Combined Modality Treatment With Brentuximab Vedotin and Radiation Therapy for Primary Cutaneous Anaplastic Large Cell Lymphoma: A Case Report

Abstract

Primary cutaneous anaplastic large cell lymphoma (pcALCL) is a rare form of non-Hodgkins lymphoma. Current frontline treatments for pcALCL include surgical resection, anthracycline-based chemotherapy, and/or radiation therapy (RT) depending on disease severity. While brentuximab vedotin (BV) has been used for refractory/ relapsed cases, it recently received Food and Drug Administration (FDA) approval for use in combination with chemotherapy for peripheral T-cell lymphomas. In this case report, we utilized a combined modality therapy of RT and BV for a limited stage aggressive pcALCL presentation for which routine management is contraindicated. A 59-year-old man with a history of peripheral vascular disease (PVD) presented with an aggressive pcALCL involving the left inferior eyelid and small ipsilateral level II hypermetabolic lymph nodes at stage IIE. Due to the patient's history of PVD, the tumor's rapid growth, possible lymph node involvement, and eye proximity, BV was chosen as the initial chemotherapy treatment followed by RT. Complete metabolic resolution of the primary cutaneous lesion and lymphadenopathy was reached after BV treatment alone; complete clinical response of the primary tumor was reached following radiation therapy. Relapse occurred within 7 months. Salvage cyclophosphamide, vincristine, etoposide, and prednisone were not effective. Retreatment with BV + RT is currently being used to treat the new lesions. Our case illustrates that a combination of BV and RT can be a safe and effective initial treatment in patients with limited stage pcALCL who cannot tolerate anthracycline-based chemotherapy. Our patient had a complete response but ultimately relapsed; thus larger clinical trials are needed to better understand early-stage disease.

Spindle-cell (Sarcomatoid) Variant of Cutaneous Anaplastic Large-cell Lymphoma (C-ALCL)

“…Limited systemic disease can be encountered, particularly in locoregional lymph nodes. Some patients with wide cutaneous dissemination require systemic therapy, and treatment with the anti-CD30 agent, brentuximab vedotin, has shown excellent responses in this cohort 16–18. Overall, C-ALCL carries a 5-year survival of over 90%, although the prognosis of C-ALCL localized to the legs is worse, with a 5-year survival of 76% 19.…”

“…Some patients with wide cutaneous dissemination require systemic therapy, and treatment with the anti-CD30 agent, brentuximab vedotin, has shown excellent responses in this cohort. [16][17][18] Overall, C-ALCL carries a 5-year survival of over 90%, although the prognosis of C-ALCL localized to the legs is worse, with a 5-year survival of 76%. 19 The involvement of locoregional lymph nodes does not appear to impart a worse prognosis.…”

Novel Drugs and Radiotherapy in Relapsed Lymphomas: Abscopal Response and Beyond

“…With the growing role of checkpoint inhibitors in HL and the goal of minimizing long term toxicity, this association does not seem to be an area of active interest, and it is unlikely to be further explored. On the other hand, one report recently documented a transient CR in a patient with ALCL using BV + RT [70]. Another retrospective analysis instead evaluated the safety of BV + RT in 12 patients with MF, with or without large cell transformation [71].…”

Safety of Concurrent Radiation Therapy With Brentuximab Vedotin in the Treatment of Lymphoma

“… 3 , 4 , 5 , 6 Although BV is generally well tolerated, alone or with other systemic therapy (ST) agents, 5 , 7 there is a paucity of data to inform the use of concurrent BV and radiation therapy (RT) (BVRT). 8 , 9 , 10 …”