Haematology: Early-stage Hodgkin: combined-modality vs chemotherapy alone (RAPID)
Free question published 27 July 2026
A 28-year-old woman has stage IA classical Hodgkin lymphoma involving a single right cervical node, with no B symptoms. She completes three cycles of ABVD and an end-of-chemotherapy FDG-PET is negative (Deauville 2). She is anxious about the long-term effects of neck radiotherapy and asks whether she can safely avoid it. Which single statement best informs this discussion?
- AOmitting radiotherapy was proven non-inferior, so radiotherapy adds nothing and should be avoided
- BA PET-negative result mandates a further two cycles of ABVD before any decision can be made
- CShe must receive involved-field radiotherapy because PET response does not predict outcome in early-stage disease
- DOmitting radiotherapy did not meet non-inferiority; it slightly increases relapse risk but both strategies give a very good prognosis
- EShe should switch to escalated BEACOPP because ABVD alone is inadequate for stage IA disease
Why D is correct
In the RAPID trial, patients with stage IA/IIA Hodgkin lymphoma who were PET-negative after three cycles of ABVD were randomised to involved-field radiotherapy or no further treatment. The strategy of no further treatment did not show non-inferiority for progression-free survival (3-year PFS 94.6% with radiotherapy versus 90.8% without; absolute difference -3.8 percentage points), but both groups had a very good prognosis, so omission can be an individualised decision balancing a small relapse increase against late toxicity.
And why the others are not
- AIncorrect: RAPID specifically did NOT demonstrate non-inferiority of omitting radiotherapy, so it is wrong to claim radiotherapy adds nothing.
- BIncorrect: in RAPID, PET-negative patients were randomised after three cycles, not mandated to receive further ABVD.
- CIncorrect: PET response is strongly prognostic in early-stage Hodgkin lymphoma, which is the entire rationale of RAPID and H10.
- EIncorrect: escalated BEACOPP is not indicated for a PET-negative early-stage patient; it is reserved for PET-positive or advanced high-risk disease.
Source RAPID - PET-directed therapy for early-stage Hodgkin's lymphoma — Radford J, Illidge T, Counsell N, et al. Results of a trial of PET-directed therapy for early-stage Hodgkin's lymphoma. N Engl J Med. 2015;372(17):1598-1607.
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