotin (anti-CD30 antibody-drug conjugate) consolidates after autologous transplant in high-risk relapsed Hodgkin (AETHERA); nivolumab is highly active in relapsed Hodgkin because 9p24.1 amplification drives PD-L1 overexpression.
- DLBCL standard: R-CHOP every 21 days for six cycles with intrathecal methotrexate added for high CNS risk — testicular, paranasal sinus, breast involvement, high CNS-IPI score.
- Double-hit lymphoma (MYC plus BCL2 and/or BCL6 rearrangement on FISH) must not receive R-CHOP — it gets dose-escalated DA-EPOCH-R; "double-expressor" (high protein on IHC only) is a different, less absolute entity.
- Relapsed DLBCL: transplant-eligible patients receive salvage (R-ICE or R-DHAP) then autologous stem cell transplant; primary refractory or post-transplant relapse moves to CAR-T (axicabtagene ciloleucel, lisocabtagene maraleucel), while unfit patients receive polatuzumab vedotin with bendamustine-rituximab.
- Follicular lymphoma: asymptomatic advanced disease is observed ("watch and wait"); first treatment is rituximab with bendamustine or CHOP, followed by rituximab maintenance every two months for two years; progression within 24 months (POD24) marks poor prognosis; tazemetostat targets EZH2-mutated relapse.
- Extranodal margins: gastric MALT lymphoma begins with Helicobacter pylori eradication, but t(11;18)(q21;q21) positive tumours rarely respond to antibiotics alone; Burkitt lymphoma gets hyper-CVAD with rituximab or CODOX-M/IVAC with rasburicase and aggressive hydration from day one.
A PET-adapted pathway in two patients
A 26-year-old presents with bulky stage IIB nodular sclerosis Hodgkin lymphoma. He receives two cycles of ABVD, and interim PET shows Deauville 2 — uptake at or below mediastinum. The pathway continues ABVD to six cycles, and radiotherapy is discussed only for bulk; Deauville 5 would have meant escalation to escalated BEACOPP, trading toxicity for control. Now place beside him a 62-year-old with a rapidly growing small-bowel mass, LDH three times normal, and CD20-positive large cells with MYC and BCL2 rearrangements confirmed on FISH: a double-hit lymphoma. R-CHOP would fail her — she goes straight to DA-EPOCH-R with intrathecal methotrexate prophylaxis and tumour lysis precautions, and her curative window depends on that FISH result being requested before cycle one. Biopsy and interim scan, not instinct, allocate intensity.
How the exam frames it
Examiners reliably probe four junctions. Nodular lymphocyte-predominant Hodgkin is presented as a CD20-positive "Hodgkin" to see whether candidates prescribe ABVD reflexively instead of rituximab-based therapy. A Deauville 3 scan after two ABVD cycles is offered as a fork — the correct answer is continue, not escalate. Double-hit and double-expressor are used interchangeably in distractors, though only the FISH-proven double hit compels DA-EPOCH-R. And the Indian-context favourite: a patient with positive hepatitis B core antibody about to start R-CHOP — antiviral prophylaxis (entecavir or tenofovir, not lamivudine monotherapy for high risk) must begin before rituximab, with TB screening prudent where latent tuberculosis is prevalent. Each junction punishes pattern-matching rather than reading the actual pathology report.
Frequently asked questions
How is the Deauville score used to adapt Hodgkin therapy?
Scores 1–3 after two ABVD cycles mean metabolic response — continue ABVD; score 4–5 mandates escalation to escalated BEACOPP or a brentuximab-based regimen, at the cost of toxicity and fertility risk.
What treatment replaces R-CHOP in double-hit lymphoma?
Dose-adjusted EPOCH-R, because R-CHOP produces unacceptably poor outcomes when MYC and BCL2 or BCL6 rearrangements coexist; intrathecal CNS prophylaxis and tumour lysis precautions accompany it.
Which DLBCL patients need CNS prophylaxis?
Those with testicular, paranasal sinus, breast or adrenal involvement, more than one extranodal site with raised LDH (high CNS-IPI), or HIV — given as intrathecal methotrexate alongside systemic therapy.
What is the first step in gastric MALT lymphoma?
Helicobacter pylori eradication for early-stage disease, with repeat endoscopy to confirm response; t(11;18)-positive or antibiotic-refractory disease proceeds to radiotherapy or rituximab-based treatment.
What is the role of autologous transplant in DLBCL?
Consolidation after salvage chemotherapy in chemosensitive first relapse; primary refractory disease and post-transplant relapse go instead to CAR-T therapy rather than further salvage.
Which agent targets CD30, and where does it fit?
Brentuximab vedotin, an antibody-drug conjugate linking anti-CD30 to monomethyl auristatin E — post-transplant consolidation in high-risk Hodgkin lymphoma, frontline with doxorubicin-vinblastine-dacarbazine in advanced stage, and in relapsed CD30-positive lymphomas.