We asked, and you answered! Here are the responses from this month’s “You Make the Call” question on treatment options for progressive classical Hodgkin lymphoma after multiple lines of therapy.
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First, the patient seems to have early favorable disease, and I would have recommended two cycles of escalated BEACOPP (doxorubicin, cyclophosphamide, etoposide, procarbazine, prednisone, bleomycin, vincristine) and two cycles of ABVD to give the best progression-free survival and avoid radiation up front in a younger patient.
At the time of relapse, the patient had two cycles of ICE with response but residual Deauville score of 5. I would have considered consolidation radiation at this point with a curative intent. However, the patient proceeded with DHAP and has progressive disease.
It would be important to know if the disease is in one radiation field. If it is, I would suggest curative intent radiation, followed by a PET-CT at least three months after completion of radiation. If the disease is not contained in a radiation field, I would recommend salvage pembrolizumab followed by consolidation with BEAM (carmustine, etoposide, cytarabine, and melphalan) AHCT. Have stem cells been collected?
Emad Abro, MBBS
Brisbane, Australia
Yes, it’s a good option, but it’s not enough as the optimal approach, so I would add brentuximab as maintenance therapy post-AHCT.
Bassam Francis Matti, MD
Baghdad, Iraq
I agree with using pembrolizumab/radiation and AHCT if there is complete response.
Cigdem Ozturk, MD
Busaiteen, Bahrain
I would go for brentuximab plus nivolumab or bendamustine, and if there is a complete response or responsive disease (more than partial response), proceed to autologous transplant.
Michalis D. Michael, MD, PhD
Nicosia, Cyprus
My approach would be to give brentuximab plus bendamustine for two cycles, followed by autologous transplant, if in remission.
Ambar Garg, MBBS, DM
Raipur, India
I would give brentuximab vedotin plus nivolumab or pembrolizumab. If in CR, I’m not sure if AHCT would add benefit because this lymphoma is clearly refractory to cytotoxic/traditional chemotherapy.
Anas Al-Janadi, MD
Grand Rapids, MI
I would treat with brentuximab plus/minus pembrolizumab and chimeric antigen receptor T-cell therapy.
Igal Fligman, MD
Mineola, NY
This Hodgkin lymphoma appears to be chemotherapy refractory. Therefore, I think it is important to attempt pembrolizumab combined with GVD (gemcitabine, vinorelbine, and liposomal doxorubicin) for two cycles to induce remission. After achieving remission, we can consider submitting her for AHCT. Phase II studies have shown good response rates and safety with this protocol.
Radiotherapy could potentially improve local response, but because she is a woman, this could increase her risk of developing breast cancer. If we decided not to pursue radiotherapy and the patient achieves partial remission, it’s possible we could use brentuximab vedotin after a bone marrow transplant, in the context of the AETHERA trial protocol.
Hegta Rodrigues Figueiroa, MD
São Paulo, Brazil
In this case of bulky disease, stage IIA Hodgkin lymphoma in an early relapse after two cycles of ABVD (with negative interim PET) and four cycles of AVD, my approach would be BV-ESHAP (brentuximab vedotin plus etoposide, methyl-prednisolone, cytarabine with or without cisplatin) until maximum response, followed by AHCT conditioned with BEAM, and later on, radiotherapy at the site of bulky disease at diagnosis.
If a PET-CT complete metabolic response is achieved, I would offer immunotherapy with nivolumab as maintenance.
Juan José Gil Fernández, MD, PhD
Madrid, Spain
