YO11 - Case Report: A Challenging Case of Managing Relapsed And Refractory Hodgkin's Disease
|Date||18 December 2016|
|Event||ESMO Asia 2016 Congress|
|Presenter||Prashanth Hari Dass|
P. Hari Dass, M. Jameson, E. Epner
A 19 year old previously well lady presented with 4 months history of enlarging cervical lymphadenopathy, night sweats & weight loss. She was HIV negative. CT scan showed a large anterior mediastinal mass & bilateral supraclavicular lymphadenopathy (Image 1). Histology showed grade 2 nodular sclerosing Hodgkin lymphoma (syncitial variant). Reed-Sternberg cells stained positively to CD30, Fascin, CD15, EBER & CD20(focally). No PAX-5 expression was present on immunohistochemistry. Disease staging was unfavourable stage IIB nodular sclerosing Hodgkin lymphoma; International Prognostic Score of 0.
She received 6 cycles of ABVD chemotherapy (doxorubicin, vinblastine, dacarbazine & bleomycin) with filgrastim. PET-CT scan after 2 cycles of chemotherapy showed complete metabolic response (Image 2). She then received involved nodal radiation, 30.6Gy in 17 fractions.
34 months later, she presented with right chest wall pain & nocturnal wheeze. Relapsed disease was confirmed on CT (Image 3) & biopsy. Immunophenotype was identical to the primary tumour except for absence of EBER staining. She received 3 cycles of IGEV (ifosfamide, gemcitabine & vinorelbine) chemotherapy followed by successful harvest of peripheral blood haemopoietic stem cells. PET-CT scan unfortunately showed disease progression (Image 4).
1 cycle of ESHAP chemotherapy (etoposide, methylprednisolone, cytarabine & cisplatin) was given while awaiting funding for brentuximab vedontin with no response (Image 5). She then received two cycles of brentuximab (1.8mg/kg). PET-CT scan showed stable pulmonary mass with improved residual moderate FDG uptake. In view of refractory disease, cycle 3 brentuximab was administered with intravenous cladribine 5mg/m2 on Day 1 & sodium valproate 500mg orally three times per day, which was well tolerated. Chest x-ray after this cycle showed dramatic reduction of the hilar mass from 11cm to 6.5cm (Image 6). This was followed by high dose BEAM chemotherapy & autologous peripheral blood stem cell transplant. CT 3 months post-autograft showed resolution of past lymphadenopathy, minor residual lung consolidation & pleural thickening (Image 7). Chest x-ray 8 months post autograft was unremarkable.