Nivolumab and Doxorubicin, Vinblastine, and Dacarbazine in Early-Stage Unfavorable Hodgkin Lymphoma: Final Analysis of the Randomized German Hodgkin Study Group Phase II NIVAHL Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.In the investigator-sponsored randomized phase II NIVAHL trial for early-stage unfavorable classical Hodgkin lymphoma (HL), two schedules of four cycles of nivolumab, doxorubicin, vinblastine, and dacarbazine followed by 30 Gy involved-site radiotherapy resulted in high complete remission rates and an unprecedented 1-year progression-free survival in 109 patients. In this article, we report the preplanned final analysis conducted three years after the registration of the last patient including long-term safety results. No survival events were observed since the primary analysis, and after a median follow-up (FU) of 41 months, the overall survival was 100% in both treatment groups. The progression-free survival was 98% and 100% in the sequential and concomitant nivolumab, doxorubicin, vinblastine, and dacarbazine treatment groups, respectively. At last FU, the mean forced expiratory pressure in one second was 95.5% (standard deviation 12.7%), the mean diffusion capacity for carbon monoxide adjusted for hemoglobin was 82.8% (standard deviation 15.4%), and the left ventricular ejection fraction was in the normal range in 95% of patients. Hypothyroidism requiring long-term medication occurred in 15% of patients, who were nearly exclusively female (87%). No second primary malignancies occurred, and no patient required corticosteroid treatment at last FU. Patient-reported normalized global quality-of-life score measured by European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 improved over time. This preplanned FU analysis of the largest anti-programmed death protein 1 HL first-line trial to date confirms the outstanding efficacy and relatively favorable safety profile of this therapeutic approach.

Efficacy of Nivolumab and AVD in Early-Stage Unfavorable Classic Hodgkin Lymphoma: The Randomized Phase 2 German Hodgkin Study Group NIVAHL Trial

Importance

In early-stage unfavorable classic Hodgkin lymphoma (cHL), conventional therapy induces high cure rates but also relevant acute and long-term toxic effects. Nivolumab is well tolerated and highly effective in relapsed/refractory cHL but has not been adequately studied in first-line treatment of early-stage cHL. The NIVAHL trial evaluated nivolumab in this setting with the aim to develop a highly effective yet tolerable systemic therapy to ultimately mitigate morbidity in patients who survive cHL.

Objective

To evaluate efficacy of 2 experimental nivolumab-based first-line treatment strategies in patients with early-stage unfavorable cHL.

Design, Setting, and Participants

This was an open-label, multicenter, phase 2 randomized clinical trial, open between April 2017 and October 2018. The trial took place at 35 trial centers across Germany, ranging from academic centers to private offices. Eligibility was defined by age 18 to 60 years, cHL confirmed by expert pathology review, early-stage unfavorable disease by German Hodgkin Study Group criteria (stage I to II with risk factor[s]), and absence of serious concomitant disease or organ dysfunction. Among 110 enrolled patients, 109 were eligible.

Interventions

Systemic therapy, per random assignment (1:1) to either concomitant treatment with 4 cycles of nivolumab and doxorubicin, vinblastine, and dacarbazine (N-AVD) or sequential treatment with 4 doses of nivolumab, 2 cycles of N-AVD, and 2 cycles of AVD at standard doses, followed by 30-Gy involved-site radiotherapy.

Main Outcomes and Measures

Complete remission (CR) rate after study treatment, aiming at excluding a CR rate of 80% or lower via a 2-sided 95% CI for each treatment group.

Results

Of 109 patients included in this study, 65 (59.6%) were women, and the median (range) age was 27 (18-60) years. At interim staging after 2 cycles of N-AVD or 4 doses of nivolumab monotherapy, 54 of 54 (100%) and 49 of 51 (96%) response-eligible patients, respectively, achieved an objective response, with CR in 47 (87%) and 26 (51%) patients, respectively. Among 101 patients eligible for primary end point analysis, 46 of 51 (90%; 95% CI, 79%-97%) patients receiving concomitant therapy and 47 of 50 (94%; 95% CI, 84%-99%) patients receiving sequential therapy achieved CR after study treatment. With a median follow-up of 13 months, 12-month progression-free survival was 100% for patients receiving concomitant treatment and 98% (95% CI, 95%-100%) for patients receiving sequential therapy.

Conclusions and Relevance

Both strategies combining nivolumab and AVD are feasible and resulted in high remission rates. Despite narrowly missing the efficacy benchmark in the concomitant group, the excellent 12-month progression-free survival and the unexpectedly high CR rate after 4 doses of nivolumab monotherapy warrant further evaluation of this approach in the first-line treatment of patients with early-stage cHL.

Trial Registration

ClinicalTrials.gov Identifier: NCT03004833.

Der Spinabschneideparameter für einige mittelschwere Kerne aus Neutronenreaktionen

In der Kernniveaudichte nach dem FERMI-Gas-Modell wird die Abhängigkeit der Dichte der Kernniveaus vom Drehimpuls des Kerns wesentlich durch den Spinabschneideparameter σ bestimmt. Dieser kann unter anderem aus den Winkelverteilungen der emittierten Teilchen und aus dem Verhältnis isomerer Wirkungsquerschnitte für Compoundkernreaktionen erhalten werden, die sich nach der statistischen Theorie der Kernreaktionen beschreiben lassen. Für einige Kernreaktionen schneller Neutronen wurden derartige Meßdaten ermittelt und daraus Spinabschneideparameter σ für die Kerne Ar37, Co58, Ni61, Ge75 und Se73 abgeleitet. Die Ergebnisse werden verglichen mit entsprechenden Angaben anderer Arbeiten für mittelschwere Kerne und mit den Voraussagen des FERMI-Gas-Modells.

Experimentelle Untersuchung und theoretische Betrachtung der (n, α)- und (n, nα)-Reaktionen in den Szintillationskristallen KJ (TI) und CsJ (TI) für Neutronenenergien von 12,1 bis 21,5 MeV

In der vorliegenden Arbeit wird über die Untersuchung der (η,α) - und (η,ηα)-Reaktionen berichtet, die von Neutronen mit Energien zwischen 12,1 und 21,5 MeV in den Szintillationskristallen KJ (T1) und CsJ (Tl) ausgelöst werden. Das angewandte Experimentierverfahren nutzt die Tatsache aus, daß mit Hilfe der genannten Kristalle eine Unterscheidung verschiedener einfallender Strahlungsarten erfolgen kann. Diese Möglichkeit wurde herangezogen, um die Energieverteilungen der α-Teilchen zu registrieren, die bei Beschuß der Kristalle mit Neutronen des angeführten Energiebereichs in den (η,α)- und (η,ηα) Reaktionen an den Elementen der Szintillatoren selbst emittiert werden. Zusätzlich erfolgte auch die Bestimmung der Wirkungsquerschnitte für diese Reaktionen als Funktion der Neutronenenergie.

Die Meßergebnisse wurden an Hand der statistischen Theorie der Kernreaktionen unter Verwendung verschiedener Niveaudichteansätze und Wirkungsquerschnitte für die Compoundkernbildung analysiert. Als Resultat ergibt sich, daß die (η,α)-Reaktion am Kalium als Verdampfungsprozeß gedeutet werden kann, während im Fall des Jods und Cäsiums neben den Verdampfungsanteilen wesentliche Beiträge aus direkten Wechselwirkungsprozessen auftreten. Von welcher Art diese direkten Prozesse möglicherweise sind, wird erörtert.

Über die Wirkungsquerschnitte einiger von 14 MeV-Neutronen in den Szintillationskristallen NaJ(Tl), KJ(TI), CsJ(TI) und Li6J(Eu) ausgelösten Kernreaktionen

Beim Studium von Reaktionen, die in den Detektorkristallen selbst ausgelöst werden, hat man den Vorteil der relativ hohen Nachweiswahrscheinlichkeit. Dabei kann man sowohl eine im Kristall durch die Beschießung mit Neutronen hervorgerufene Radioaktivität erfassen, als auch die Energieverteilung von Teilchenreaktionen ausmessen. Durch Aktivierung wurden bestimmt:

σnp(Ι127) =25±15 mb, relativ zu σn, 2n(Ι127) = 1,2 b,

onp(Na23) = 9 ± 4 mb; σnα(Na23) =29 ±9 mb,

σnα(Κ41) = 12± 5mb.

Zählt man die durch die Tritium-Neutronen ausgelösten Prozesse noch in Koinzidenz mit den α-Teilchen von D(T,α)n, so kann man auch absolute Wirkungsquerschnitte messen; allerdings nur die Gesamtwirkungsquerschnitte aller im Kristall nebeneinander auftretenden Reaktionen.

Die Methode der gleichzeitigen Bestimmung der Impulsanstiegszeiten gestattet dann aber auch die Unterscheidung von Impulsen, die von α-Teilchen, Protonen oder Elektronen herrühren. So wurden bestimmt:

σnp(Cs133 + J127) = 34 ± 5 mb,

σn, np(Cs133 + J127) = 6± 1 mb.

σnp(K39) = 354 ±54 mb,

σnα(Κ39) = 110 ±16 mb.

σn, np(K39) = 186 ±28 mb.

Aus den Protonenenergieverteilungen konnten mittels der Statistischen Theorie die Kerntemperaturen für die (n,p)- und die (n,np)-Prozesse ermittelt werden.

Clinical heterogeneity of 21-hydroxylase deficiency of sibs with identical 21-hydroxylase genes

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is a disorder with different clinical manifestations, that results from mutations in the P-450(c21) gene. Direct sequence analysis of P-450(c21) genes in a family demonstrates that patients with different clinical forms of congenital adrenal hyperplasia can have identical P-450(c21) genes, suggesting that other effects play a role in developing the different clinical forms.

[Oxacillin-induced granulocytopenia]

A girl at the age of nearly 13 years with a haemodynamic insignificant defect of the ventricular septum fell ill with a staphylococcal endocarditis of the aortic valve. After a high dosage therapy with oxacillin for some weeks occurred a leucocytopenia which was reversible after discontinuation of this therapy. Because we could find only few reports about this problem in the german literature, we will report about our patient and give a short survey of literature.

Determination of continuous neutron energy spectra for dosimetric purposes

The energy distribution of 3H(d, n)4He neutrons from a neutron therapy facility has been studied in different depths in a lucite phantom with two methods. Thin foils of 8 different target materials with well-known excitation functions and reaction thresholds between 1.8 and 12.6 MeV for the reactions to be observed have been activated. Secondly, recoil proton spectra have been measured with a small stilbene crystal. In both cases neutron energy spectra have been determined with unfolding methods. The two techniques are compared with respect to the application in neutron dosimetry and for monitoring purposes in neutron therapy.