Haematology: Advanced Hodgkin: response-adapted therapy (RATHL)
Free question published 18 August 2026
A 45-year-old man with stage IIIB classical Hodgkin lymphoma starts ABVD. After two cycles his interim PET-CT is negative (Deauville 2). He has noticed mild exertional breathlessness. What is the most appropriate adjustment to his remaining four cycles of chemotherapy?
- AContinue full ABVD for cycles 3 to 6 with no change
- BEscalate to BEACOPP for cycles 3 to 6
- CStop chemotherapy and consolidate with involved-site radiotherapy
- DOmit doxorubicin to reduce cardiotoxicity and continue BVD
- EOmit bleomycin and continue AVD for cycles 3 to 6
Why E is correct
In the RATHL trial, patients with advanced Hodgkin lymphoma and a negative interim PET after two cycles of ABVD were randomised to continue ABVD or to omit bleomycin (AVD) for cycles 3 to 6. Omitting bleomycin gave a 3-year PFS of 84.4% versus 85.7% with continued ABVD (absolute difference 1.6 percentage points) with fewer severe respiratory adverse events, so de-escalation to AVD is appropriate, particularly relevant in a patient with early breathlessness.
And why the others are not
- AIncorrect: RATHL supports omitting bleomycin after a negative interim PET to reduce pulmonary toxicity without significant loss of efficacy.
- BIncorrect: escalation to BEACOPP in RATHL was reserved for interim-PET-positive patients, not PET-negative patients.
- CIncorrect: radiotherapy was not recommended for patients with negative interim scans in RATHL, and chemotherapy should be completed.
- DIncorrect: it is bleomycin (lung toxicity), not doxorubicin, that is omitted in the AVD de-escalation; dropping doxorubicin is not part of the regimen.
Source RATHL - Response-adapted therapy guided by interim PET in advanced Hodgkin lymphoma — Johnson P, Federico M, Kirkwood A, et al. Adapted Treatment Guided by Interim PET-CT Scan in Advanced Hodgkin's Lymphoma. N Engl J Med. 2016;374(25):2419-2429.
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