Salvage Therapy in Hodgkin's Lymphoma

Abstract

Hodgkin's disease is a rare malignancy that affects approximately 7,500 patients per year in the U.S., leading to an estimated 1,400 deaths. The relapse rate for this disease varies from around 5% for early-stage disease to 35% for patients with advanced disease. Patients who relapse after chemotherapy have about a 20% cure rate with conventional salvage chemotherapy. Two randomized phase III studies have shown an improved failure-free survival rate with high-dose chemotherapy and autologous stem cell support compared with conventional chemotherapy in re- CASE PRESENTATIONMr. T is a 50-year-old African-American male with a past medical history significant for type 2 diabetes mellitus. In January 2002, he presented to the emergency room with complaints of fever, chills, right groin pain, and a 25-pound weight loss over the last several months. Initial laboratory evaluation revealed an elevated white cell count of 11,800, hemoglobin of 11.7 g/dl, hematocrit of 35.8, platelet count of 406,000, and an elevated blood sugar of 516 mg/dl. A chest radiograph revealed right paratracheal lymphadenopathy and a patchy density overlying the left upper lung field. A computed tomography (CT) scan of the chest, abdomen, and pelvis showed enlarged lymph nodes in the mediastinum and the prevascular, right paratracheal, subcarinal, left axillary, left subclavian, azygoesophageal recess, and inguinal and bilateral iliac regions. A biopsy of the enlarged right cervical lymph node revealed fibrofatty connective tissue. A mediastinoscopy with biopsy was performed, and the pathology revealed mixed cellularity-type Hodgkin's lymphoma (Fig. 1). A gallium scan was positive in the mediastinal, left axillary, and right inguinal nodes. A bone marrow biopsy revealed Hodgkin's lymphoma, and the patient was considered to have clinical-stage IVB disease (Fig. 2). He underwent treatment with adriamycin, bleomycin, vincristine, and dacarbazine (ABVD) chemotherapy for four cycles. Restaging gallium scan was negative for nodal uptake, and a CT scan showed significant decrease in the lymphadenopathy. After four additional cycles of ABVD, repeat staging revealed new gallium-avid disease in the right paratracheal region, with stable disease upon CT scan. Repeat bone marrow biopsy was negative. The patient was considered to have refractory disease and underwent salvage therapy with rituximab, ifosfamide, carboplatin, and etoposide. After two cycles, he had a negative gallium

Brentuximab Vedotin

“…However, approximately 5% of early-stage disease and 30% to 40% of advanced stage disease relapse after first-line treatment. Patients with relapsed and refractory Hodgkin lymphoma typically receive salvage chemotherapy followed by ASCT (4). However, for patients who relapse after ASCT, effective therapeutic options are limited.…”

CD30: an important new target in hematologic malignancies

“…Relapse rates for HL following first-line chemotherapy vary from around 5% for early stage disease to 35% for advanced disease [3,4,12]. Conventional salvage regimens for refractory or relapsed HL after first-line combination chemotherapy have a modest cure rate of about 20% [13].…”

“…The British National Lymphoma Investigation and the GHSG conducted two randomized phase III trials, which concluded that ASCT improves PFS, but failed to show an improvement in overall survival compared with conventional salvage chemotherapy in relapsed patients [14,15]. Gemcitabine, vinblastine, or vinorelbine can be used with moderate efficacy for palliation in patients who relapse after ASCT [12,[16][17][18][19][20]. Therefore, despite the impressive overall results in HL, there is considerable room for improvement in both upfront treatment and salvage settings, particularly for patients with adverse IPS, especially those older than age 60, patients with primary refractory disease, and/or patients whose disease relapses following ASCT.…”

Relapsed Hodgkin lymphoma in adolescents: focus on current high-dose chemotherapy and autologous stem cell transplant

“…Extensive experience with agents such as gemcitabine, vinorelbine, and vinblastine has been described and is briefly summarized in Table 2. [31][32][33][34][35][36][37][38] Such an approach might allow for prolongation of life with good quality with the possibility of prolonged remission.…”