Management of Relapsed Hodgkin Lymphoma After ABVD Without Radiation in a 14-Year-Old
This patient should proceed to salvage chemotherapy (DHAP, ESHAP, ICE, or MiniBEAM) followed by high-dose chemotherapy with autologous stem cell transplantation if chemosensitive. 1
Rationale for High-Dose Chemotherapy and Autologous Stem Cell Transplantation
Younger patients who relapse after prior chemotherapy should receive high-dose chemotherapy (HDCT) and autologous stem-cell transplantation as the standard of care. 1 This approach offers the best chance for long-term cure in relapsed disease, with approximately 50% of relapsed patients achieving durable remission with standard salvage therapies. 1
The most established salvage regimens include DHAP (dexamethasone, cytarabine, cisplatin), ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin), ICE (ifosfamide, carboplatin, etoposide), or MiniBEAM (carmustine, etoposide, cytarabine, melphalan). 1 These regimens are typically given for 2 cycles to assess chemosensitivity and mobilize stem cells prior to transplantation. 1
If the disease remains chemosensitive to salvage therapy, stem-cell collection should proceed, followed by high-dose chemotherapy (typically BEAM: carmustine, etoposide, cytarabine, melphalan) and autologous stem-cell transplantation. 1
Critical Considerations for This Pediatric Patient
This patient's initial treatment was suboptimal because she received ABVD without radiation therapy. 1 Standard treatment for early-stage favorable disease is 2 cycles of ABVD followed by 30 Gy involved-field radiotherapy, while early-stage unfavorable disease requires 4 cycles of ABVD followed by 30 Gy involved-field radiotherapy. 1 The omission of radiation substantially increases relapse risk. 1
The lack of radiation in the initial treatment actually provides a therapeutic advantage now, as this patient has not been exposed to the long-term cardiopulmonary and secondary malignancy risks associated with mediastinal radiation. 1, 2 This makes her an excellent candidate for aggressive salvage therapy without compounding late effects.
Response Assessment Strategy
PET/CT scanning should be performed after 2 cycles of salvage chemotherapy to assess chemosensitivity before proceeding to stem cell collection and transplantation. 2 Only patients who demonstrate chemosensitive disease (negative or significantly improved PET) should proceed to autologous transplantation. 1
If the patient demonstrates chemosensitive disease on interim PET, proceed immediately to stem cell mobilization and collection, followed by high-dose chemotherapy and autologous stem cell transplantation. 1
Alternative Approaches if Transplant Fails or Disease is Refractory
For patients who relapse after autologous stem cell transplantation or who have refractory disease to salvage chemotherapy, gemcitabine alone or in combination should be used with a palliative approach. 1
Chemotherapy-sensitive younger patients with a suitable donor may proceed to allogeneic transplant, though this remains experimental. 1
Brentuximab vedotin (a CD30-directed antibody-drug conjugate) has shown encouraging results in relapsed/refractory disease and represents an important option for patients who fail autologous transplantation. 3
Common Pitfalls to Avoid
Do not attempt to re-treat with ABVD or similar first-line regimens. 1 This patient has already demonstrated resistance to ABVD, and repeating the same chemotherapy will not achieve durable remission.
Do not delay salvage therapy to add radiation alone. 1 While radiation may have been omitted initially, at relapse the priority is systemic salvage chemotherapy followed by transplantation, not local radiation.
Do not proceed to autologous transplantation without first confirming chemosensitivity to salvage therapy. 1 Patients with chemoresistant disease have poor outcomes with transplantation and should be considered for alternative approaches including clinical trials or allogeneic transplantation if a donor is available.
Ensure fertility preservation counseling occurs before initiating salvage therapy, as high-dose chemotherapy and transplantation carry significant gonadal toxicity risk. 2, 3 This is particularly critical for a 14-year-old female patient.