Prognostic value of pretransplant FDG-PET in refractory/relapsed Hodgkin lymphoma treated with autologous stem cell transplantation: systematic review and meta-analysis

Pembrolizumab Added to Ifosfamide, Carboplatin, and Etoposide Chemotherapy for Relapsed or Refractory Classic Hodgkin Lymphoma: A Multi-institutional Phase 2 Investigator-Initiated Nonrandomized Clinical Trial

Importance

To our knowledge, this is the first clinical trial designed to investigate concurrent treatment with a checkpoint inhibitor and conventional chemotherapy in relapsed or refractory classic Hodgkin lymphoma in patients destined for an autologous stem cell transplant.

Objective

To evaluate the complete response rate as assessed by 18F-fluorodeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) after salvage therapy for patients with relapsed or refractory classic Hodgkin lymphoma.

Design, Setting, and Participants

A single-group, phase 2, multi-institutional nonrandomized clinical trial to evaluate the addition of pembrolizumab to ifosfamide, carboplatin, and etoposide (ICE) chemotherapy was conducted from April 20, 2017, to October 29, 2020, at 5 US sites. The 42 patients were aged 18 years or older, with an Eastern Cooperative Oncology Group Performance Status Scale score of 0 or 1 and biopsy-proven relapsed or refractory classic Hodgkin lymphoma after 1 or 2 prior lines of chemotherapy. Patients were required to be appropriate candidates for transplant, with measurable lesions detected by FDG-PET/CT.

Interventions

Two cycles of pembrolizumab (200 mg intravenously on day 1) with ICE chemotherapy every 21 days, followed by stem cell mobilization and collection, and then 1 cycle of pembrolizumab monotherapy followed by FDG-PET/CT response assessment.

Main Outcomes and Measures

The primary end point was complete response rate detected by FDG-PET/CT, defined as a Deauville score of 3 or lower. Patients with a complete response proceeded to an autologous stem cell transplant. Secondary end points included progression-free survival, overall survival, stem cell mobilization, and neutrophil and platelet engraftment. Adverse events were monitored to assess safety.

Results

Forty-two patients were enrolled, with 37 evaluable for the primary end point. The median age was 34 years (range, 19-70 years), 25 patients were female (68%), 6 were African American (16%), and 26 were White (70%). The complete response rate for the 37 patients assessed by FDG-PET/CT imaging was 86.5% (95% CI, 71.2%-95.5%); the overall response rate was 97.3% (36 patients), with 10.8% partial responses (4 patients). New areas of FDG-PET positivity in 2 patients were biopsied, showing noncaseating granuloma in 1 case and a reactive lymph node in a second. Progression-free survival and overall survival 2-year estimates were 87.2% (32 patients; 95% CI, 77.3%-98.3%) and 95.1% (95% CI, 88.8%-100%), respectively. The addition of pembrolizumab to ICE chemotherapy did not negatively affect stem cell mobilization or collection or engraftment, similar to prior experience in this patient population and setting.

Conclusions and Relevance

Results suggest that the addition of pembrolizumab to ICE chemotherapy was well tolerated and highly effective in comparison with prior reports of chemotherapy-only regimens, supporting further investigation in patients with relapsed or refractory classic Hodgkin lymphoma eligible for an autologous stem cell transplant.

Trial Registration

ClinicalTrials.gov Identifier: NCT03077828.

Single or tandem autologous stem cell transplantation for treating Chinese patients with refractory/relapsed classical Hodgkin lymphoma

BACKGROUND

Autologous stem cell transplantation (ASCT) is the standard treatment strategy for refractory or relapsed classical Hodgkin lymphoma (R/R cHL). However, a single transplantation is insufficient to cure the disease because of unfavorable risk factors. Herein, we evaluated the outcomes of single or tandem ASCT in patients with R/R cHL, especially in high-risk patients.

METHODS

We retrospectively analyzed R/R cHL patients who underwent single or tandem ASCT between April 2000 and June 2021 at the Beijing Cancer Hospital and Peking University International Hospital.

RESULTS

A total of 134 patients were enrolled. Patients were allocated to a favorable-risk group (group A, n = 33), an unfavorable-risk group (group B, n = 81) that underwent single ASCT, and an unfavorable-risk group that underwent tandem ASCT (group C, n = 20). The median follow-up time was 99 months (range, 91-107 months), and no treatment-related deaths occurred after single or tandem ASCT. However, 27 patients (2 in group C) died during the follow-up period. The groups A, B, and C had 5-year progression-free survival (PFS) rates of 77.05%, 45%, and 74.67%, respectively (p = 0.0014), and 5-year overall survival (OS) rates of 89.85%, 76.06%, and 95%, respectively (p = 0.18). Neither the median PFS rates of groups A and C nor the OS rates of all groups were reached.

CONCLUSIONS

Our study discusses the advantages of tandem transplantation for high-risk patients with R/R cHL.

18F-FDG PET/CT prognostic role in predicting response to salvage therapy in relapsed/refractory Hodgkin's lymphoma

PURPOSE

To evaluate the response predictors, both clinical and ¹⁸F-FDG PET/CT parameters, in Hodgkin's lymphoma (HL) patients diagnosed with refractory/relapsed disease who were planned to receive salvage therapy.

METHODS

In this retrospective study, all HL patients referred to our center between March 2015 and July 2021 were reviewed. Patients with refractory/relapsed disease who were candidates for salvage therapy were included. ¹⁸F-FDG PET/CT measurements at the time of diagnosis were extracted as the predictors, and the lesions' response at the end of the salvage therapy was considered the outcomes. The Kaplan-Meier method and multiple Cox regression were utilized to find the significant parameters to predict the time to reach the complete response. The statistical significance level was set at a two-sided p-value <0.05.

RESULTS

A total of 303 tumoral lesions from 64 patients were included. Regarding the factors associated with the response, B symptoms (p-value < 0.01), pathologic subtype (p-value < 0.001), and patient stage (p-value < 0.01) were the significant clinical parameters. In addition, SUVmax (p-value = 0.03), SUVmax/hepatic background SUVmax (p-value = 0.04), SUVmean (in all thresholds; 41% p-value = 0.02, 51% p-value = 0.04, 61% p-value = 0.01), and MTV (in all thresholds; 41% p-value = 0.04, 51% p-value = 0.04, 61% p-value = 0.05) were the significant parameters in the ¹⁸F-FDG PET/CT scans. At the median follow-up of 9 months, we found that pathologic subtype (p-value < 0.01), patient stage (p-value = 0.03), SUVmax (p-value = 0.02), SUVmax/hepatic background SUVmax (p-value = 0.03), SUVmean (in all thresholds; 41% p-value = 0.01, 51% p-value = 0.02, 61% p-value = 0.02), and MTV ≥ 41% (p-value = 0.02) were significant predictive factors. Multiple Cox regression showed the pathologic subtype (p-value = 0.02), SUVmax (p-value = 0.02), and MTV ≥ 41% (p-value = 0.04) were the most significant predictors.

CONCLUSION

Our study demonstrated that by knowing the histopathology of the lesions, the pre-treatment ¹⁸F-FDG PET/CT might be able to predict response after salvage therapy in the relapsed/refractory HL.

Target receptor identification and subsequent treatment of resected brain tumors with encapsulated and engineered allogeneic stem cells

Cellular therapies offer a promising therapeutic strategy for the highly malignant brain tumor, glioblastoma (GBM). However, their clinical translation is limited by the lack of effective target identification and stringent testing in pre-clinical models that replicate standard treatment in GBM patients. In this study, we show the detection of cell surface death receptor (DR) target on CD146-enriched circulating tumor cells (CTC) captured from the blood of mice bearing GBM and patients diagnosed with GBM. Next, we developed allogeneic "off-the-shelf" clinical-grade bifunctional mesenchymal stem cells (MSCBif) expressing DR-targeted ligand and a safety kill switch. We show that biodegradable hydrogel encapsulated MSCBif (EnMSCBif) has a profound therapeutic efficacy in mice bearing patient-derived invasive, primary and recurrent GBM tumors following surgical resection. Activation of the kill switch enhances the efficacy of MSCBif and results in their elimination post-tumor treatment which can be tracked by positron emission tomography (PET) imaging. This study establishes a foundation towards a clinical trial of EnMSCBif in primary and recurrent GBM patients.

Autologous Stem Cell Transplantation in Hodgkin Lymphoma-Latest Advances in the Era of Novel Therapies

Standard treatment for relapsed and/or refractory (r/r) Hodgkin lymphoma (HL) consists of salvage therapy, historically consisting of multiagent cytotoxic chemotherapy, followed by autologous stem cell transplantation (autoHCT) in responding patients. With this approach, most patients can proceed to autoHCT, of whom approximately half are cured. However, the introduction of the novel agents brentuximab vedotin (BV) and the checkpoint inhibitors (CPI) nivolumab and pembrolizumab has changed the decision making and peri-transplant decision making, as early incorporation of one or more of these agents can reduce or even eliminate the need for cytotoxic chemotherapy prior to autoHCT. Furthermore, post-autoHCT maintenance therapy with BV has also been shown to decrease relapse in high-risk rel/ref HL patients. In this review, we survey the current data regarding autoHCT in HL with a focus on pre-autoHCT salvage as well as maintenance strategies, and we also talk about the emerging data challenging the long-held dogma of chemosensitivity being a requirement for successful autoHCT.

Current salvage therapies in Hodgkin lymphoma

Hodgkin lymphoma is a B-cell malignancy with approximately 85-95% complete remission rate following frontline therapy; however, relapsed/refractory disease occurs in roughly 10-30% of patients after treatment. Salvage therapy conventionally relies upon cytotoxic chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation. A considerable number of patients experience relapse after transplantation, and further salvage management has included the use of allogeneic transplantation and radiotherapy. In the past decade, novel therapies including, brentuximab vedotin, PD-1 inhibitors, and the incorporation of PET-imaging into management have changed the paradigm of relapsed/refractory disease care. Novel therapies have been investigated in both single and combination regimens with other novel therapies and traditional chemotherapies. There is promising early work into the utility of CD30.CAR-T cell therapy, AFM13, camidanlumab tesirine, novel PD-1 inhibitors, and JAK1/JAK2 inhibition in management. Herein, we will review current salvage therapies in Hodgkin lymphoma and future directions in relapsed/refractory disease management.

Promising remissions in relapsed refractory classical Hodgkin lymphoma patients requiring multiple salvage regimens before transplantation in the brentuximab vedotin era

Relapsed/refractory classical Hodgkin lymphoma (R/R cHL) patients refractory to first line salvage have poor outcomes. Herein we report the outcome of R/R cHL patients requiring ≥two vs. one line in the era of chemo-immunotherapy. Among 55 R/R cHL patients, 33 (60%) required one, 22 (40%) required ≥two lines. At 2 years, the estimated PFS and OS for patients requiring one vs. ≥two lines was 71.2% (50.1–84.7) vs. 51.9% (27.6–71.6), p= 0.16 and 84.6% (63–94) vs. 84% (58–95), p= 0.88, respectively. Patients requiring ≥two salvage lines prior to HCT can achieve comparable outcomes to those requiring one, possibly due to brentuximab vedotin leading to higher CMR rates.

Long-term outcome of patients receiving haematopoietic allogeneic stem cell transplantation as first transplant for high-risk Hodgkin lymphoma: a retrospective analysis from the Lymphoma Working Party-EBMT

We analysed long-term outcome of patients receiving haematopoietic allogeneic stem cell transplantation (allo-HSCT) as a first transplant for high-risk Hodgkin lymphoma (HL). One hundred and ninety patients were included in this study, 63% of them had previously received brentuximab vedotin and/or checkpoint inhibitors. Seventy patients (37%) received an unrelated donor allo-HSCT, 99 (51%) had myeloablative conditioning (MAC) and 60% had in vivo T-cell/depleted grafts (TCD). The 100-day cumulative incidence (CI) of grade II-IV acute graft-versus-host disease (GVHD) was 25% and the 3-year CI of chronic GVHD was 38%. The 3-year CI of non-relapse mortality (NRM) and relapse rate were 21% and 38% respectively. After a median follow-up of 58 months, 3-year overall survival (OS) and progression-free survival (PFS) were 58% and 41% respectively. Multivariate analysis showed that, in comparison to reduced-intensity conditioning regimens with or without TCD, MAC using TCD had similar NRM and a lower risk of relapse leading to significantly better OS and PFS. MAC without TCD was associated with higher NRM and worse survival outcomes. These results suggest that in patients with high-risk HL and candidates of allo-HSCT, a MAC strategy with TCD might be the best option.

Long-term remissions in patients with early relapse of diffuse large B-cell lymphoma following high-dose chemotherapy, autologous stem cell transplantation, and radiotherapy of residual disease

PURPOSE

The prognosis of an early relapse of diffuse large B-cell lymphoma (DLBCL) appears to be poor following autologous stem cell transplantation (ASCT). The aim of this study is to contribute data to the open question on whether additional radiotherapy can improve the outcome.

PATIENTS AND METHODS

Forty-eight patients with an early relapse (median 4 months after the end of initial immunochemotherapy, range 1-11) of DLBCL have been treated in our institution with high-dose therapy (usually the BEAM protocol) and ASCT since 2008 (median age 61 years, range 28-73). Twenty-three patients received ASCT in a second treatment line, 25 in a third line (19 refractory to second-line salvage therapy, 5 after second relapse). Fifteen of these 48 patients received radiotherapy (36-50 Gy, median 40) of residual masses after ASCT.

RESULTS

Three-year overall survival (OS) and progression-free survival (PFS) after second-line ASCT were 61 and 57%, after third-line ASCT 47 and 44%, respectively, without significant differences. A prognostic factor was the International Prognostic Index (IPI) at the start of salvage therapy. Three-year OS and PFS in low-risk patients were 69 and 69%, in low-intermediate-risk 63 and 53%, and in high-intermediate-risk 23 and 23%, respectively (p = 0.033). Twenty-three patients achieved a sustained complete remission (13-146 months, median 62).

CONCLUSION

Sustained long-term remissions can be achieved in patients with early relapse of DLBCL following ASCT in a second or third treatment line, particularly in patients with low- and low-intermediate-risk IPI, following radiotherapy of residual disease after ASCT. Further investigations are required to clarify which patients need an alternative therapy (potentially CAR T‑cells or allogeneic transplantation).

New approaches to managing relapsed/refractory Hodgkin lymphoma: the role of checkpoint inhibitors and beyond

Introduction: While most patients with Hodgkin lymphoma (HL) are successfully cured with frontline therapy, unfortunately far too many patients have primary refractory disease or relapse after initial treatment, and outcomes for these patients remain suboptimal.Areas Covered: Treatment for relapsed/refractory (R/R) HL remains an ongoing challenge; however, the approval of brentuximab vedotin (BV) and the checkpoint inhibitors pembrolizumab and nivolumab have given us promising therapies with high response rates and improved progression free survival. We performed a literature search using PubMed on all HL studies investigating immunotherapy within the past 10 years.Expert Opinion: Both BV and checkpoint inhibitors have good single agent activity but appear more effective when given together and combine well with chemotherapy. Other novel agents under study include bispecific chimeric antibody constructs and chimeric antigen receptor T-cells (CAR-T). Here we review the data supporting novel therapies and immunotherapies for R/R HL.

FDG PET/CT to Detect Incidental Findings in Patients With Hepatocellular Carcinoma-Additional Benefit for Patients Considered for Liver Transplantation?

PURPOSE

FDG PET/CT has been described for noninvasive grading, detection of extrahepatic spread, and recurrence in hepatocellular carcinoma (HCC). As compared with localized imaging approaches (MRI, ultrasonography), FDG PET/CT not only focuses on the liver, but covers a long field of view from the base of the skull to the thighs, visualizing pathologic findings not related to HCC. The aims of this retrospective study were to (1) describe the frequency of relevant incidental findings on FDG PET/CT in HCC patients, (2) evaluate the impact on treatment strategy in HCC patients considered for liver transplantation, and (3) to discuss the role of FDG PET/CT in patients considered for transplantation in general.

METHODS

Four hundred thirty-nine FDG PET/CT examinations of 345 HCC patients were screened for incidental findings. The clinical information system was searched for examinations performed after FDG PET/CT and aimed at verification of incidental findings. Of 345 HCC patients, 81 patients were considered for liver transplantation. The impact of incidental findings was recorded separately for this subgroup.

RESULTS

One hundred one patients with incidental findings in 439 FDG PET/CT examinations were identified. The incidental findings comprised 22 neoplasms (9 malignant) and 52 inflammations. Liver transplantation was not performed because of an incidental finding on FDG PET/CT in 9 (11.1%) of 81 patients.

CONCLUSIONS

FDG PET/CT is capable of identifying relevant incidental findings (ie, secondary malignancy, benign tumors, and inflammation) in HCC patients and HCC patients considered for liver transplantation and thus influencing HCC patient management. FDG PET/CT might also be beneficial in patients considered for transplantation of different organs.

Disease Status at Transplant has a Significant Impact on Outcomes of Autologous Transplantation (ASCT) in Patients with Hodgkin Lymphoma—A Single Center Experience

High dose chemotherapy followed by autologous stem cell transplantation is the treatment of choice for relapsed Hodgkin lymphoma (HL). We analyzed 100 consecutive patients who underwent ASCT at our center between January 1999 and June 2019 for relapsed or refractory disease with a median age of 28 years (range: 9-65). At ASCT, 59 were in complete remission (CR) while 31 achieved partial remission (PR) and 10 had refractory disease (RD). Most had BEAM conditioning with a median infused cell dose of 4.84 × 10⁶ CD 34 cells/kg. Prompt engraftment occurred in 97 patients at a median of 11 days. The day 100 transplant related mortality (TRM) was 5%. At a median of 37 months follow up, 79 patients are alive while 34 have relapsed. The 3-year event free survival (EFS) and overall survival (OS) are 62.3 ± 0.5% and 77.9 ± 4.4% respectively. The 3-year OS for patients in CR, PR and RD were 83.0 ± 5.2%, 78.4 ± 8.1% and 38.9 ± 1.7 respectively [p = 0.007] while the 3-year EFS for CR, PR and RD were 73.1 ± 6.2%, 61.3 ± 9.2% and 25.0 ± 1.5 respectively [p = 0.005]. Only disease status at time of ASCT was found to correlate with both OS and EFS. ASCT for HL is associated with good outcomes and low TRM. Disease status at ASCT impacted both OS and EFS and strategies to improve outcomes in patients with refractory disease needs to be explored.

Overview and recent advances in PET/CT imaging in lymphoma and multiple myeloma

Imaging in hematological diseases has evolved extensively over the past several decades. Positron emission tomography/computed tomography (PET/CT) with of 2-[18 F]-fluoro-2-deoxy-d-glucose ([18 F] FDG) is currently essential for accurate staging and for early and late therapy response assessment for all FDG-avid lymphoproliferative histologies. The widely adopted visual Deauville 5-point scale and Lugano Classification recommendations have recently standardized PET scans interpretation and improved lymphoma patient management. In addition [18 F] FDG-PET is routinely recommended for initial evaluation and treatment response assessment of Multiple Myeloma (MM) with significant contribution in risk-stratification and prognostication, although magnetic resonance imaging remains the Gold Standard for the assessment of bone marrow involvement. In this review, an overview of the role of [18 F] FDG-PET, in hematological malignancies is provided, particularly focusing on Hodgkin lymphoma (HL) and Diffuse Large B Cell Lymphoma (DLBCL), both in adult and pediatric populations, and MM, at each point of patient management. Potential alternative molecular imaging applications in this field, such as non-[18 F] FDG-tracers, whole body magnetic resonance imaging (WB-MRI), hybrid PET/MRI and emerging radiomics research are briefly presented.

Prognostic Value of 2-Deoxy-2-[18F]fluoro-D-glucose Positron Emission Tomography/Computed Tomography after Autologous Hematopoietic Stem Cell Transplantation in Lymphoma Using Deauville Scores

Purpose

In the present study, we mainly aimed to evaluate the prognostic value of 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]F-FDG) positron emission tomography (PET)/computed tomography (CT) after autologous stem cell transplantation (ASCT) in lymphoma. Procedures. A total of 76 lymphoma patients who benefited from [¹⁸F]F-FDG PET-CT (within 3 months and 3–6 months) after ASCT in our institution between April 2010 and December 2019 were enrolled in this retrospective study. These abovementioned patients were divided into two groups based on the Deauville criteria. The Kaplan–Meier method was used in survival analysis, and the log-rank method was adopted in comparison. Prognostic factor analysis was performed by the Cox regression model.

Results

Positive post-ASCT [¹⁸F]F-FDG PET-CT was associated with lower progression-free survival (PFS) and overall survival (OS) (p = 0.001 and p = 0.022, respectively). Univariate analysis showed the post-ASCT PET-CT result was the only independent factor associated with PFS (p = 0.002). Both the number of previous treatments and post-ASCT PET-CT result had a different impact on OS (p = 0.040 and p = 0.028, respectively). Multivariate analysis showed the post-ASCT PET-CT result was the only independent factor associated with OS (p = 0.028). The results showed no significant change from the abovementioned results when DS < 3 was defined as the negative result. For patients who had a PET-CT scan within 3–6 months after ASCT, the negative PET-CT group had a better prognosis including PFS and OS (p = 0.009 and p = 0.025, respectively). However, among the patients receiving PET-CT within 3 months, the result was not statistically significant (p = 0.064 and p = 0.445, respectively).

Conclusion

Collectively, we found that the post-ASCT [¹⁸F]F-FDG PET-CT was a strong indicator for PFS and OS, and a time window of 3–6 months was appropriate for post-ASCT [¹⁸F]F-FDG PET-CT. Trial registration number: ChiCTR2100042745.

FDG PET for Assessment of Autologous Stem Cell Transplantation

The appropriate selection of patients to undergo hematopoietic stem cell transplant (HSCT) is critical due to the risk of treatment-related morbidity and mortality. The prognostic value of FDG-PET/CT in response assessment in hematologic malignancies is well-established and has led to numerous investigations into the role of FDG-PET/CT in the evaluation of patients in the setting of HSCT. This article discusses the most common indications for autologous stem cell transplant (autoSCT) in which FDG-PET/CT has been evaluated, including for lymphoma and multiple myeloma. For relapsed/refractory Hodgkin lymphoma, achieving a negative FDG-PET/CT scan, regardless of the number of the regimens, prior to autoSCT is an important prognostic factor for posttransplant outcome. The data in the pretransplant setting are more variable for non-Hodgkin lymphoma. For both Hodgkin and non-Hodgkin lymphoma, studies have primarily used a visual assessment for FDG-PET/CT interpretation, with the Deauville score the current standard criteria. Optimization of thresholds for specific regimens pretransplant as well as integration of additional semiquantitative parameters to assess response remain active areas of research. For multiple myeloma, FDG-PET/CT has emerged as the recommended imaging modality of choice for assessing response to treatment. Data suggest that FDG-PET/CT may provide prognostic and predictive value for assessing outcome after autoSCT.

Salvage Therapy for Hodgkin's Lymphoma: A Review of Current Regimens and Outcomes

Relapse/refractory Hodgkin lymphoma patients are still a clinical concern. Indeed, despite more effective first-line chemotherapy regimens and better stratification of unresponsive patients by clinical factors and use of early PET, roughly one-third of such patients need salvage chemotherapy and consolidation with high-dose chemotherapy. In this paper, the authors review the different salvage treatments, with special emphasis on newer combinations with brentuximab vedotin or check point inhibitors. The overall response rate is constantly increasing, with a complete remission rate approaching 80%. Functional response evaluation by PET imaging is a strong predictive factor of longer survival, and more sophisticated tools, such as detection of circulating tumour DNA, are emerging to refine the disease-status assessment after treatment. Consolidation by high-dose chemotherapy is still considered the standard of care in chemosensitive patients, leading to a high fraction of patients towards long-term disease control. Maintenance therapy with BV is now approved, reducing disease relapse/progression. An increasing number of Hodgkin lymphoma patients will be cured after first- and second-line therapy, and long-term toxicity needs to be continuously assessed and avoided.

Hodgkin Lymphoma in Children and Adolescents: Advances in Pathology, Diagnosis, and Treatment Strategies

Strategies used for the treatment of children with Hodgkin lymphoma (HL) over the last four decades have resulted in excellent long-term survivals. However, the short- and long-term treatment-associated morbidities were high. In an attempt to reduce complications, the current treatment strategies apply initial risk stratification principles based on certain host and tumor risk factors to help assign patients to the appropriate risk group and tailor therapy based on response to chemotherapy (CTR). Radiotherapy (RT) was only given to certain groups of patients who show suboptimal response to CTR. Enrollment of patients in clinical trials allowed testing newer treatment strategies, which has improved the outcome significantly. High-dose CTR with stem cell support remains the mainstay of treatment for relapsed and refractory HL. Newer targeted medications are being increasingly used for the treatment of patients with relapsed and refractory HL, but results are variable. In this review report, we give extensive account about the pathophysiology, clinical presentation, histopathological diagnosis, modern investigation techniques, the most recent risk adapted treatment strategies, and the use and effect of novel medications. In addition, we discuss in details the short- and long-term therapy-related complications and future prospects in the management of HL.

Relapsing/refractory HL after autotransplantation: which treatment?

For advanced-stage Hodgkin lymphoma (HL), front-line chemotherapy, alone or in combination with radiotherapy, leads to 5-year progression-free survival (PFS) rates and freedom-from-treatment failure (FFTF) rates of 70-85%, regardless of the chemotherapy regimen applied. Patients with HL experiencing disease progression during or within 3 months of front-line therapy (primary refractory) and patients whose disease relapses after a complete response have a second chance of treatment. The standard of care for relapsed or refractory HL is second-line chemotherapy followed by autologous stem cell transplantation (ASCT), which can induce long-term remission in approximately 40-50% of patients. However, HL recurrence occurs in about 50% of patients after ASCT, usually within the first year, and represents a significant therapeutic challenge. Allogeneic transplantation from HLA-matched donors represents the standard of care for patients with HL relapsing after- or refractory to ASCT.

Relapse or refractory Hodgkin lymphoma: determining risk of relapse or progression after autologous stem-cell transplantation

The treatment of classic Hodgkin lymphoma (HL) is a success in onco-hematology. Despite the high cure rate of HL with initial therapy, 5-10% of patients are primary refractory and 10-20% will eventually relapse. The standard treatment for these patients is salvage chemotherapy and autologous stem cell transplantation (ASCT). Only about half of these patients will benefit from this procedure. The prognosis of relapsed refractory (rr) HL has improved with the introduction of effective drugs. With these options available, identification of reliable risk factors is important to guide treatment over the course of disease. Different variables including performance status, anemia, B symptoms, laboratory abnormalities, treatment intensity before ASCT, response to therapy, and duration of remission, have been analyzed to determine risk for progression-free survival (PFS) and overall survival (OS) after ASCT. This review will discuss the publications analyzing these factors, the validated risk scores useful to identify patients at high risk of progression after ASCT, and will describe future perspectives.

Optimizing outcomes in relapsed/refractory Hodgkin lymphoma: a review of current and forthcoming therapeutic strategies

The outcome of patients with relapsed/refractory classical Hodgkin lymphoma (rr-cHL) has improved considerably in recent years owing to the approval of highly active novel agents such as brentuximab vedotin and Programmed Death-1 (PD-1) inhibitors. Although no randomized trials have been conducted to provide formal proof, it is almost undisputable that the survival of these patients has been prolonged. As autologous stem-cell transplantation (SCT) remains the standard of care for second-line therapy of most patients with rr-cHL, optimization of second-line regimens with the use of brentuximab vedotin, or, in the future, checkpoint inhibitors, is promising to increase both the eligibility rate for transplant and the final outcome. The need for subsequent therapy, and especially allogeneic SCT, can be reduced with brentuximab vedotin consolidation for 1 year, while pembrolizumab is also being tested in this setting. Several other drug categories appear to be active in rr-cHL, but their development has been delayed by the appearance of brentuximab vedotin, nivolumab and pembrolizumab, which have dominated the field of rr-cHL treatment in the last 5 years. Combinations of active drugs in chemo-free approaches may further increase efficacy and hopefully reduce toxicity in rr-cHL, but are still under development.

Risk and Response Adapted Treatment Guidelines for Managing First Relapsed and Refractory Classical Hodgkin Lymphoma in Children and Young People. Recommendations from the EuroNet Pediatric Hodgkin Lymphoma Group

The objective of this guideline is to aid clinicians in making individual salvage treatment plans for pediatric and adolescent patients with first relapse or refractory (R/R) classical Hodgkin lymphoma (cHL). While salvage with standard dose chemotherapy followed by high dose chemotherapy and autologous stem cell transplant is often considered the standard of care in adult practice, pediatric practice adopts a more individualized risk stratified and response adapted approach to salvage treatment with greater use of non-transplant salvage. Here, we present on behalf of the EuroNet Pediatric Hodgkin Lymphoma group, evidence and consensus-based guidelines for standardized diagnostic, prognostic and response procedures to allocate children and adolescents with R/R cHL to stratified salvage treatments.

High-dose chemotherapy followed by autologous stem cell transplantation for patients with refractory/relapsed classical Hodgkin lymphoma: a single center experience from China

To evaluate the outcomes of refractory/relapsed cHL patients after high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) in Beijing Cancer hospital and to identify the prognostic risk factors. We retrospectively analyzed 115 relapsed/refractory cHL patients who accepted HDCT and ASCT in our cancer center and had complete follow-up data from April 2000 to May 2017. Ages of these 115 patients at ASCT ranged from 14 to 63 (median age 28). Forty-four (38.3%) patients achieved CR and 50 (43.5%) patients achieved PR before ASCT. Thirty-seven (48.7%) patients of those 76 patients who did PET-CT before ASCT had negative PET-CT scans. The median follow-up time was 72 months. A total of 23 patients died in our study. The 5-year OS and PFS rates of all patients after ASCT were 78.7% and 53%, respectively. The 5-year OS rates after ASCT of patients who were in CR or PR or less than PR status before ASCT were 92.8%, 68.2%, and 76.2%, respectively (log-rank = 2.913, p = 0.233). And their 5-year PFS rates after ASCT were 69.2%, 54.2%, and 18.5%, respectively (log-rank = 13.615, p = 0.001). Univariate analysis revealed that ECOG (p = 0.010; hazard ratio = 1.578), disease status before ASCT (CR: p = 0.001; hazard ratio = 0.227) and after ASCT (CR: p < 0.001; hazard ratio = 0.154), and PET-CT results after ASCT (p = 0.023; hazard ratio = 0.438) significantly impact patients' PFS while number of pretransplant salvage chemotherapy (p = 0.037; hazard ratio = 2.521), radiotherapy (p = 0.046; hazard ratio = 0.423), and disease status after ASCT (CR: p = 0.010; hazard ratio = 0.197) significantly affected patients' OS. Multivariate analysis shown only disease status before ASCT (p = 0.002) had significant impact on PFS and disease status after ASCT (p = 0.021) had significant impact on OS. R/R HL patients can still obtain long-term PFS after HDCT and ASCT and disease status before ASCT was the most significant prognostic factor for PFS.

The role of PET/CT in the modern treatment of Hodgkin lymphoma

Classical Hodgkin Lymphoma is distinguished from other lymphomas by its peculiar biology and heterogeneous chemosensitivity. Most of the patients respond to the standard first-line treatment and are cured, however, in selected cases, the disease relapses or remains primarily refractory. Among predictive/prognostic factors ¹⁸FDG positron emission tomography (PET), fully integrated with computed tomography (PET/CT) proved to be extremely useful in identifying patients with poor prognosis at the time of diagnosis, during and at the end of treatment. The aim of this review is to present the current role of PET/CT in cHL at staging, interim and end of therapy assessment and its ability to guide treatment with a response- and risk-adapted strategy in clinical practice. Finally, quantitative PET measurement and the concurrent use of PET with selected biomarkers are discussed.

Treatment-Resistant Hodgkin Lymphoma: Defining the Role of Autologous Transplantation

Autologous hematopoietic stem cell transplant (AHCT) remains the current standard of care for patients with relapsed or refractory Hodgkin lymphoma (HL) after frontline chemotherapy. However, treatment paradigms for HL are rapidly changing with positron emission tomography-adapted therapy, as well as the incorporation of brentuximab vedotin and checkpoint inhibitors into frontline, salvage, and maintenance therapy for HL. Patients who relapse or are refractory to these novel agents are likely to have different responses and outcomes with AHCT than the 3-year event-free survivals of 50% historically reported with AHCT for patients failing conventional combination chemotherapy. This article reviews the current data on the efficacy of AHCT, pretransplant prognostic markers, pretransplant salvage regimens, peritransplant radiation therapy, and posttransplant maintenance therapy in classic HL. Future research should reexamine the efficacy, timing, risk factors, pretransplant salvage regimens, and maintenance approaches posttransplant in the era of brentuximab vedotin and checkpoint inhibitors for HL.

Haploidentical Transplants with Post-Transplant Cyclophosphamide for Relapsed or Refractory Hodgkin Lymphoma: The Role of Comorbidity Index and Pretransplant Positron Emission Tomography

Disease relapse remains an unmet medical need for patients with Hodgkin lymphoma (HL) receiving an allogeneic hematopoietic cell transplantation (HCT). With the aim of identifying patients at high risk for post-transplant relapse, we retrospectively reviewed 41 HL patients who had received haploidentical (haplo) nonmyeloablative (NMA) HCT with high dose post-transplant cyclophosphamide (PT-Cy) for graft-versus-host (GVHD) prophylaxis. Primary refractory disease, relapse within 6 months from autologous stem cell transplantation, age, pretransplant chemotherapy, HCT comorbidity index (HCT-CI), sex mismatch, tumor burden and pretransplant fluorodeoxyglucose positron emission tomography (FDG-PET) status, assessed by Deauville score, were analyzed as variables influencing outcomes. All but 1 patient engrafted: median time to neutrophil and platelet recovery was 15 (interquartile range, 13 to 23) days and 19 (interquartile range, 12 to 28) days, respectively. Cumulative incidence of severe (grade III to IV) acute graft-versus-host disease (GVHD) and 3-year moderate-severe chronic GVHD was 2.4% and 11.8%, respectively. The 3-year overall (OS), progression free (PFS), and graft relapse-free survival (GRFS) were 75.6%, 43.9%, and 39%, respectively. On multivariate analysis, 3-year OS was significantly worse in patients with HCT-CI ≥3 (hazard ratio [HR], 5.0; 95% confidence interval [CI], 1.1 to 21.8; P = .03). Three-year relapse rate, 3-year PFS, and 3-year GRFS were significantly worse in patients with HCT-CI ≥3 (HR, 3.5; 95% CI, 1.3 to 9.3; P = .01; HR, 3.3; 95% CI, 1.2 to 9.0; P = .02; and HR, 4.2; 95% CI, 1.7 to 9.9; P = .001, respectively) and in patients with a Deauville score ≥4 on pretransplant FDG-PET (HR, 4.4; 95% CI, 1.6-12.4; P = .005, HR, 3.8; 95% CI, 1.5 to 9.7; P = .005; and 3.2; 95% CI, 1.3 to 7.9; P = .01, respectively). On univariate analysis, 3-year NRM was significantly worse only in patients with a HCT-CI ≥3 (HR, 17.6; 95% CI, 1.4 to 221.0). Among relapsed or refractory HL patients undergoing haplo NMA HCT with PT-Cy, pretransplant FDG-PET with a Deauville score ≥4 and HCT-CI ≥3 identified patients at high risk of relapse. Moreover, an HCT-CI ≥3 was associated with higher NRM and lower OS.

Role of FDG PET-CT in the treatment management of Hodgkin lymphoma

Fluorodeoxyglucose (FDG) positons emission tomography (PET)-computed tomography (CT) is used in many ways at baseline and during the treatment of patients with Hodgkin lymphoma. Many properties of the technique are used in the different steps of patient's management. Initial staging with PET-CT is more accurate than conventional imaging and PET-CT also became the gold standard imaging at the end of treatment with a negative PET-CT mandatory for reaching a complete remission. Early assessment of response by PET-CT is one of the most powerful prognostic factors for progression-free survival of patients with localized and advanced stages and allows guiding treatment. Conversely, previous studies showed that there is no role of FDG PET-CT for the patient's follow-up.

Transplant strategies in relapsed/refractory Hodgkin lymphoma

The majority of patients with Hodgkin lymphoma (HL) are cured with initial therapy. However, high-dose therapy with autologous hematopoietic cell transplant (AHCT) allows for the cure of an additional portion of patients with relapsed or primary refractory disease. Positron emission tomography-negative complete remission before AHCT is critical for long-term disease control. Several salvage options are available with comparable response rates, and the choice can be dependent of comorbidities and logistics. Radiation therapy can also improve the remission rate and is an important therapeutic option for selected patients. Brentuximab vedotin (BV) maintenance after AHCT is beneficial in patients at high risk for relapse, especially those with more than 1 risk factor, but can have the possibility of significant side effects, primarily neuropathy. Newer agents with novel mechanisms of action are under investigation to improve response rates for patients with subsequent relapse, although are not curative alone. BV and the checkpoint inhibitors nivolumab and pembrolizumab are very effective with limited side effects and can bridge patients to curative allogeneic transplants (allo-HCT). Consideration for immune-mediated toxicities, timing of allogeneic hematopoietic cell transplant based on response, and the potential for increased graft-versus-host disease remain important. Overall, prospective investigations continue to improve outcomes and minimize toxicity for relapsed or primary refractory HL patients.

Interim results of brentuximab vedotin in combination with nivolumab in patients with relapsed or refractory Hodgkin lymphoma

In this phase 1/2 study, brentuximab vedotin (BV) and nivolumab (Nivo) administered in combination were evaluated as initial salvage therapy in patients with relapsed or refractory (R/R) classical Hodgkin lymphoma (HL). Patients received up to 4 cycles of combination treatment, with BV administered on day 1 and Nivo on day 8 of the first cycle. For cycles 2 to 4, BV and Nivo were both administered on day 1. After study treatment, responses were evaluated by investigators per the 2014 Lugano classification, and patients could proceed to autologous stem cell transplantation (ASCT). Sixty-two patients were enrolled; the complete response rate among all treated patients (n = 61) was 61%, with an objective response rate of 82%. Before ASCT, adverse events (AEs) occurred in 98% of patients, mostly grades 1 and 2. Infusion-related reactions (IRRs) occurred in 44% of patients overall, with 41% of patients experiencing an IRR during at least 1 infusion of BV. Five patients (8%) were treated with systemic steroids for immune-related AEs. A reduction of peripheral T-cell subsets including regulatory T cells was observed after the first dose of BV, and reduced serum levels of thymus- and activation-regulated chemokine concurrent with an increase in proinflammatory cytokines and chemokines were seen after the first BV plus Nivo infusions. The combination of BV plus Nivo was an active and well-tolerated first salvage regimen, potentially providing patients with R/R HL an alternative to traditional chemotherapy. This trial was registered at www.clinicaltrials.gov as #NCT02572167.

Autologous stem-cell transplantation after second-line brentuximab vedotin in relapsed or refractory Hodgkin lymphoma

Background

We previously demonstrated that brentuximab vedotin (BV) used as second-line therapy in patients with Hodgkin lymphoma is a tolerable and effective bridge to autologous hematopoietic cell transplantation (AHCT). Here, we report the post-AHCT outcomes of patients treated with second-line standard/fixed-dose BV and an additional cohort of patients where positron-emission tomography adapted dose-escalation of second-line BV was utilized.

Patients and methods

Patients on the dose-escalation cohort received 1.8 mg/kg of BV intravenously every 3 weeks for two cycles. Patients in complete remission (CR) after two cycles received two additional cycles of BV at 1.8 mg/kg, while patients with stable disease or partial response were escalated to 2.4 mg/kg for two cycles. All patients, regardless of treatment cohort, proceeded directly to AHCT or received additional pre-AHCT therapy at the discretion of the treating physician based on remission status after second-line BV.

Results

Of the 20 patients enrolled to the BV dose-escalation cohort, 8 patients underwent BV dose-escalation. BV escalation was well-tolerated, but no patients who were escalated converted to CR. Of 56 evaluable patients treated across cohorts, the overall response rate (ORR) to second-line BV was 75% with 43% CR. Twenty-eight (50%) patients proceeded directly to AHCT without post-BV chemotherapy, and a total of 50 patients proceeded to AHCT. Thirteen patients received consolidative post-AHCT therapy with either radiation, BV, or a PD-1 inhibitor. After AHCT, the 2-year progression-free survival (PFS) and overall survival were 67% and 93%, respectively. The 2-year PFS among patients in CR at the time of AHCT (n = 37) was 71% compared with 54% in patients not in CR (p = 0.12). The 2-year PFS in patients who proceeded to AHCT directly after receiving BV alone was 77%.

Conclusions

Second-line BV is an effective bridge to AHCT that produces responses of sufficient depth to provide durable remission in conjunction with AHCT (clinicaltrials.gov: NCT01393717).

Pretransplant functional imaging and outcome in pediatric patients with relapsed/refractory Hodgkin lymphoma undergoing autologous transplantation

BACKGROUND

Pretransplant functional imaging (FI), particularly a negative positron emission tomography (PET), is a strong predictor of outcome in adults with relapsed or refractory Hodgkin lymphoma (HL), but data in pediatrics are limited.

METHODS

The medical records of 49 consecutive pediatric patients, who received autologous transplant at a single institution, were retrospectively analyzed. All patients had either gallium or PET scan before transplant and were conditioned with carmustine, etoposide, cytarabine, and melphalan (BEAM). Deauville scores were retrospectively assigned for patients with PET (score ≥ 4 positive).

RESULTS

Of the 49 patients (median age, 16.2 years), 41 (84%) were pretransplant FI negative and eight (16%) were pretransplant FI positive, after first- to fourth-line salvage therapy, and a median of two salvage cycles. Eighteen patients (37%) received posttransplant radiation. At a median follow up of 46 months, 45 patients (92%) were alive and disease free, and there were three nonrelapse deaths and only one relapse death (Deauville score of 5). The 4-year progression-free survival (PFS) for the entire cohort was 92% (95% confidence interval [CI]: 78-97), and PFS based on pretransplant disease status was 95% (95% CI: 82-99%) in the negative FI group versus 75% (95% CI: 31-93) if positive FI (P = 0.057).

CONCLUSION

Our analysis revealed outstanding outcomes for children and adolescents with relapsed/refractory HL. There were too few relapses to identify the predictive value of pretransplant metabolic status, but pediatric patients with relapsed/refractory HL and a negative pretransplant FI had excellent survival.

Evaluating the Predictive Ability of Initial Staging F-18 FDG PET/CT for the Prognosis of Non-Hodgkin Malignant Lymphoma Patients Who Underwent Stem Cell Transplantation

Objectives

This study aimed to determine the value of clinical prognostic factors and semiquantitative metabolic parameters from initial staging fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) in non-Hodgkin lymphoma (NHL) patients treated with stem cell transplantation (SCT).

Methods

A total of 39 malignant lymphoma patients who underwent initial staging F-18 FDG PET/CT were enrolled in this study. SUVmax, MTV_wb, and TLG_wb were measured during the initial staging PET/CT. Receiver operating characteristic curve (ROC) analysis was adopted to dichotomize continuous variables. Log-rank test and Cox proportional hazard regression analysis were used to evaluate disease-free survival (DFS) rate.

Results

Among the 39 patients with malignant lymphoma, 17 (43.6%) had a relapse. For several clinical factors such as age, ECOG performance score, AMC/ALC score, stages, and revised International Prognostic Index score, differences between the two dichotomized groups were statistically insignificant. In univariate analysis, DFS estimates were 71.0 ± 7.8 months and 18.0 ± 5.9 months in high-SUVmax and low-SUVmax group, respectively (P < 0.01). For MTV_wb, DFS estimates were 46.6 ± 12.4 months and 69.1 ± 8.5 months in high-MTV_wb and low-MTV_wb group, respectively (P = 0.12). For TLG_wb, DFS estimates were 65.3 ± 7.5 months and 13.7 ± 8.6 months in high-TLG_wb and low-TLG_wb group, respectively (P = 0.02). In Cox proportional hazard regression analysis, only MTV_wb showed statistical significance (HR 3.01, 95% CI 1.04-8.74, P = 0.04).

Conclusion

In NHL patients treated with SCT, the MTV_wb of initial staging F-18 FDG PET/CT was an independent prognostic factor.

Current strategies for salvage treatment for relapsed classical Hodgkin lymphoma

Hodgkin lymphoma (HL) is curable in 70-80% of patients with first-line therapy. However, relapses occur in a minority of patients with favorable early stage disease and are more frequent in patients with advanced HL. Salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell transplant (ASCT) for patients with chemotherapy-sensitive disease is a standard treatment sequence for relapsed or refractory (rel/ref) HL. Patients who achieve complete response prior to ASCT have better survival outcomes. The choice of salvage chemotherapy therapy is becoming increasingly difficult in the era of novel agents, as there are no randomized studies to guide the choice of a second-line regimen. In this article, we will review current salvage therapy options, including combination chemotherapy and novel-agent-based salvage regimens for rel/ref HL.

Risk-adapted transplant strategies for high-risk Hodgkin lymphoma: are we there?

PURPOSE OF REVIEW

The treatment of high-risk classic Hodgkin lymphoma (cHL) patients remains challenging, especially after autologous stem cell transplant (ASCT) failure. Moreover, the outcome of chemorefractory patients is still poor.

RECENT FINDINGS

The development of novel targeted therapies has changed the therapeutic options for high-risk patients. To improve outcome, treatment algorithms should integrate up-front, newly established prognostic markers. Tandem ASCT instead of single ASCT has been proposed as an option to improve outcome for high-risk patients. Availability of less toxic reduced intensity conditioning regimens and recent development in haploidentical transplantation have widened applicability and improved outcomes of allo-hematopoietic cell transplantation. Their exact role in cHL is still controversial and there is no consensus on the optimal transplantation strategy. In this context, results of tandem ASCT should also be compared with those of the autologous/reduced intensity conditioning-allo tandem approach. In this review, we discuss how transplantation strategies (auto and allo) can fit into the salvage treatment plan for patients with relapsed/refractory cHL, taking into account the new drugs available and integrating modern risk assessment.

SUMMARY

We speculated that improvements could be achieved by transplanting patients in earlier phases of their disease, if necessary after 'bridging' using the new drugs, and we propose an algorithm integrating the different treatment options.

How to Approach a Patient With Limited Stage Hodgkin Lymphoma Who Remains PET Positive at the End of Chemotherapy: Radiation Therapy?

The use of 18-F fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography has emerged as a crucial tool for response-adapted therapy in Hodgkin lymphoma (HL). Although more studies have focused on the predictive value of an interim or early PET obtained after 2 cycles of chemotherapy, there are indications that the end of therapy PET might even be more predictive of outcome. The optimal treatment of patients with limited stage HL who are PET-positive after chemotherapy is unknown. Here we review the prognostic significance of end of treatment PET in early stage HL, the role of consolidative radiotherapy in patients who have FDG-PET avidity at the end of chemotherapy, and discuss the place of salvage chemotherapy and autologous transplantation in these patients.

Advances in the pathophysiology and treatment of relapsed/refractory Hodgkin's lymphoma with an emphasis on targeted therapies and transplantation strategies

Hodgkin’s lymphoma (HL) is highly curable with first-line therapy. However, a minority of patients present with refractory disease or experience relapse after completion of frontline treatment. These patients are treated with salvage chemotherapy followed by autologous stem cell transplantation (ASCT), which remains the standard of care with curative potential for refractory or relapsed HL. Nevertheless, a significant percentage of such patients will progress after ASCT, and allogeneic hematopoietic stem cell transplantation remains the only curative approach in that setting. Recent advances in the pathophysiology of refractory or relapsed HL have provided the rationale for the development of novel targeted therapies with potent anti-HL activity and favorable toxicity profile, in contrast to cytotoxic chemotherapy. Brentuximab vedotin and programmed cell death-1-based immunotherapy have proven efficacy in the management of refractory or relapsed HL, whereas several other agents have shown promise in early clinical trials. Several of these agents are being incorporated with transplantation strategies in order to improve the outcomes of refractory or relapsed HL. In this review we summarize the current knowledge regarding the mechanisms responsible for the development of refractory/relapsed HL and the outcomes with current treatment strategies, with an emphasis on targeted therapies and hematopoietic stem cell transplantation.

Pretreatment metabolic parameters measured by 18F-FDG-PET to predict the outcome of first-line chemotherapy in extensive-stage small-cell lung cancer

OBJECTIVE

Patients' pretreatment metabolic burden, as measured by radiotracer fluorine-18 fluorodeoxyglucose (F-FDG) PET/computed tomography (CT), has been shown to predict treatment outcome in various malignancies. However, its predictive role in extensive-stage small cell lung cancer (SCLC) has not been definitively determined. This retrospective study investigated the viability of using common pretreatment metabolic parameters, obtained through F-FDG-PET/CT, to predict outcomes of first-line chemotherapy in extensive-stage SCLC.

PARTICIPANTS AND METHODS

The study population comprised 154 consecutive patients with extensive-stage SCLC who underwent a pretreatment F-FDG-PET/CT scan and received standard first-line chemotherapy between January 2011 and December 2015.

RESULTS

Ten (6.5%) and 66 (42.9%) patients achieved a complete or a partial response, respectively (considered an objective response); 35 (22.7%) and 43 (27.9%) experienced stable or progressive disease. The metabolic tumor volume (MTV) was a significant factor for predicting an objective response. For predicting disease control (objective response or stable disease), MTV and total lesion glycolysis (TLG) were nonindependent factors.

CONCLUSION

Greater MTV and TLG could indicate a poorer response to first-line chemotherapy for patients with extensive-stage SCLC, but the predictive efficiency was not high enough for routine reliance. For patients who are not suitable to receive first-line chemotherapy, MTV and TLG may help guide clinical decisions.

Novel agents and strategies in transplant-eligible patients with relapsed and refractory Hodgkin lymphoma

The majority of patients with Hodgkin lymphoma are cured with frontline therapy; however, 10% to 15% with early-stage disease and 20% to 30% with advanced stage require second-line therapy that includes a potentially curative transplant, of which an additional 50% to 55% are cured. Those with multiply relapsed disease traditionally would receive novel agents on a clinical trial or combination chemotherapy as a potential bridge to an allogeneic stem cell transplant. This treatment paradigm has changed with the availability of brentuximab vedotin, an antibody drug conjugate used pre- and post-ASCT, as well as for palliation. With the availability of the checkpoint inhibitors, nivolumab and pembrolizumab, there will be another shift in treatment, with these agents being used for palliation and potentially replacing allogeneic stem cell transplantation in certain patient populations. Finally, up-front management is also changing and this will have an impact on how patients in the relapsed and refractory setting will be treated.