A 28-year-old woman with newly diagnosed classical Hodgkin lymphoma, stage IIIB with bulky mediastinal involvement, is being counselled about chemotherapy. She is concerned about cardiotoxicity given her family history of cardiomyopathy. Which regimen is most appropriate?

## Cardiotoxicity Risk and Regimen Selection in Hodgkin Lymphoma **Key Point:** ABVD remains the first-line regimen even in patients with cardiotoxicity risk factors. Doxorubicin cardiotoxicity is dose-dependent and manageable with monitoring and cardioprotection (e.g., liposomal doxorubicin, dexrazoxane, or ACE inhibitors). ### Cardiotoxicity Profile Comparison | Regimen | Doxorubicin Dose | Cardiotoxicity Risk | Efficacy | Preferred in Cardiac Risk? | |---------|------------------|---------------------|----------|---------------------------| | ABVD | 300 mg/m² total | Moderate (dose-dependent) | Excellent | **Yes** (with monitoring) | | Escalated BEACOPP | 400 mg/m² total | **High** (cumulative) | Excellent | No | | Doxorubicin-free | 0 | Low | Inferior | No | | Stanford V | 300 mg/m² total | Moderate | Excellent | Alternative only | **High-Yield:** The key principle is that ABVD should NOT be abandoned due to cardiac risk alone. Instead: 1. **Baseline cardiac assessment:** Echocardiography or MUGA scan before therapy 2. **Cardioprotection strategies:** - Liposomal doxorubicin (reduces cardiotoxicity) - Dexrazoxane (iron chelator, reduces anthracycline cardiotoxicity) - ACE inhibitors or beta-blockers for prophylaxis 3. **Serial monitoring:** Echocardiography after cumulative doxorubicin doses of 300, 400, and 450 mg/m² 4. **Dose modification:** If LVEF drops >10% or to <50%, consider liposomal formulation or regimen switch **Clinical Pearl:** In young patients with long life expectancy (like this 28-year-old), ABVD with cardiac monitoring is superior to doxorubicin-free regimens because cure rates are much higher, and late cardiotoxicity can be managed with modern cardioprotective strategies. **Warning:** Removing doxorubicin entirely (option 3) would significantly reduce cure rates and is not justified by family history alone. Escalated BEACOPP (option 2) would increase, not decrease, cardiotoxicity.