Pembrolizumab Added to Ifosfamide, Carboplatin, and Etoposide Chemotherapy for Relapsed or Refractory Classic Hodgkin Lymphoma: A Multi-institutional Phase 2 Investigator-Initiated Nonrandomized Clinical Trial

Importance

To our knowledge, this is the first clinical trial designed to investigate concurrent treatment with a checkpoint inhibitor and conventional chemotherapy in relapsed or refractory classic Hodgkin lymphoma in patients destined for an autologous stem cell transplant.

Objective

To evaluate the complete response rate as assessed by 18F-fluorodeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) after salvage therapy for patients with relapsed or refractory classic Hodgkin lymphoma.

Design, Setting, and Participants

A single-group, phase 2, multi-institutional nonrandomized clinical trial to evaluate the addition of pembrolizumab to ifosfamide, carboplatin, and etoposide (ICE) chemotherapy was conducted from April 20, 2017, to October 29, 2020, at 5 US sites. The 42 patients were aged 18 years or older, with an Eastern Cooperative Oncology Group Performance Status Scale score of 0 or 1 and biopsy-proven relapsed or refractory classic Hodgkin lymphoma after 1 or 2 prior lines of chemotherapy. Patients were required to be appropriate candidates for transplant, with measurable lesions detected by FDG-PET/CT.

Interventions

Two cycles of pembrolizumab (200 mg intravenously on day 1) with ICE chemotherapy every 21 days, followed by stem cell mobilization and collection, and then 1 cycle of pembrolizumab monotherapy followed by FDG-PET/CT response assessment.

Main Outcomes and Measures

The primary end point was complete response rate detected by FDG-PET/CT, defined as a Deauville score of 3 or lower. Patients with a complete response proceeded to an autologous stem cell transplant. Secondary end points included progression-free survival, overall survival, stem cell mobilization, and neutrophil and platelet engraftment. Adverse events were monitored to assess safety.

Results

Forty-two patients were enrolled, with 37 evaluable for the primary end point. The median age was 34 years (range, 19-70 years), 25 patients were female (68%), 6 were African American (16%), and 26 were White (70%). The complete response rate for the 37 patients assessed by FDG-PET/CT imaging was 86.5% (95% CI, 71.2%-95.5%); the overall response rate was 97.3% (36 patients), with 10.8% partial responses (4 patients). New areas of FDG-PET positivity in 2 patients were biopsied, showing noncaseating granuloma in 1 case and a reactive lymph node in a second. Progression-free survival and overall survival 2-year estimates were 87.2% (32 patients; 95% CI, 77.3%-98.3%) and 95.1% (95% CI, 88.8%-100%), respectively. The addition of pembrolizumab to ICE chemotherapy did not negatively affect stem cell mobilization or collection or engraftment, similar to prior experience in this patient population and setting.

Conclusions and Relevance

Results suggest that the addition of pembrolizumab to ICE chemotherapy was well tolerated and highly effective in comparison with prior reports of chemotherapy-only regimens, supporting further investigation in patients with relapsed or refractory classic Hodgkin lymphoma eligible for an autologous stem cell transplant.

Trial Registration

ClinicalTrials.gov Identifier: NCT03077828.

Potential Significant Changes in Nuclear Regulatory Commission Policies Regarding Training and Experience Requirements for the Use of Radiopharmaceuticals

The Code of Federal Regulations is a single-source repository of all rules and regulations promulgated by federal departments and agencies. In Title 10, Chapter 1, Part 35, Subpart D, §§35.100 to 35.290 detail regulations for the use of unsealed by product material not requiring a written directive (ie, diagnostic radiopharmaceuticals), and in Subpart E, §§35.300 to 35.396 detail regulations for the use of unsealed by product material requiring a written directive (ie, therapeutic radionuclides). Currently proposed changes for both Subparts D and E could have profound effects on patient care, public safety, and the practice of nuclear medicine, diagnostic radiology, and radiation oncology. This article details those proposed changes and actions under way to prevent promulgation of proposals that could negatively affect patient care and public safety.

Training and Education Requirements for Authorized Users of Therapeutic Radiopharmaceuticals: Changes Under Consideration for 10CFR35.390 and Their Potential Impact

The US Nuclear Regulatory Commission (NRC) and 38 Agreement States have the regulatory authority to promulgate and enforce regulations related to the use of radioisotopes for medical purposes. Elements of these regulations include training and experience (T&E) requirements for individuals authorized to use the agents. These regulations are specified in 10CFR35.390. At this time, the NRC is considering significant revisions to the T&E requirements. This article describes current regulations and concerns related to the proposed changes and details the ACR organizational response.

Position paper on the development of a middle level provider in nuclear medicine: the nuclear medicine practitioner

The development of an educational program and credentialing structure to support and recognize an advanced level of the practice of nuclear medicine technology is now underway. This work parallels the efforts in many, if not most, health care disciplines as they seek to achieve the twin goals of developing enhanced career paths and providing the best possible patient care in an environment where science and technology can run roughshod over concepts taught in the classroom a mere decade ago. Education is key to both goals. A master's level degree in nuclear medicine technology, coupled with an advanced practice credential recognizing both the educational achievement and a level of clinical expertise, will give nuclear medicine practitioners the knowledge and the right to practice their profession at a high level of autonomy, leading to more efficient and higher quality health care services. To that end the following position paper was prepared by members of the Advance Practice Task Force of the SNMTS and presented to the SNMTS Executive Council and the SNM Board of Directors. In June 2005, the executive council and the board of directors approved a resolution supporting the establishment of a middle level provider in nuclear medicine known as the nuclear medicine practitioner.

Infiltrator Angioplasty Balloon Catheter: a device for combined angioplasty and intramural site-specific treatment

OBJECTIVES

We describe a new angioplasty device (Infiltrator Angioplasty Balloon Catheter; IABC) with intramural drug delivery capability. The conventional balloon part of the device, when inflated, dilates the vessel or has three rows of longitudinally mounted infiltrator nipples to penetrate the tunica media. Through an independent infiltrator port and nipples, drugs can be infiltrated directly into the vessel wall.

METHODS

The device was tested in 117 normal coronary arteries of 58 farm pigs.

RESULTS

(1) The infiltration procedure does not damage the vessel angiographically or histologically. At the infiltration site, the endothelial layer and the internal elastic lamina has a controlled interruption, and the infiltrated fluid is distributed among the medial layers, causing a mild focal edema and medial thickening (1.8 times on average). (2) Rhodamine tracer is circularly and evenly distributed through the whole width of the vessel wall within 10 min after infiltration. (3) Two weeks after the infiltration procedure, the medial layer reveals mild local thickening and remodelling without luminal narrowing. (4) Of the intramurally infiltrated Tcm99-labeled surfurcolloid, 83.8% is detectable at 5 min after the delivery procedure by gamma camera. (5) The IABC, if oversized, is able to achieve angiographic dilatation in normal pig coronary arteries, causing histologic damage similar to or less than that induced by conventional balloon dilatation.

CONCLUSIONS

The IABC can deliver fluid-phase substances directly into the vessel wall with microliter accuracy and with 90% efficiency without significant acute and subacute damage to the vessel wall. It is also suitable for combined dilatation and local drug delivery.

The effect of fine-needle aspiration biopsy on the thyroid scan

Fine-needle aspiration biopsy (FNAB) is the most sensitive and specific procedure in diagnosing benign from malignant thyroid nodular disease. The effects of a FNAB on the thyroid scan, however, have never been studied. This assumes importance because a hot nodule on scan has been advocated as useful to differentiate certain benign from malignant follicular neoplasms. Thyroid scans were performed before and after FNAB on 11 patients with nodular thyroid disease and an area of normal or increased uptake either in the nodule or in a contralateral enlarged lobe to determine if the biopsy changed the pattern of isotope uptake. For this study, biopsies were done in the area of normal or increased uptake. In two patients, there was a reduction in isotope concentration in three nodules after FNAB, whereas no change was demonstrable in nine other patients. Review of the literature revealed a number of prior reports of hemorrhage, necrosis, or infarction of thyroid nodules after FNAB. Based on these data and the demonstration of a change in scan pattern in a patient following FNAB, it is concluded that FNAB may decrease the isotope uptake in thyroid nodules; therefore, the concept of clinical judgments being based on the scan pattern after FNAB should be reevaluated.

Errors in the determination of left ventricular functional parameters

Gated blood-pool scans of the left ventricle are routinely employed for determination of the left ventricular ejection fraction. Recently, attempts have been made to evaluate other left ventricular functional parameters. These values include peak emptying rate (PER), time to peak emptying rate (TPER), peak filling rate (PFR), and time to peak filling rate (TPFR). In studying these parameters clinically, we identified many software errors and assumptions that impact on these values. These errors may also affect the determination of left ventricular ejection fraction (EF). We conclude that before any serious investigation of left ventricular functional parameters is undertaken, a detailed evaluation and standardization of the acquisition and edge detection algorithms must be performed.

Intracranial tumors: unexpected uptake of I-123 HIPDM

I-123 HIPDM is a brain imaging agent thought to reflect cerebral cortical perfusion. Increased uptake of I-123 HIPDM occurred unexpectedly in two cases of intracranial tumors.

Ventilation-perfusion scintigraphy in suspected pulmonary embolism: correlation with pulmonary angiography and refinement of criteria for interpretation

Retrospective analysis of 139 ventilation-perfusion (V/Q) lung scans obtained for suspected pulmonary embolism (PE) was undertaken, using the Biello criteria for interpretation. All scans were correlated with chest radiographs obtained within 24 hours and with pulmonary angiograms obtained within 72 hours of the V/Q study. The prevalence of PE in the high-, intermediate-, and low-probability groups was 89.5%, 49.3%, and 3.6%, respectively. Using minor modifications of these criteria, V/Q scans interpreted as high or low probability had a sensitivity of 97.1%, specificity of 94.3%, and accuracy of 95.7%. Perfusion defects corresponding to radiographic abnormalities that were present for at least 10 days were less likely to be associated with PE. Separate analysis of 27 perfusion-only lung scans that met all other criteria for inclusion in the study confirmed the nonspecificity of perfusion-only lung imaging and indicated the need for ventilation imaging with Tc-99m-DTPA aerosol or Kr-81m gas for portable studies.

Radionuclide cerebral imaging for confirmation of brain death in children: the significance of dural sinus activity

Radionuclide cerebral imaging revealed no cortical flow, but recorded persistent dural sinus activity in 14 of 55 clinically brain dead children. Of these 14 children, 13 had isoelectric electroencephalograms. Postmortem liquefactive necrosis was present in 7 cases. Although studies that demonstrated the absence of flow were confirmatory of brain death, dural sinus radioactivity in the delayed static images persisted in the presence of brain death.

The ultrasonographic characterization of tendons

Ultrasonography has not been utilized in the diagnosis of musculoskeletal disorders. However, the superficial location of tendons and ligaments lend themselves to evaluation by this modality. The ultrasonographic characteristics of the normal Achilles tendon are described in both the rabbit and man. The characteristic ultrasonographic findings after injury to the Achilles tendon are also determined. This imaging technique provides a sharp definition of the tendon and surrounding structures and easily demonstrates abnormalities. The superficially located quadriceps tendon is also well visualized by ultrasound and representative examples are shown. Ultrasound should be considered as another useful method for evaluation of these superficial musculoskeletal structures.