OpenOnco · Treatment Plan

Treatment plan — Classical Hodgkin Lymphoma

PLAN-CHL-2L-001-V1 · v1 · 2026-09-09

Patient

CHL-2L-001 · Algorithm: ALGO-CHL-2L

DiagnosisClassical Hodgkin Lymphoma

MOH / ICD-10C81.9

ICD-O-39650/3

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

Primary current-line option

Aggressive plan

★ DEFAULT

Indication

IND-CHL-2L-PEMBROLIZUMAB

Regimen

Pembrolizumab 200 mg IV q3w — r/r cHL post-BV (KEYNOTE-204 schedule)

Drugs + NSZU

Pembrolizumab (DRUG-PEMBROLIZUMAB) 200 mg flat dose · IV every 21 days, until progression or unacceptable toxicity (typical max 35 cycles ~2 years per KEYNOTE-204) · IV ✓ NSZU covered

Hard contraindications

CI-PEMBROLIZUMAB-AUTOIMMUNE

Reason

Primary current-line option selected by ALGO-CHL-2L at step 3.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-CHL-2L-BRENTUXIMAB-MAINTENANCE

Regimen

Brentuximab vedotin maintenance post-ASCT for high-risk cHL (AETHERA, 16 cycles)

Drugs + NSZU

Brentuximab vedotin (DRUG-BRENTUXIMAB-VEDOTIN) 1.8 mg/kg (max 180 mg) · IV every 21 days × 16 cycles, starting 30-45 days post-ASCT · IV ✓ NSZU covered

Supportive care

SUP-PJP-PROPHYLAXIS

Hard contraindications

CI-BORTEZOMIB-SEVERE-NEUROPATHY

Reason

Current-line alternative presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-HIV-SEROLOGY	HIV Antibody/Antigen	Critical	lab	—	all tracks
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	all tracks
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-PREGNANCY	Beta-HCG	Critical	lab	—	all tracks
TEST-ECHO	Echocardiography	Standard	imaging	—	all tracks
TEST-LN-CORE-BIOPSY	Core LN Biopsy	Standard	histology	—	all tracks
TEST-PET-CT	FDG PET/CT (whole body)	Standard	imaging	—	all tracks

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Frailty profile precluding full-dose ABVD or A+AVD in classical Hodgkin lymphoma: ECOG ≥3, OR (age ≥60 with ≥2 comorbidities — elderly cHL has worse outcomes regardless of regimen), OR composite frailty (age ≥75 + Charlson ≥3 + albumin <3.5). Triggers de-escalation to AVD (omit bleomycin), VEPEMB (gem-vinorelbine-based), or BV-AVD.
Elderly cHL (>60y) outcomes substantially worse — bleomycin pulmonary toxicity disproportionately high (>20% pneumonitis with BLEO in age ≥60 per German Hodgkin trials); omit bleomycin or use BV substitution (A+AVD per ECHELON-1 elderly…
RF-CHL-FRAILTY-AGESRC-NCCN-BCELL-2025SRC-ESMO-HODGKIN-2024
Classical Hodgkin lymphoma primary-refractory disease (positive interim PET2 with Deauville 4-5 or end-of-treatment PET-positive) OR early relapse <12 months post-ABVD/A+AVD — high-risk subset routes to salvage chemo (ICE / DHAP / BV-bendamustine) followed by autoSCT consolidation; consider BV-nivolumab combination for chemo-refractory.
Interim-PET-adapted approach (RATHL / AHL2011): PET2 positive → intensify (BEACOPP-esc) or salvage workup; PET2 negative → omit bleomycin (AVD). Primary-refractory or <12mo relapse: salvage chemoimmuno (BV-bendamustine, BV-DHAP, ICE) with…
RF-CHL-TRANSFORMATION-PROGRESSIONSRC-NCCN-BCELL-2025SRC-ESMO-HODGKIN-2024
Patient has NOT previously received brentuximab vedotin (BV) — eligible for BV-containing first-line and salvage regimens in CD30-expressing diseases: A+AVD in advanced cHL (ECHELON-1, Connors NEJM 2018), BV-CHP in CD30+ PTCL/ALCL (ECHELON-2, Horwitz Lancet 2019), BV monotherapy or BV-containing salvage in R/R cHL (AETHERA post-ASCT consolidation). This eligibility flag is used as an inclusion gate for BV-using algorithm branches; firing means standard BV-route is open. Co-fires with disease-specific CD30-positivity flags.
Inclusion-gate flag (eligibility), not a routing flag — direction "intensify" reflects "BV-route is the preferred first-line where applicable; absence of prior BV does NOT alone trigger BV-using regimen, but it removes the…
RF-PRIOR-BV-NAIVESRC-ECHELON-1-CONNORS-2018SRC-ECHELON-2-HORWITZ-2019SRC-AETHERA-MOSKOWITZ-2015

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Pembrolizumab (and other PD-1/PD-L1 inhibitors) augment T-cell responses; in patients with active autoimmunity or post-transplant immunosuppression, this can precipitate severe organ-specific flares (colitis, hepatitis, pneumonitis, transplant rejection) that may be fatal or require transplant loss. CI-PEMBROLIZUMAB-AUTOIMMUNE
Severe pre-existing peripheral neuropathy is an absolute contraindication to bortezomib — therapy will likely worsen the neuropathy to a disabling and often permanent extent.CI-BORTEZOMIB-SEVERE-NEUROPATHY

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Aggressive plan (IND-CHL-2L-PEMBROLIZUMAB)

Do NOT prescribe in active autoimmune disease (CI-PEMBROLIZUMAB-AUTOIMMUNE) — risk of severe irAE flare.
Do NOT prescribe in solid-organ transplant — risk of acute graft rejection from PD-1 blockade.
Do NOT ignore baseline thyroid function + cortisol + glucose — endocrine irAE common.
Do NOT ignore new pneumonitis-suspect symptoms (cough, dyspnea) — HRCT immediately; pneumonitis is most-feared irAE.
Do NOT discontinue for Grade 1 endocrinopathy — replacement therapy + continue treatment.
Do NOT ignore myocarditis-suspect symptoms (chest pain, dyspnea, troponin rise) — discontinue + emergent cardiology.
Do NOT forget the plan toward alloSCT consolidation in fit transplant-eligible responders — PD-1 monotherapy is not curative, durable PR + bridge to SCT.
Do NOT plan alloSCT immediately after PD-1 termination — pembrolizumab impacts on post-allo GVHD risk; ≥4 weeks washout + careful conditioning regimen selection.
Do NOT prescribe without funding pathway clarification — pembrolizumab off-label for cHL in UA.

Aggressive plan (IND-CHL-2L-BRENTUXIMAB-MAINTENANCE)

Do NOT combine with bleomycin — additive lethal pulmonary toxicity (absolute).
Do NOT prescribe in pre-existing Grade ≥2 peripheral neuropathy — risk-benefit unfavorable; surveillance only.
Do NOT start maintenance before 30 days post-ASCT — risk of poor engraftment + cytopenia.
Do NOT start maintenance after 45 days post-ASCT — best benefit when started early (AETHERA inclusion criterion).
Do NOT ignore new neuropathy — reduce dose to 1.2 mg/kg on resume; permanent discontinuation for Grade ≥3.
Do NOT continue maintenance beyond 16 cycles — protocol-defined; longer benefit not established.
Do NOT use for low-risk cHL (CR pre-ASCT + relapse >12 mo + nodal-only at relapse) — risk-benefit unfavorable.
Do NOT prescribe without funding pathway clarification — brentuximab is NOT NSZU-reimbursed for cHL maintenance.
Do NOT forget PJP prophylaxis during maintenance + ≥6 mo after last dose.

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Aggressive plan

Induction · Pembrolizumab 200 mg IV q3w — r/r cHL post-BV (KEYNOTE-204 schedule)

21-day cycles × Until progression or unacceptable toxicity (typically ≤2 years / 35 cycles)

Aggressive plan

Induction · Brentuximab vedotin maintenance post-ASCT for high-risk cHL (AETHERA, 16 cycles)

21-day cycles × 16 cycles (~12 months) starting 30-45 days post-ASCT

MDT brief

Discussion questions (3, 1 blocking)

BLOCKING OQ-CD20-CONFIRMATION
Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
Anti-CD20 therapy is the backbone of most lines of treatment; absence of CD20 expression fully changes the regimen.
→ pathologist
OQ-STAGING-COMPLETE
Has complete staging been done (Lugano + PET/CT or CT)?
Prognosis and track selection depend on stage and tumor burden.
→ radiologist
OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (4 steps)

#	Owner	Topic	Action
1	pathologist	Pathology confirmation BLOCKING	Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
2	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
3	radiologist	Staging / disease burden	Has complete staging been done (Lugano + PET/CT or CT)?
4	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (required) — mandatory virtual specialists (1)

Hematologist / oncohematologist required
Lymphoma diagnosis — leading specialty for treatment management.
Owns: OQ-LDH-CURRENT

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Pathologist (general) recommended
Confirm lymphoma histology + assess transformation risk (DLBCL/Richter).
Owns: OQ-CD20-CONFIRMATION

Data quality

Incomplete for MDT sign-off. MDT sign-off is incomplete until critical clinical data gaps are resolved.

Biomarker coverage: 0/0 known (100%), 0 missing, 0 default-track gaps
Missing critical: cd20_ihc_status, lugano_stage
Missing recommended: ldh_ratio_to_uln, fib4_index, pet_ct_date
Unevaluated RedFlags: RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-CHL-FRAILTY-AGE, RF-CHL-INFECTION-SCREENING, RF-CHL-TRANSFORMATION-PROGRESSION

Missing data for doctor action

Priority	Clinical item	Owner	Why it matters	Next action	Blocks
CRITICAL	CD20 IHC status `cd20_ihc_status`	pathologist	Confirms CD20-directed therapy is biologically appropriate.	Verify CD20 IHC result, specimen, method, and report date.	-
CRITICAL	Lugano stage `lugano_stage`	radiologist	Defines lymphoma extent and supports tumor-burden and response-assessment decisions.	Document Lugano stage from PET/CT or contrast CT staging.	-
RECOMMENDED	LDH ratio to ULN `ldh_ratio_to_uln`	medical_oncologist	Supports prognostic scoring and aggressive-biology flags.	Enter LDH with local upper limit of normal.	-
RECOMMENDED	FIB-4 liver fibrosis index `fib4_index`	infectious_disease_hepatology	Screens hepatic fibrosis risk before hepatotoxic therapy or antiviral coordination.	Calculate FIB-4 from age, AST, ALT, and platelet count.	-
RECOMMENDED	PET/CT date `pet_ct_date`	radiologist	Shows whether baseline staging is recent enough for treatment planning and later response comparison.	Document baseline PET/CT date or explain alternative staging modality.	-

Technical MDT skill metadata (3/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-ESMO-LYMPHOMA-2025: Lymphomas: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up (2025)
SRC-NCCN-BCELL-2025: NCCN Clinical Practice Guidelines in Oncology: B-Cell Lymphomas (v.2.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-09-09.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT07551583	Phase II Study Of Nivolumab Plus AVD In Pediatric, Adolescent, And Young Adult Patients With CHL	PHASE2	RECRUITING	M.D. Anderson Cancer Center	—	Small N (<50) Single country
NCT02797717	Treatment for Classical Hodgkin Lymphoma in Children and Adolescents	NA	RECRUITING	GALIA AVRAHAMI	—	Single country
NCT07209059	PET-Adapted First-Line Therapy With Nivolumab for Advanced Hodgkin Lymphoma	PHASE2	RECRUITING	National Research Center for Hematology, Russia	—	Small N (<50) Single country
NCT06984146	Nivo40-AVD for Advanced Classic Hodgkin Lymphoma	PHASE2	RECRUITING	National Medical Research Radiological Centre of the Ministry of Health of Russia	—	Surrogate endpoint only Single country
NCT05039073	Brentuximab Vedotin and Nivolumab for the Treatment of Relapsed/Refractory Classic Hodgkin Lymphoma Previously Treated With Brentuximab Vedotin or Checkpoint Inhibitors	PHASE2	RECRUITING	Emory University	—	Small N (<50) Surrogate endpoint only Single country
NCT05934084	Lifestyles Implemented-Survivorship Care Plan In Lymphoma Survivors	NA	RECRUITING	Fondazione Italiana Linfomi - ETS	—	Single country
NCT07021989	ctDNA-Guided Therapy for Relapsed/Refractory Hodgkin Lymphoma	PHASE2	RECRUITING	Michael Spinner, MD	—	Small N (<50) Single country
NCT06170489	A Phase III Clinical Study Comparing JS004 Plus Toripalimab With Investigator-Selected Chemotherapy in Patients With PD-(L)1monoclonal Antibody Refractory Classic Hodgkin Lymphoma (cHL)	PHASE3	RECRUITING	Shanghai Junshi Bioscience Co., Ltd.	—	Surrogate endpoint only Single country
NCT06393361	Chidamide Decitabine Plus Anti-PD-1 Antibody for Patients With R/R cHL Who Are Transplant-ineligible or Refused Transplant.	PHASE2	RECRUITING	Chinese PLA General Hospital	—	Surrogate endpoint only Single country
NCT07275216	Pembrolizumab in Combination With Chemotherapy for the Treatment of Frail Hodgkin Lymphoma Patients Ineligible for Standard Treatment	PHASE2	RECRUITING	City of Hope Medical Center	—	Small N (<50) Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Aggressive plan Pembrolizumab 200 mg IV q3w — r/r cHL post-BV (KEYNOTE-204 schedule) (REG-PEMBROLIZUMAB-CHL)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan Brentuximab vedotin maintenance post-ASCT for high-risk cHL (AETHERA, 16 cycles) (REG-BRENTUXIMAB-MAINTENANCE-CHL)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT07551583 Phase II Study Of Nivolumab Plus AVD In Pediatric, Adolescent, And Young Adult Patients With CHL No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT02797717 Treatment for Classical Hodgkin Lymphoma in Children and Adolescents No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07209059 PET-Adapted First-Line Therapy With Nivolumab for Advanced Hodgkin Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06984146 Nivo40-AVD for Advanced Classic Hodgkin Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05039073 Brentuximab Vedotin and Nivolumab for the Treatment of Relapsed/Refractory Classic Hodgkin Lymphoma Previously Treated With Brentuximab Vedotin or Checkpoint Inhibitors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05934084 Lifestyles Implemented-Survivorship Care Plan In Lymphoma Survivors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07021989 ctDNA-Guided Therapy for Relapsed/Refractory Hodgkin Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06170489 A Phase III Clinical Study Comparing JS004 Plus Toripalimab With Investigator-Selected Chemotherapy in Patients With PD-(L)1monoclonal Antibody Refractory Classic Hodgkin Lymphoma (cHL) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06393361 Chidamide Decitabine Plus Anti-PD-1 Antibody for Patients With R/R cHL Who Are Transplant-ineligible or Refused Transplant. No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07275216 Pembrolizumab in Combination With Chemotherapy for the Treatment of Frail Hodgkin Lymphoma Patients Ineligible for Standard Treatment No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-09-09.

plan_id: PLAN-CHL-2L-001-V1 | version: 1 | generated: 2026-09-09T12:26:41.255991+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.