Salvage Therapy in Hodgkin’s Lymphoma

Abstract

1. Appraise the most important properties of a salvage chemotherapy regimen and name at least three effective regimens.2. Evaluate poor-risk clinical features pre-HDCT/ASCT that reduce the chance for cure and design a more effective alternative transplant approach.3. Hypothesize the reasons for the effectiveness of monoclonal antibodies that have shown activity against relapsed HL.This article is available for continuing medical education credit at CME.TheOncologist.com. CME CME ABSTRACTHodgkin's lymphoma (HL) is a commonly cured malignancy. Unfortunately, patients who are refractory to or relapse after first-line treatment pose a significant therapeutic challenge. There is evidence that these patients are best treated with an approach involving salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell transplant (HDCT/ASCT). This approach may result in cure, with better results in patients with low-risk relapse. In patients with high-risk relapse and refractory disease, HDCT/ASCT is rarely curative. More aggressive transplant approaches have shown promising results in this group and are currently under active investigation. For those relapsing after HDCT/ASCT, there exists a range of therapeutic options, including further salvage chemotherapy, reduced-intensity allogeneic transplantation, monoclonal antibody therapy, and novel agents. All patients in this category should be considered for enrollment in clinical trials. This review discusses the evidence behind the current practice in patients with relapsed or refractory HL. Specifically, the efficacy of various salvage chemotherapy regimens, the risk factors influencing outcome with HDCT/ASCT, and the results with alternative transplant approaches, monoclonal antibody therapies, and novel agents are addressed. We conclude by providing our approach to these patients, with the hope that this will serve as a framework for the practicing oncologist.

Classical Hodgkin's lymphoma: the Lymphoma Study Association guidelines for relapsed and refractory adult patients eligible for transplant

“…2,20 For methodological reasons, it is impossible to compare response rate among these regimens. It is the recommendation of the LYSA expert panel to use a platinum-based regimen such as DHAP (dexamethasone, high-dose cytarabine-cisplatin) or ICE (ifosfamide-carboplatin-etoposide) for patients previously treated with ABVD or BEACOPP (especially if mediastinal radiotherapy has been delivered), given the risk of cardiac toxicity if the cumulative dose of doxorubicin has already reached 300-400 mg/m 2 .…”

“…Some experts suggested that this strategy should also be proposed to patients accumulating poor-risk factors, as well as in patients needing more than one line of salvage chemotherapy before displaying chemosensitivity, in agreement with the recommendations of Mendler and Friedberg. 20 In contrast, other LYSA experts emphasize that this latter group of patients are at high risk for rapid progression before any GVL effect can occur, and that they should then be oriented toward a second ASCT rather than RIC-allo. Benefit to risk ratio of RIC-allo and donor availability should also be weighted in the decision.…”

Diffuse large B-cell lymphoma of bones in a patient after allogeneic hematopoietic stem cells transplantation due to Hodgkin’s lymphoma

“…Currently, in such cases the standard procedure is to implement a phase II rescue chemotherapy and mega-dose chemotherapy supported by autologous haematopoietic stem cell transplantation [9]. In the described case, such a treatment was chosen; however, due to the failure of stem cell collection, it was decided to conduct an allogeneic transplantation from a related donor: in this case, a brother.…”

“…Nevertheless, the introduction of reduced intensity conditioning (RIC) allowed a reduction in transplant related mortality. Analysis of the data demonstrate that RIC with alloHSCT enables long survival in 20-30% of patients [8][9][10].…”

Primary Resistant Course and Recurrence of the Hodgkin,s Lymphoma. Preventable Losses at “Most Recoverable” Hemoblastosis

“…Оче-видным является и то, что возможность достижения ремиссии зависит от противоопухолевой эффективно-сти выбранного индукционного режима [63,64]. Од-нако к понятию «эффективность» индукционного режима у больных, которым планируется проведение ТКПГ, предъявляется гораздо больше требований, чем просто высокая частота достижения ремиссий.…”