A 45-year-old man with relapsed classical Hodgkin lymphoma (relapse 18 months after completing ABVD) is referred for salvage therapy. Which chemotherapy regimen is the drug of choice for salvage treatment?

Explanation

## Salvage Chemotherapy for Relapsed Hodgkin Lymphoma **Key Point:** ESHAP (or other platinum-based salvage regimens like DHAP, ICE) is the standard salvage regimen for relapsed/refractory classical Hodgkin lymphoma. These regimens are designed to achieve chemosensitivity and allow subsequent stem cell transplantation (SCT). ### Salvage Regimen Strategy **High-Yield:** The goal of salvage therapy is NOT cure with chemotherapy alone, but rather: 1. Achieve chemosensitivity (partial or complete response) 2. Mobilize and collect peripheral blood stem cells 3. Proceed to autologous SCT (ASCT), which offers 40–50% long-term survival in chemosensitive relapsed disease ### ESHAP Regimen Composition | Drug | Dose | Mechanism | Role | |------|------|-----------|------| | Etoposide | 40 mg/m²/day × 4 | Topoisomerase II inhibitor | Backbone | | Sargamostim (GM-CSF) | 250 μg/m²/day | Haematopoietic growth factor | Stem cell mobilization | | Cytarabine (Ara-C) | 2000 mg/m²/day × 4 | Antimetabolite | Synergistic | | Cisplatin | 25 mg/m²/day × 4 | Platinum alkylator | Broad-spectrum activity | **Mnemonic:** **ESHAP** = **E**toposide, **S**argamostim, **H**igh-dose **A**ra-C, **P**latin (cisplatin) ### Why ABVD Rechallenge Fails - **Cross-resistance:** Relapse within 12 months of ABVD indicates chemoresistant disease - **Mechanism:** Tumour cells have developed resistance to ABVD components (doxorubicin, bleomycin, vinblastine, dacarbazine) - **Outcome:** Repeating ABVD results in <10% response rate - **Guideline:** ABVD rechallenge is only considered if relapse occurs >12 months after completion (late relapse, chemosensitive disease) **Clinical Pearl:** This patient relapsed at 18 months — borderline timing. However, the standard approach is to use platinum-based salvage (ESHAP, DHAP, or ICE) followed by ASCT, as this offers superior long-term survival compared to ABVD rechallenge alone. ### Alternative Salvage Regimens - **DHAP:** Dexamethasone, high-dose cytarabine, cisplatin (similar efficacy to ESHAP) - **ICE:** Ifosfamide, carboplatin, etoposide (alternative platinum regimen) - **Modern approach:** Checkpoint inhibitors (nivolumab, pembrolizumab) are increasingly used in relapsed/refractory disease, often as bridge to SCT **Warning:** Do not confuse salvage therapy with primary therapy. ESHAP is NOT first-line (that is ABVD) but is the standard salvage approach.