Real-Life Retrospective Turkiye Data of the De-Escalation of ABVD to AVD in Hodgkin Lymphoma: On Behalf of the TSH Turkish Lymphoma Study Group

<b>Background:</b> Classical Hodgkin lymphoma (cHL) demonstrates high survival rates with the ABVD regimen (doxorubicin, bleomycin, vinblastine, dacarbazine); however, the use of bleomycin is associated with a significant risk of pulmonary toxicity. The Risk-Adapted Treatment of HL (RATHL) trial demonstrated that omitting bleomycin in patients with favorable interim Positron Emission Tomography (PET-CT) results did not adversely affect survival outcomes. In this study, we present real-world data from advanced-stage HL patients treated according to the RATHL protocol. <b>Methods:</b> This multicenter, retrospective study included newly diagnosed cHL patients with Ann Arbor stage IIB-IV disease or stage IIA disease with bulky disease or with involvement of three or more sites, enrolled from 29 centers across Türkiye. The analysis focused on patients whose initial treatment was de-escalated from ABVD to AVD (bleomycin was omitted). Data were collected on demographic and clinical prognostic characteristics, interim PET-CT findings (evaluated using the Deauville score), progression-free survival (PFS) and overall survival (OS). Survival outcomes were assessed using Kaplan-Meier analysis. <b>Results:</b> A total of 379 patients were included, with a median age of 34 years (range: 18-78). Following interim PET-CT assessments (After 2 cycles of ABVD), Deauville scores were 1 in 39.8% of patients, 2 in 39.1%, and 3 in 21.1%. Based on these results, bleomycin was omitted immediately after interim PET-CT in 73.9% of patients, after one additional ABVD cycle in 12.1%, and after two additional cycles in 14%. The median follow-up duration was 28 months (range: 6-96). The 3-year PFS and OS rates were 86.0% and 96.1%, respectively. Patients with Deauville scores of 1-2 had a 3-year PFS rate of 87.6%, compared to 79.8% in those with a score of 3 (<i>p</i> = 0.087). Increased age, poor Eastern Cooperative Oncology Group Scale (ECOG) performance status, bulky disease, and higher International Prognostic Scores (IPS) were significantly associated with inferior OS (<i>p</i> < 0.05). There were no significant differences in OS among patients who received 2, 3, or 4 cycles of ABVD. However, among patients treated with 2 cycles of ABVD, both extranodal involvement (<i>p</i> = 0.039) and higher IPS (<i>p</i> = 0.002) were significantly associated with decreased PFS. <b>Conclusions:</b> Our findings demonstrate that PET-guided de-escalation of bleomycin after two cycles of ABVD is feasible, effective, and safe in real-world multicenter practice in Türkiye. The survival outcomes are comparable to those reported in the RATHL study, reinforcing the role of interim PET-CT in guiding individualized therapy. However, patients with high IPS or extranodal involvement may require more tailored management strategies.

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Journal
Journal of Clinical Medicine
Published
2025-09-26
DOI
https://doi.org/10.3390/jcm14196813
Primary Topic
Lymphoma Diagnosis and Treatment
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article
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article

Real-Life Retrospective Turkiye Data of the De-Escalation of ABVD to AVD in Hodgkin Lymphoma: On Behalf of the TSH Turkish Lymphoma Study Group

Hale Bülbül, Selin Merih Urlu, Duygu Nurdan Avcı, Aysun Şentürk Yıkılmaz et al.
Journal of Clinical Medicine
Lymphoma Diagnosis and Treatment
article

Real-Life Retrospective Turkiye Data of the De-Escalation of ABVD to AVD in Hodgkin Lymphoma: On Behalf of the TSH Turkish Lymphoma Study Group

Hale Bülbül, Selin Merih Urlu, Duygu Nurdan Avcı, Aysun Şentürk Yıkılmaz, Ayfer Gedük, Esra Terzi Demirsoy, İrfan Yavaşoğlu, Fatma Keklik Karadağ, Tayfur Toptaş, Taha Ulutan Kars, Süreyya Yiğit Kaya, A. Burhan Ferhanoglu, Nurcan Alhan, Meral Uluköylü Mengüç, Tuba Ersal, Deniz Gören, Elif Birtaş Ateşoğlu, Leylagül Kaynar, Özge Soyer Kösemehmetoğlu, Erman Öztürk, Fatoş Dilan Köseoğlu, Fatma Arıkan, Ebru Pekgüç, Fahir Özkalemkaş, Ayşe Hilal Eroğlu Küçükdiler, Ekin Kırcalı, Eren Gündüz, Zafer Serenli Yeğen, Volkan Karakuş, Gülsüm Özet, Simten Dağdaş, Ömür Gökmen Sevindik, Mahmut Yeral, Selin Küçükyurt, Savaş Öztürk, Güldane Cengiz Seval, Ahmet Kürşad Güneş, Emine Merve Savaş, Pınar Tığlıoğlu, Emel İşleyen, Merve Ecem Erdoğan Yön, Selami Koçak Toprak, Atakan Teki̇nalp, Cem Selim, Hava Üsküdar Teke, Özgür Mehtap, Serkan Güven, Muhıt Özcan, Fatma Aykaş, Ozan Salim, Nihan Alkış, Şeyma Yıldız
article en

Abstract

<b>Background:</b> Classical Hodgkin lymphoma (cHL) demonstrates high survival rates with the ABVD regimen (doxorubicin, bleomycin, vinblastine, dacarbazine); however, the use of bleomycin is associated with a significant risk of pulmonary toxicity. The Risk-Adapted Treatment of HL (RATHL) trial demonstrated that omitting bleomycin in patients with favorable interim Positron Emission Tomography (PET-CT) results did not adversely affect survival outcomes. In this study, we present real-world data from advanced-stage HL patients treated according to the RATHL protocol. <b>Methods:</b> This multicenter, retrospective study included newly diagnosed cHL patients with Ann Arbor stage IIB-IV disease or stage IIA disease with bulky disease or with involvement of three or more sites, enrolled from 29 centers across Türkiye. The analysis focused on patients whose initial treatment was de-escalated from ABVD to AVD (bleomycin was omitted). Data were collected on demographic and clinical prognostic characteristics, interim PET-CT findings (evaluated using the Deauville score), progression-free survival (PFS) and overall survival (OS). Survival outcomes were assessed using Kaplan-Meier analysis. <b>Results:</b> A total of 379 patients were included, with a median age of 34 years (range: 18-78). Following interim PET-CT assessments (After 2 cycles of ABVD), Deauville scores were 1 in 39.8% of patients, 2 in 39.1%, and 3 in 21.1%. Based on these results, bleomycin was omitted immediately after interim PET-CT in 73.9% of patients, after one additional ABVD cycle in 12.1%, and after two additional cycles in 14%. The median follow-up duration was 28 months (range: 6-96). The 3-year PFS and OS rates were 86.0% and 96.1%, respectively. Patients with Deauville scores of 1-2 had a 3-year PFS rate of 87.6%, compared to 79.8% in those with a score of 3 (<i>p</i> = 0.087). Increased age, poor Eastern Cooperative Oncology Group Scale (ECOG) performance status, bulky disease, and higher International Prognostic Scores (IPS) were significantly associated with inferior OS (<i>p</i> < 0.05). There were no significant differences in OS among patients who received 2, 3, or 4 cycles of ABVD. However, among patients treated with 2 cycles of ABVD, both extranodal involvement (<i>p</i> = 0.039) and higher IPS (<i>p</i> = 0.002) were significantly associated with decreased PFS. <b>Conclusions:</b> Our findings demonstrate that PET-guided de-escalation of bleomycin after two cycles of ABVD is feasible, effective, and safe in real-world multicenter practice in Türkiye. The survival outcomes are comparable to those reported in the RATHL study, reinforcing the role of interim PET-CT in guiding individualized therapy. However, patients with high IPS or extranodal involvement may require more tailored management strategies.

Journal of Clinical MedicineVol. 14(19)
Bursa Uludağ Üni̇versi̇tesi̇ (TR), Izmir University (TR), Selçuk University (TR), Ankara University (TR), Bilkent University (TR), Başkent University (TR), Bursa Technical University (TR), Akdeniz University (TR), Niloufer Hospital (IN), Istanbul Medipol University (TR), Konya Numune Hastanesi (TR), Canakkale Onsekiz Mart Universitesi Tip Fakultesi Hastanesi (TR), Memorial Ankara Hospital (TR), Türkisch-Deutsche Universität (TR), Istanbul Florence Nightingale Hospital (TR), Necmettin Erbakan University (TR), Antalya Eğitim ve Araştırma Hastanesi (TR), Alanya University (TR), Konya Eğitim ve Araştırma Hastanesi (TR), Başkent University Hospital (TR), Izmir Tepecik Eğitim ve Araştırma Hastanesi (TR), Denizli Devlet Hastanesi (TR), Yeditepe University Hospital (TR), Antalya IVF (TR), Amerikan Hastanesi (TR), S.B.Ü. Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi (TR), Eskişehir Osmangazi University (TR), Kocaeli Üniversitesi (TR), Istanbul Medeniyet University (TR), Marmara University (TR), Adnan Menderes University (TR), Gazi University (TR)
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Lymphoma Diagnosis and Treatment
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