# Hodgkin and Non-Hodgkin Lymphoma Management

> Lymphoma management for NEET-SS Medical Oncology: ABVD with interim PET, R-CHOP for DLBCL, double-hit escalation, follicular strategy and CNS prophylaxis.

- Canonical URL: https://prepelephant.com/topics/neet-ss/medical-oncology/lymphoma-onco-dm
- Exam / course: NEET-SS · Subject: Medical Oncology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Hodgkin and Non-Hodgkin Lymphoma Management", PrepElephant, https://prepelephant.com/topics/neet-ss/medical-oncology/lymphoma-onco-dm

## 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.