YO11 - Case Report: A Challenging Case of Managing Relapsed And Refractory Hodgkin's Disease

Date 18 December 2016
Event ESMO Asia 2016 Congress
Session Poster lunch
Topics Lymphomas
Presenter Prashanth Hari Dass
Authors P. Hari Dass, M. Jameson, E. Epner
  • Medical Oncology, Waikato Hospital, 3240 - Hamilton/NZ


Case Summary

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.