From the Guidelines
High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is the treatment of choice for most patients with relapsed or refractory Hodgkin's lymphoma (HL). The most commonly used salvage regimens include ICE (ifosfamide, carboplatin, etoposide), DHAP (dexamethasone, high-dose cytarabine, cisplatin), GDP (gemcitabine, dexamethasone, cisplatin), and IGEV (ifosfamide, gemcitabine, vinorelbine, prednisone) 1. These regimens are usually administered for 2-4 cycles before proceeding to stem cell collection and ASCT.
For patients who relapse after ASCT or are ineligible for transplant, targeted therapies have become important options. Brentuximab vedotin (an anti-CD30 antibody-drug conjugate) is typically given at 1.8 mg/kg IV every 3 weeks 1. PD-1 inhibitors like pembrolizumab (200 mg IV every 3 weeks) or nivolumab (240 mg IV every 2 weeks) have shown significant efficacy in this setting.
Some key points to consider in the management of relapsed or refractory HL include:
- The use of brentuximab vedotin as consolidation therapy after ASCT has been shown to improve tumor control in patients with high-risk disease 1.
- Allogeneic stem cell transplantation remains an option for select younger patients with good performance status who have failed multiple lines of therapy 1.
- The choice of salvage therapy should be individualized based on the patient's prior treatment history, duration of remission, comorbidities, and fitness for intensive therapy, as these factors significantly impact treatment outcomes and tolerability 1.
- Achieving a negative PET scan should be the goal of salvage therapy, irrespective of the applied protocol 1.
Overall, the management of relapsed or refractory HL requires a multidisciplinary approach, taking into account the patient's individual characteristics, disease status, and treatment history.
From the FDA Drug Label
1.4 Relapsed Classical Hodgkin Lymphoma (cHL) ADCETRIS is indicated for the treatment of adult patients with cHL after failure of auto-HSCT or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not auto-HSCT candidates. The salvage options for relapsed Hodgkin's lymphoma include brentuximab vedotin (IV), specifically for adult patients who have failed auto-HSCT or at least two prior multi-agent chemotherapy regimens and are not auto-HSCT candidates 2.
- Key points:
- Failed auto-HSCT
- Failed at least two prior multi-agent chemotherapy regimens
- Not an auto-HSCT candidate
- Treatment option: brentuximab vedotin (IV)
From the Research
Salvage Options for Relapsed Hodgkin's Lymphoma
The treatment for relapsed Hodgkin's lymphoma (HL) typically involves salvage chemotherapy followed by autologous stem cell transplantation (ASCT) 3. Several salvage regimens have been used before ASCT, but the optimal regimen is still unclear.
Salvage Regimens
Some of the salvage regimens that have been studied include:
- Gemcitabine, cisplatin, and dexamethasone (GDP) 4
- Brentuximab vedotin combined with ifosfamide, carboplatin, and etoposide (BV-ICE) 5
- Augmented ifosfamide, carboplatin, and etoposide (augICE) 6
Efficacy and Safety
These regimens have shown promising results in terms of efficacy and safety:
- The GDP regimen has been shown to be effective and safe, with a high response rate and favorable toxicity profile 4
- The BV-ICE regimen has been shown to be active and rapidly administered, despite a complete response rate lower than the prespecified phase 2 target 5
- The augICE regimen has been shown to be effective in achieving PET-negativity in patients with relapsed or refractory HL 6
Targeted Therapies
Targeted therapies, such as brentuximab vedotin and PD-1 inhibitors, have also been shown to be effective in the treatment of relapsed HL 7. These therapies have improved outcomes for patients with relapsed disease, and their integration into existing treatment regimens is being investigated.
PET-Adapted Salvage Therapy
PET-adapted salvage therapy, which involves using PET scans to guide treatment decisions, has also been shown to be effective in achieving PET-negativity in patients with relapsed or refractory HL 6. This approach may optimize the chance of cure after HDT/ASCT.