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Gibb A, Pirrie SJ, Linton K, Warbey V, Paterson K, Davies AJ, Collins GP, Menne T, McKay P, Fields PA, Miall FM, Nagy E, Wheatley K, Reed R, Baricevic-Jones I, Barrington S, Radford J. Results of a UK National Cancer Research Institute Phase II study of brentuximab vedotin using a response-adapted design in the first-line treatment of patients with classical Hodgkin lymphoma unsuitable for chemotherapy due to age, frailty or comorbidity (BREVITY). Br J Haematol 2021; 193:63-71. [PMID: 32926420 DOI: 10.1111/bjh.17073] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/04/2020] [Indexed: 11/25/2022]
Abstract
Standard treatment for classical Hodgkin lymphoma (cHL) is poorly tolerated in older patients and results disappointing. We assessed safety and efficacy of brentuximab vedotin (BV), in previously untreated patients with cHL unfit for standard treatment due to age, frailty or comorbidity. The primary outcome was complete metabolic response (CMR) by positron emission tomography/computed tomography after four BV cycles (PET4). The secondary outcomes included progression-free survival (PFS), overall survival (OS), and toxicity. In all, 35 patients with a median age of 77 years and median total Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score of 6 were evaluable for toxicity and 31 for response. A median of four cycles were given (range one-16). In all, 14 patients required dose reduction due to toxicity and 11 patients stopped treatment due to adverse events (AEs). A total of 716 AEs were reported, of which 626 (88%) were Grade 1/2 and 27 (77%) patients had at least one AE Grade ≥3. At PET4, CMR was 25·8% [95% confidence interval (CI) 13·7-42.2%] and objective response rate 83·9% (95% CI 63·7-90·8%). Median PFS was 7·3 months (95% CI 5·2-9·0), and OS 19·5 months. Our results suggest that BV monotherapy is tolerable but suboptimal in the front-line therapy of elderly or comorbid patients with cHL. Combining BV with other agents may be more effective. Trial Registration: Clinicaltrials.gov identifier: NCT02567851.
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Affiliation(s)
- Adam Gibb
- National Institute for Health Research (NIHR) Manchester Clinical Research Facility, The Christie NHS Foundation Trust, Manchester, UK
| | - Sarah J Pirrie
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Kim Linton
- National Institute for Health Research (NIHR) Manchester Clinical Research Facility, The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Victoria Warbey
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK
| | - Kathryn Paterson
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Andrew J Davies
- Cancer Research UK Centre, Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Graham P Collins
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford, UK
| | | | - Pamela McKay
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | | | - Eszter Nagy
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Rachel Reed
- Stoller Biomarker Discovery Centre, University of Manchester, Manchester, UK
| | | | - Sally Barrington
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK
| | - John Radford
- National Institute for Health Research (NIHR) Manchester Clinical Research Facility, The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
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Allen PB, Ayers A, Behera M, Evens AM, Flowers C. A systematic review of therapeutic regimens for older patients with newly diagnosed Hodgkin lymphoma. Leuk Lymphoma 2020; 61:1555-1564. [PMID: 32102579 DOI: 10.1080/10428194.2020.1731497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Classical Hodgkin lymphoma (cHL) in older adults is associated with inferior outcomes and increased toxicity compared to younger patients. Novel therapies like brentuximab vedotin (BV) have yielded promising results, yet their optimal use in older cHL remains unclear. We performed a systematic review to assess outcomes and toxicity associated with frontline regimens in older cHL. We screened 196 references involving chemotherapy without BV and 662 references containing BV and included 9 studies (12 arms) without BV and 6 studies (7 arms) with BV. Progression-free survival (PFS) ranged from 47 to 84% at 2 years in BV-containing arms and 42-79% at 5 years in non-BV containing trials. Pulmonary toxicity was more common in arms receiving >2 cycles of bleomycin, whereas peripheral neuropathy was associated with cumulative BV dose. This review summarizes available treatment outcomes in newly diagnosed older cHL patients and may aid clinicians in decision-making regarding available frontline approaches.Key PointsThis systematic review suggests that >2 cycles of bleomycin is associated with excess pulmonary toxicity in cHL patients older than 60 years of age.Peripheral neuropathy was more frequent in patients receiving BV-containing regimens and was associated with cumulative BV dose.BV-containing regimens are associated with high response rates in advanced-stage patients, but follow-up is limited.
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Affiliation(s)
- Pamela B Allen
- Department of Hematology and Oncology, Winship Cancer Institution of Emory University, Atlanta, GA, USA
| | - Amy Ayers
- Department of Hematology and Oncology, Winship Cancer Institution of Emory University, Atlanta, GA, USA
| | - Madhusmita Behera
- Department of Research Informatics, Winship Cancer Institution of Emory University, Atlanta, GA, USA
| | - Andrew M Evens
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Vassilakopoulos TP, Chatzidimitriou C, Asimakopoulos JV, Arapaki M, Tzoras E, Angelopoulou MK, Konstantopoulos K. Immunotherapy in Hodgkin Lymphoma: Present Status and Future Strategies. Cancers (Basel) 2019; 11:E1071. [PMID: 31362369 PMCID: PMC6721364 DOI: 10.3390/cancers11081071] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/17/2022] Open
Abstract
Although classical Hodgkin lymphoma (cHL) is usually curable, 20-30% of the patients experience treatment failure and most of them are typically treated with salvage chemotherapy and autologous stem cell transplantation (autoSCT). However, 45-55% of that subset further relapse or progress despite intensive treatment. At the advanced stage of the disease course, recently developed immunotherapeutic approaches have provided very promising results with prolonged remissions or disease stabilization in many patients. Brentuximab vedotin (BV) has been approved for patients with relapsed/refractory cHL (rr-cHL) who have failed autoSCT, as a consolidation after autoSCT in high-risk patients, as well as for patients who are ineligible for autoSCT or multiagent chemotherapy who have failed ≥ two treatment lines. However, except of the consolidation setting, 90-95% of the patients will progress and require further treatment. In this clinical setting, immune checkpoint inhibitors (CPIs) have produced impressive results. Both nivolumab and pembrolizumab have been approved for rr-cHL after autoSCT and BV failure, while pembrolizumab has also been licensed for transplant ineligible patients after BV failure. Other CPIs, sintilimab and tislelizumab, have been successfully tested in China, albeit in less heavily pretreated populations. Recent data suggest that the efficacy of CPIs may be augmented by hypomethylating agents, such as decitabine. As a result of their success in heavily pretreated disease, BV and CPIs are moving to earlier lines of treatment. BV was recently licensed by the FDA for the first-line treatment of stage III/IV Hodgkin lymphoma (HL) in combination with AVD (only stage IV according to the European Medicines Agency (EMA)). CPIs are currently being evaluated in combination with AVD in phase II trials of first-line treatment. The impact of BV and CPIs was also investigated in the setting of second-line salvage therapy. Finally, combinations of targeted therapies are under evaluation. Based on these exciting results, it appears reasonable to predict that an improvement in survival and a potential increase in the cure rates of cHL will soon become evident.
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Affiliation(s)
- Theodoros P Vassilakopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece.
| | - Chrysovalantou Chatzidimitriou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece
| | - John V Asimakopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece
| | - Maria Arapaki
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece
| | - Evangelos Tzoras
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece
| | - Maria K Angelopoulou
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece
| | - Kostas Konstantopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece
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4
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Tomassetti S, Herrera AF. Update on the role of brentuximab vedotin in classical Hodgkin lymphoma. Ther Adv Hematol 2018; 9:261-272. [PMID: 30210755 DOI: 10.1177/2040620718786833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/12/2018] [Indexed: 12/11/2022] Open
Abstract
Brentuximab vedotin (BV) is an effective and well-tolerated treatment for patients with classical Hodgkin lymphoma (HL). It was initially approved by the US FDA for the treatment of HL after failure of autologous hematopoietic stem cell transplant (autoHSCT) or after failure of at least two prior lines of multiagent chemotherapy in patients who are not transplant candidates, and then subsequently, as consolidation therapy after autoHSCT in patients who are at high risk for relapse. However, the role of BV in the treatment of HL is evolving. BV has shown promising efficacy as a salvage treatment in the second-line setting prior to autoHSCT. Most recently, the ECHELON-1 trial demonstrated that BV combined with AVD for the treatment of newly diagnosed advanced stage HL improved modified progression-free survival (mPFS) compared with standard ABVD. Based on these results, the US FDA has approved BV as part of the initial treatment of advanced stage HL. With the approval of BV as front-line therapy, depending on how widely the use of BV plus AVD is adopted, the role of BV in the treatment of patients with relapsed or refractory (rel/ref) HL may need to be redefined. BV retreatment can be effective, and studies of rational BV-based combination regimens may help to improve response rates and overcome BV resistance. Furthermore, BV has been demonstrated to be effective in the initial treatment of elderly or unfit patients, and ongoing studies are evaluating the addition of BV to initial chemotherapy in patients with early stage HL.
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Affiliation(s)
- Sarah Tomassetti
- Division of Hematology and Medical Oncology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Alex F Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, 1500 E Duarte Road, Duarte, CA 91010, USA
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Cole PD, McCarten KM, Pei Q, Spira M, Metzger ML, Drachtman RA, Horton TM, Bush R, Blaney SM, Weigel BJ, Kelly KM. Brentuximab vedotin with gemcitabine for paediatric and young adult patients with relapsed or refractory Hodgkin's lymphoma (AHOD1221): a Children's Oncology Group, multicentre single-arm, phase 1-2 trial. Lancet Oncol 2018; 19:1229-1238. [PMID: 30122620 PMCID: PMC6487196 DOI: 10.1016/s1470-2045(18)30426-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with primary refractory Hodgkin's lymphoma or early relapse have a poor prognosis. Although many salvage regimens have been developed, there is no standard of care. Brentuximab vedotin and gemcitabine have been shown to be active in patients with relapsed or refractory Hodgkin's lymphoma when used as monotherapy, and each has been successfully used in combination with other agents. Preclinical data suggest that brentuximab vedotin can sensitise lymphoma cells to gemcitabine, supporting the use of the combination. We aimed to define the safety and efficacy of brentuximab vedotin with gemcitabine in children and young adults with primary refractory Hodgkin's lymphoma or early relapse. METHODS In this Children's Oncology Group, multicentre, single-arm, phase 1-2 trial, we recruited patients with Hodgkin's lymphoma from hospitals across the USA and Canada. Eligible patients were aged younger than 30 years, had no previous brentuximab vedotin exposure, and had primary refractory disease or relapse of less than 1 year from completion of initial treatment. Each 21-day cycle consisted of 1000 mg/m2 intravenous gemcitabine on days 1 and 8 and intravenous brentuximab vedotin on day 1 at 1·4 mg/kg or 1·8 mg/kg. The primary objectives were to establish the recommended phase 2 dose of brentuximab vedotin in this combination, the safety of the combination, and the proportion of patients who achieved a complete response among those treated at the recommended phase 2 level, within four cycles of treatment. This trial is registered with ClinicalTrials.gov, number NCT01780662. FINDINGS Between Feb 5, 2013, and Aug 19, 2016, 46 patients were enrolled, including one who was found to be ineligible, in the two phases of the study. The recommended phase 2 dose of brentuximab vedotin was 1·8 mg/kg in combination with gemcitabine 1000 mg/m2. 24 (57%) of 42 evaluable patients (95% CI 41-72) given this dose level had a complete response within the first four cycles of treatment. Four (31%) of 13 patients with a partial response or stable disease had all target lesions with Deauville scores of 3 or less after cycle 4. By modern response criteria, these were also complete responses (total number with complete response 28 [67%] of 42 [95% CI 51-80]). The most common grade 3-4 adverse events in all 42 participants treated at the recommended phase 2 dose were neutropenia (15 [36%]), rash (15 [36%]), transaminitis (9 [21%]), and pruritus (4 [10%]). There were no treatment-related deaths. INTERPRETATION Brentuximab vedotin with gemcitabine is a safe combination treatment with a tolerable toxicity profile for patients with primary refractory Hodgkin's lymphoma or high-risk relapse. The preliminary activity of this combination shown in this trial warrants further investigation in randomised controlled trials. FUNDING National Institutes of Health and the St. Baldrick's Foundation.
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Affiliation(s)
- Peter D Cole
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA; Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | | | - Qinglin Pei
- Department of Biostatistics, University of Florida, Gainesville, FL, USA; Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | | | | | - Richard A Drachtman
- Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Terzah M Horton
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Rizvan Bush
- Children's Oncology Group, Statistics and Data Center, Monrovia, CA, USA
| | - Susan M Blaney
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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6
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Viviani S, Guidetti A. Efficacy of antibody-drug conjugate brentuximab vedotin in treating Hodgkin's lymphoma. Expert Opin Biol Ther 2018; 18:841-849. [PMID: 29999431 DOI: 10.1080/14712598.2018.1499723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hodgkin's lymphoma (HL) patients refractory to first-line therapy or relapsed after autologous stem cell transplantation have a dismal prognosis, and their treatment represents an unmet medical need. Brentuximab vedotin (BV) is a second-generation antibody-drug conjugate (ADC) constituted by an anti-CD30 antibody linked to the cytotoxic drug monomethyl auristatin E. The first administration of BV in relapsed and refractory HL patients in a phase I study showed an impressive antilymphoma activity and prompted development of the drug. Areas covered: This article reviews pharmaceutical characteristics of ADC and specific chemical features of BV related to mechanism of action and mechanism of resistance. Administration recommendation and main toxicities will also be described. Antilymphoma efficacy of BV alone and in combination with conventional chemotherapy and new compounds in different settings of HL patients will be examined. Expert opinion: BV seems to be an effective and safe option for treatment of HL patients. BV alone or in association with chemotherapy as salvage regimen or as bridge to autologous or allogeneic transplant showed encouraging results. Exploration of new drug combinations and new settings of treatment is warranted in order to reduce long-term therapy-related toxicities and ameliorate survival of poor prognosis patients.
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Affiliation(s)
- Simonetta Viviani
- a Division of Hematology and BMT Unit, Department of Medical Oncology and Hematology , Fondazione IRCCS Istituto Nazionale Tumori , Milano , Italy
| | - Anna Guidetti
- a Division of Hematology and BMT Unit, Department of Medical Oncology and Hematology , Fondazione IRCCS Istituto Nazionale Tumori , Milano , Italy.,b Department of Oncology and Hemato-Oncology , University of Milano , Milano , Italy
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7
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Wróbel T, Biecek P, Rybka J, Szulgo A, Sorbotten N, Giza A, Tyczyńska A, Nowara E, Badora-Rybicka A, Adamowicz K, Kulikowski W, Kroll-Balcerzak R, Balcerzak A, Spychałowicz W, Kalinka-Warzocha E, Kumiega B, Drozd-Sokołowska J, Subocz E, Sałek A, Machaczka M, Hołojda J, Pogrzeba J, Dobrzyńska O, Chmielowska E, Jurczak W, Knopińska-Posłuszny W, Leśniewski-Kmak K, Maciej Zaucha J. Hodgkin lymphoma of the elderly patients: a retrospective multicenter analysis from the Polish Lymphoma Research Group. Leuk Lymphoma 2018; 60:341-348. [DOI: 10.1080/10428194.2018.1482539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Tomasz Wróbel
- Department of Hematology, Wroclaw Medical University, Wrocław, Poland
| | - Przemysław Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Justyna Rybka
- Department of Hematology, Wroclaw Medical University, Wrocław, Poland
| | - Anna Szulgo
- Department of Oncology, Center of Oncology of Professor Franciszek Łukaszczyk, Bydgoszcz, Poland
| | - Natalia Sorbotten
- Department of Oncology, Center of Oncology of Professor Franciszek Łukaszczyk, Bydgoszcz, Poland
| | - Agnieszka Giza
- Department of Hematology, Collegium Medicum of the Jagiellonian University, Kraków, Poland
| | - Agata Tyczyńska
- Department of Oncology and Radiotherapy, Gdynia Oncology Center, Gdynia, Poland
| | - Elżbieta Nowara
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | | | | | | | | | - Andrzej Balcerzak
- Department of Hematology, University of Medical Sciences, Poznan, Poland
| | - Wojciech Spychałowicz
- Internal Medicine and Oncology Clinic, Silesian Medical University, Katowice, Poland
| | | | - Beata Kumiega
- Department of Hematology, Brzozow Oncology Center, Brzozów, Poland
| | - Joanna Drozd-Sokołowska
- Department of Haematology, Oncology and Internal Medicine, The Medical University of Warsaw, Warsaw, Poland
| | - Edyta Subocz
- Department of Haematology, Military Institute of Medicine in Warsaw, Warsaw, Poland
| | - Agata Sałek
- Department of Hematology KSW No.1 and Medical Faculty, University of Rzeszow, Rzeszow, Poland
| | - Maciej Machaczka
- Department of Hematology KSW No.1 and Medical Faculty, University of Rzeszow, Rzeszow, Poland
| | - Jadwiga Hołojda
- Department of Hematology, Provincial Specialist Hospital, Legnica, Poland
| | - Joanna Pogrzeba
- Department of Hematology, Provincial Specialist Hospital, Opole, Poland
| | - Olga Dobrzyńska
- Department of Hematology, Wroclaw Medical University, Wrocław, Poland
| | - Ewa Chmielowska
- Department of Oncology, Center of Oncology of Professor Franciszek Łukaszczyk, Bydgoszcz, Poland
| | - Wojciech Jurczak
- Department of Hematology, Collegium Medicum of the Jagiellonian University, Kraków, Poland
| | | | - Krzysztof Leśniewski-Kmak
- Department of Oncology and Radiotherapy, Gdynia Oncology Center, Gdynia, Poland
- Department of Oncological Propaedeutics, Medical University of Gdańsk, Gdańsk, Poland
| | - Jan Maciej Zaucha
- Department of Oncology and Radiotherapy, Gdynia Oncology Center, Gdynia, Poland
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
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8
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Carella AM, Corradini P, Mussetti A, Ricardi U, Vitolo U, Viviani S. Treatment of classical Hodgkin lymphoma in the era of brentuximab vedotin and immune checkpoint inhibitors. Ann Hematol 2018; 97:1301-1315. [PMID: 29802458 DOI: 10.1007/s00277-018-3366-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/06/2018] [Indexed: 12/19/2022]
Abstract
The majority of Hodgkin lymphoma patients are now cured with conventional first-line therapy; however, 10-15% of early-stage disease and less than 30% of advanced-stage patients are refractory(rare) or relapsed. Salvage second-line therapy combined with high-dose therapy and autologous stem-cell transplantation can cure 40-50% of patients. Recently novel agents (Brentuximab Vedotin and Immune Checkpoint inhibitors) have demonstrated evidence of therapeutic activity and are potential bridge to an allogeneic stem-cell transplantation. The review is aimed to present not only salvage strategies; indeed, the paper contains paragraphs about therapy and new treatment options at diagnosis.
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Affiliation(s)
- A M Carella
- Division of Hematology and BMT Unit, Ospedale Policlinico San Martino, Genoa, Italy.
| | - P Corradini
- Division of Hematology and BMT Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Mussetti
- Division of Hematology and BMT Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - U Ricardi
- Department of Oncology, Università di Torino, Turin, Italy
| | - U Vitolo
- AOU Citta' della Salute e della Scienza, Turin, Italy
| | - S Viviani
- Division of Hematology and BMT Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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9
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Watkins MP, Fanale MA, Bartlett NL. SOHO State of the Art Updates and Next Questions: Hodgkin Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:81-90. [PMID: 29366607 DOI: 10.1016/j.clml.2018.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 01/02/2018] [Indexed: 01/05/2023]
Abstract
Until recently, advances in classic Hodgkin lymphoma (HL) treatment primarily consisted of minor modifications of highly effective decades-old chemotherapy and radiation approaches. In early-stage disease, excellent outcomes have been reported with fewer cycles of chemotherapy, lower doses, smaller radiation fields and in some circumstances, radiation elimination. In advanced-stage disease, maintaining the dose intensity of standard chemotherapy regimens has resulted in modest improvements in outcomes. During the past decade, the use of early interim positron emission tomography (PET) scans to escalate or de-escalate treatment has been the subject of intense investigation with the goal of maximizing efficacy and minimizing toxicity. Important updates from recent PET-directed trials include; elimination of bleomycin in patients with advanced-stage HL and negative interim PET findings, the benefit of therapy escalation in patients with unfavorable early-stage HL and positive interim PET findings, and the minimal benefit of consolidative radiotherapy in patients with unfavorable early-stage HL and negative interim PET findings. A more nuanced approach to consolidative radiotherapy is required for patients with favorable early-stage disease based on age, disease sites, secondary cancer risk, and cardiovascular disease. Brentuximab vedotin and nivolumab/pembrolizumab have provided promising new options with surprisingly high response rates and modest toxicity for patients with relapsed HL whose disease does not respond to standard treatments. Incorporating these agents into earlier therapy is an area of active investigation for all stages of HL. Although the overall prognosis for HL patients has seen incremental improvement, efforts to optimize treatment with more effective and less toxic approaches continue.
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10
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Bartlett NL. Emerging role of novel therapies in Hodgkin lymphoma: proceed with caution. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:317-323. [PMID: 29222273 PMCID: PMC6142541 DOI: 10.1182/asheducation-2017.1.317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Based on very high response rates in the relapsed and refractory setting, brentuximab vedotin and the programmed cell death protein 1 (PD-1) inhibitors, nivolumab and pembrolizumab, have quickly been incorporated into clinical trials for first- and second-line therapy of Hodgkin lymphoma. Preliminary data show that brentuximab vedotin alone is not adequate therapy for newly diagnosed Hodgkin lymphoma in older patients, but modestly decreases the risk of relapse when combined with adriamycin, vinblastine, and dacarbazine in patients with previously untreated advanced-stage disease. In second-line therapy, combining brentuximab vedotin with conventional chemotherapy or with PD-1 inhibitors as pretransplant salvage is associated with high overall and complete response rates, although further follow up is needed to assess whether posttransplant outcomes are improved. Although these new drugs are well tolerated when given as single agents, unexpected toxicities have been encountered with combination regimens, specifically severe pulmonary toxicity with the bleomycin and brentuximab vedotin combination and frequent infusion-related reactions. There is concern with the use of PD-1 inhibitors as first-line therapy due to the theoretical potential for more frequent or severe immune-mediated toxicities in patients who have not received prior chemotherapy. Aside from these concerns, these new agents have the potential to improve outcomes for patients even further, bringing us closer to eradicating recurrent Hodgkin lymphoma.
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Affiliation(s)
- Nancy L Bartlett
- Washington University School of Medicine, Siteman Cancer Center, St. Louis, MO
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