A 28-year-old man from Delhi presents with a 3-month history of progressive painless cervical lymphadenopathy, fever, and night sweats. Excisional lymph node biopsy shows classical Hodgkin lymphoma (cHL), nodular sclerosis subtype. CT chest and abdomen are normal. PET-CT shows uptake only in cervical nodes (Stage IA). What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has early-stage (Stage IA) classical Hodgkin lymphoma with favorable prognostic features (young age, limited disease, no bulky mass). The standard of care for early-stage cHL has evolved toward combined modality therapy (CMT) to optimize cure while minimizing late toxicity. ## Treatment Rationale for Early-Stage cHL **Key Point:** Early-stage cHL (Stage I–II) with favorable risk factors is best treated with combined modality therapy: 2–4 cycles of chemotherapy (ABVD or escalated BEACOPP) followed by involved-field radiotherapy (IFRT). **High-Yield:** The combination of chemotherapy + IFRT achieves ≥90% 5-year progression-free survival in early-stage cHL, with significantly lower relapse rates than either modality alone. ### Why Combined Modality Therapy? 1. **Chemotherapy component** — eradicates micrometastatic disease and systemic burden 2. **Radiotherapy component** — provides local control and reduces risk of nodal relapse 3. **Reduced toxicity** — 2 cycles ABVD + IFRT (30 Gy) has lower cumulative cardiopulmonary and secondary malignancy risk than either full-course chemotherapy or extended radiation alone ### Dosing & Duration - **ABVD:** 2 cycles for early-stage favorable disease (vs. 4 cycles for intermediate/unfavorable) - **IFRT:** 30 Gy in 15 fractions to involved field (cervical nodes in this case) - **Total duration:** ~12 weeks **Clinical Pearl:** Modern protocols prioritize de-escalation in favorable early-stage disease to reduce late toxicities (secondary malignancies, cardiac dysfunction, pulmonary fibrosis) while maintaining excellent cure rates. ## Why Not the Other Options? | Option | Why Incorrect | |--------|---------------| | Observation alone | Unacceptable; early-stage cHL is curable with active treatment. Observation is not standard and risks progression. | | ABVD 4 cycles only | Chemotherapy monotherapy for early-stage cHL has higher relapse rates (~20–25%) compared to CMT (~5–10%). IFRT is needed for optimal local control. | | IFRT alone (30 Gy) | Radiotherapy monotherapy has been largely abandoned due to higher relapse rates and risk of late toxicities. Chemotherapy is essential to address systemic disease risk. | [cite:Harrison 21e Ch 104]