Potential to Cure Advanced Stage cHL

Jonathon B. Cohen, MD, MS: This patient went on to brentuximab vedotin plus AVD [doxorubicin (Adriamycin), vinblastine (Oncovin), and dacarbazine] [BVAVD], and after 2 cycles of therapy, we did obtain an interim PET CT. It’s important to recognize that this is not designed to be a PET-directed therapy in that at least at the time the study was initially reported, we really didn’t understand the importance of interim PET. Subsequently, it has been reported out that interim PET is predictive of outcome in patients with BVAVD, and fortunately, this patient did have an interim PET with a Deauville [score]of 3, which supported continuing treatment through the full 6 cycles. This patient has now completed therapy and has achieved a complete remission.

Patients [who] complete induction therapy for classical Hodgkin lymphoma [cHL] [who] achieve a complete remission can expect to have a prolonged progression-free survival, and many of those patients will actually be cured. We know from a number of studies that have been conducted that having a negative interim PET is particularly important, and then again, having that end-of-treatment PET show no evidence of disease is important. So I would say that this patient has a very high likelihood of being cured of their disease. And, in fact, when we look at long-term follow-up of patients treated for Hodgkin lymphoma, we find that after the first year to 18 months that the most common cause of death for those patients is actually complications of treatment or other causes and not necessarily the Hodgkin lymphoma itself.

For patients [who] complete induction therapy for classical Hodgkin lymphoma, most of them will ultimately be cured of their disease and will not require any additional treatment. However, if a patient were to relapse several years down the road, or even several months down the road, we typically would consider evaluating that patient for an autologous stem cell transplant. This is typically accomplished first by completing aggressive salvage therapy, which is designed to re-induce the remission, and then moving forward with high-dose therapy and stem cell rescue. This can be a curative approach in up to 50% of patients, although that number can vary widely based on a number of factors, including the time to relapse.

For a patient with advanced-stage classical Hodgkin lymphoma, we now have a number of very good options for patients to receive. We have BVAVD, which now has an FDA label in the frontline setting. And then we also have a very reasonable approach with PET-adapted therapy using ABVD [doxorubicin, bleomycin, vinblastine, dacarbazine], with the possibility of de-escalating to AVD for a patient [who’s] PET-negative.

I think it’s very important for anyone [who’s] treating a patient with classical Hodgkin lymphoma to truly take into consideration the patient and their particular comorbidities when making a treatment decision. I think it’s also important to recognize that should you decide to proceed with a PET-adapted approach, that you be prepared to escalate to BEACOPP [bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone] should you find that the interim PET is positive. That’s how we feel that that strategy is most appropriately applied. In general, however, patients can be expected to do well, but it’s very important to remember that there can be toxicities identified and that many of these patients are young people and sometimes complications that are encountered during therapy can last for many years and can significantly alter the lifestyle for these patients. So it’s very important to monitor them while they’re on therapy and then in the months and years afterwards.

Transcript edited for clarity.

A 22-Year-Old Woman With Stage IV Classical Hodgkin Lymphoma

History & Physical

• A 22-year-old female presented with right cervical nodes developing over several months
• Initially evaluated by her OB/GYN who recommended observation. She subsequently developed neck pain while drinking wine
• Referred for lymph node biopsy -> classical Hodgkin lymphoma
• Past medical history: unremarkable
• Social history: No tobacco use; occasional ETOH; Division 1 swimmer, NKDA
• Family History:
  • Maternal grandfather — Squamous cell cancer
  • Maternal grandmother — Melanoma
  • Aunt — Breast Cancer
  • 2 healthy siblings

Laboratory Values

• WBC 19.8 (85% PMN’s)
• Hgb 12.0
• Plts 571
• ESR 30
• Cr 0.76
• Albumin 4.2
• HIV/Hepatitis Negative

Staging PET/CT

• Intrathoracic adenopathy
  • R cervical 2.3 x 1.9 (SUV 9.3)
  • L cervical 2.2 x 1.8 (SUV 8.8)
  • Ant Mediastinum 4.8 x 2.9 (SUV 21.3)
  • R axillary 2.8 x 2.8 (SUV 12.2)
• Spleen SUV 2.9 with normal size
• Diffuse uptake in the axial skeleton (SUVs 4.9-5.5)
• Mediastinum SUV 1.8 / Liver 2.4

Pathology

• Nodular sclerosis classical Hodgkin Lymphoma
• Per IHC, Hodgkin cells express CD30, CD15, PAX5 (weak); negative for CD3, CD20, CD45

Treatment:A(BV)VD x 6

• Interim PET/CT with Deauville 3
• Tolerated well with GCSF support