ESMO Preceptorship Programme

Role of Immunotherapy in Refractory Hodgkins

Lymphoma

Margaret Therese B. Bendebel, MD

University of Santo Tomas Hospital, MD

Immuno - Onncology– Singapore– 20-21 November 2019

ESMO PRECEPTORSHIP PROGRAMME

DISCLOSURE OF INTEREST

None

ESMO PRECEPTORSHIP PROGRAMME

Clinical Profile

F.G.

69 year-old

Female

Retired teacher

(+) Family history: lung and liver carcinomas

cc: left neck mass

Course of Illness

(+) painless left neck mass

(+) bothersome pruritus

(+) drenching night sweats

(+) significant weight loss

PPE: palpable cervical lymphadenopathies

Excision biopsy, left neck mass: Hodgkin Lymphoma; (+) CD30, PAX-5; (-) CD15

Bone marrow aspiration biopsy: atypical lymphoid proliferation, consider Nodular Sclerosing type of Hodgkin Lymphoma

CT scan w/ IV contrast of Neck, Chest and Whole Abdomen: diffuse lymphomatous involvement – left supraclavicular lymph nodes

largest measuring 1.4 x 1.2 cm – Right lobe of thyroid gland

enlarged extending to thoracic cavity

– Sclerotic changes C2 and C7 – right pulmonary calcified and non-

calcified nodules with right peribronchial calcified lymph nodes

– multiple compressive lymphomatous infiltrations in the retroperitoneum

A> Hodgkin Lymphoma Stage IV-BP> ABVD x 12 doses

ESMO PRECEPTORSHIP PROGRAMME

Course of Illness

Four months after ABVD: – progression of left cervical lymphadenopathy– worsening pruritus

PPE: (+) multiple palpable lymphadenopathies at the left cervical and supraclavicular areas, both axillary and inguinal areas (all approximately 2-3 cm. in size, left more than the right); (-) hepatosplenomegaly

Whole body scintigraphy: recurrent active disease

Excision biopsy, left inguinal lymph node: Classical Hodgkin Lymphoma-Nodular Sclerosis Nuclear Grade 2, : (+) CD30, PAX-5, CD 15 (-)

v

Left cervical node SUV 3.5

Left axillary node SUV up to 7.3

Mesenteric and paraaortic SUV up to 4.9

Peripancreatic SUV up to 4.8

Gastrohepatic SUV up to 4.7

Bilateral iliac nodes SUV up to 8.7 (L), 5.7 (R)

Bilateral inguinal nodes SUV up to 11.9 (L), 9.3 (R)

Left gluteal node SUV 9.1

Left iliac soft tissue SUV 14.3

Posterior left iliac bone SUV 6.5

ESMO PRECEPTORSHIP PROGRAMME

Conclusion:Hypermetabolic lymph nodes in the left cervical, left axillary, mesenteric root,

paraaortic, gastrohepatic, peripancreatic, left iliac, both inguinal, and left gluteal regions are consistent with malignant lymphadenopathies.

Hypermetabolic left iliac bone and soft tissue lesions are consistent with metastases. Irregular metabolic activity in the vertebrae with mixed lytic and sclerotic changes is also likely due to metastases.

P> ICE x 4 cycles

Course of Illness

Eight months after ICE: Progressive Disease

P> Brentuximab Vedotin1.8 mg/kg

PET CT scan: increase in hypermetabolic lesions in the nodes in neck, chest, abdomen/pelvis and skeletal structures

ESMO PRECEPTORSHIP PROGRAMME

Course of Illness

Re-evaluation CT scan after 3 cycles of BV: – Same size of left paratracheal mass inseparable from

the thyroid gland, resolution of lymphadenopathies in

the mediastinum

Post-treatment contrast-enhanced CT scan 6

weeks after 8 cycles of BV: – No significant change in the size of the

heterogeneously enhancing masses previously noted,

with left iliac bone destructive mass

Course of Illness Seven months after BV:– Progressive weight loss, left

hip pain with recurrent infections

Excision biopsy, left axillary lymph node: consistent with Hodgkin Lymphoma

Repeat PET-CT: interval increase in previously noted hypermetabolic enlarged lymph nodes

P> Pembrolizumab2mg/kg x 6 cycles

Course of Illness

Latest PET-CT scan: exhibited metabolic resolution

ESMO Preceptorship Programme

Thank you for your attention!