Controversies in the Management of Early-Stage Hodgkin Lymphoma: The Role of Radiation Therapy

The treatment of early-stage Hodgkin lymphoma is one of oncology's great success stories. Numerous large randomized trials have tested and refined conventional chemotherapy regimens, optimized radiation therapy (RT) approaches, explored the integration of metabolic imaging such as PET/CT, and are now evaluating novel agents. What was once a fatal disease is now cured in almost all patients. Combined-modality therapy, typically involving a short course of chemotherapy followed by low-dose, highly conformal RT, has emerged as the most effective strategy for achieving durable remissions. Nonetheless, concerns about the long-term toxicities associated with RT have prompted investigations into chemotherapy-only regimens as a potential alternative to combined-modality therapy. To date, neither interim nor postchemotherapy PET/CT imaging has been able to identify patients who can safely omit consolidation RT without compromising efficacy, although additional studies are ongoing. Meanwhile, novel agents such as nivolumab and brentuximab vedotin have significantly advanced the treatment of advanced-stage disease and are now demonstrating promising activity in early-stage Hodgkin lymphoma. In parallel with advances in systemic therapy, radiation technologies have also progressed substantially. Techniques such as proton therapy, intensity-modulated RT, and image-guided RT dramatically reduce radiation exposure to healthy tissues compared with historical approaches, thereby improving the therapeutic ratio. Despite the high cure rates achieved today, clinical trials continue to explore novel and personalized approaches to achieve long-term remission without compromising quality of life.