Devil’s in the details.

Red devil, that is. The German HD10 trial established 2 cycles of ABVD followed by involved field radiation to 20 Gy as the standard of care for very favorable Hodgkins lymphoma. Recently-published 7-year outcomes of the EORTC H9-F trial don’t change this standard, but they do offer a couple of insights. It’s design was 6 cycles of EBVP (note the epirubicin in place of doxorubicin and prednisone in place of dacarbazine when compared to the HD10 ABVD regimen) with a 3-way randomization among complete responders to 36 Gy in 18 fractions versus 20 Gy in 10 fractions versus no radiation. The no radiation arm closed early due to early failures. 20 Gy was non-inferior to 36 Gy at 5 years, but did result in numerically higher late relapses. Most importantly, all recurrence-free survival rates--even with the most intensive 36 Gy arm--were worse than those achieved in the HD10 trial with as little as 2 cycles of ABVD. Bottom line: radiation can only be safely deintensified with the appropriate systemic therapy, and for favorable Hodgkins lymphoma that includes doxorubicin along with bleomycin, vinblastine and dacarbazine.