Double-refractory Hodgkin lymphoma: tackling relapse after brentuximab vedotin and checkpoint inhibitors

Emerging immunotherapies in the Hodgkin lymphoma armamentarium

INTRODUCTION

Brentuximab vedotin and PD-1 inhibitors have improved outcomes for classic Hodgkin lymphoma (cHL), but better therapies are needed for patients who relapse after these agents. Based on an improved understanding of cHL biology, there is a robust pipeline of novel therapies in development. In this review, we highlight emerging immunotherapeutic agents and combinations for cHL.

AREAS COVERED

We review clinical trials of novel PD-1/PD-L1 inhibitors beyond FDA-approved agents, checkpoint inhibitors targeting CTLA-4, LAG-3, TIM-3, TIGIT, and CD47/SIRPα, PD-1 inhibitor combinations with immunomodulatory agents and epigenetic modifying therapies, antibody-drug conjugates, bispecific antibodies, and cellular therapies including anti-CD30 CAR-T and allogeneic NK cell therapy. We review the key safety and efficacy data from published phase 1-2 studies and highlight trials in progress, including the first phase 3 trial for PD-1 inhibitor-refractory cHL.

EXPERT OPINION

Many novel immunotherapies hold great promise in cHL. Rational combinations with existing agents and next-generation antibody and CAR-T constructs may improve response rates and durability. Identifying biomarkers of response to these immunotherapies and using more sensitive tools to assess response, such as circulating tumor DNA, may further inform treatment decisions and enable a precision medicine approach in the future.

Patient-reported outcomes in CD30-directed CAR-T cells against relapsed/refractory CD30+ lymphomas

Chimeric antigen receptor (CAR)-T cells targeting CD30 have demonstrated high response rates with durable remissions observed in a subset of patients with relapsed/refractory CD30+ hematologic malignancies, particularly classical Hodgkin lymphoma. This therapy has low rates of toxicity including cytokine release syndrome with no neurotoxicity observed in our phase 2 study. We collected patient-reported outcomes (PROs) on patients treated with CD30 directed CAR-T cells to evaluate the impact of this therapy on their symptom experience. We collected PROs including PROMIS (Patient-Reported Outcomes Measurement Information System) Global Health and Physical Function questionnaires and selected symptom questions from the NCI PRO-CTCAE in patients enrolled on our clinical trial of CD30-directed CAR-T cells at procurement, at time of CAR-T cell infusion, and at various time points post treatment. We compared PROMIS scores and overall symptom burden between pre-procurement, time of infusion, and at 4 weeks post infusion. At least one PRO measurement during the study period was found in 23 out of the 28 enrolled patients. Patient overall symptom burden, global health and mental health, and physical function were at or above baseline levels at 4 weeks post CAR-T cell infusion. In addition, PROMIS scores for patients who participated in the clinical trial were similar to the average healthy population. CD30 CAR-T cell therapy has a favorable toxicity profile with patient physical function and symptom burden recovering to at least their baseline pretreatment health by 1 month post infusion. Trial registration number: NCT02690545.

A Phase 2 Trial of Ibrutinib and Nivolumab in Patients with Relapsed or Refractory Classical Hodgkin's Lymphoma

BACKGROUND

Relapsed or refractory classical Hodgkin lymphoma (cHL) remains a difficult treatment challenge. Although checkpoint inhibitors (CPI) have provided clinical benefit for these patients, responses are generally not durable, and progression eventually occurs. Discovering combination therapies which maximize the immune response of CPI therapy may overcome this limitation. We hypothesized that adding ibrutinib to nivolumab will lead to deeper and more durable responses in cHL by promoting a more favorable immune microenvironment leading to enhanced T-cell-mediated anti-lymphoma responses.

METHODS

We conducted a single arm, phase II clinical trial testing the efficacy of nivolumab in combination with ibrutinib in patients ≥18 years of age with histologically confirmed cHL who had received at least one prior line of therapy. Prior treatment with CPIs was allowed. Ibrutinib was administered at 560 mg daily until progression in combination with nivolumab 3 mg/kg IV every 3 weeks for up to 16 cycles. The primary objective was complete response rate (CRR) assessed per Lugano criteria. Secondary objectives included overall response rate (ORR), safety, progression free survival (PFS), and duration of response (DoR).

RESULTS

A total of 17 patients from two academic centers were enrolled. The median age of all patients was 40 (range 20-84). The median number of prior lines of treatment was five (range 1-8), including 10 patients (58.8%) who had progressed on prior nivolumab therapy. Most treatment related events were mild (

CONCLUSIONS

Combined nivolumab and ibrutinib led to a CRR of 29.4% in R/R cHL. Although this study did not meet its primary efficacy endpoint of a CRR of 50%, likely due to enrollment of heavily pretreated patients including over half of who had progressed on prior nivolumab treatment, responses that were achieved with combination ibrutinib and nivolumab therapy tended to be durable even in the case of prior progression on nivolumab therapy. Larger studies investigating the efficacy of dual BTK inhibitor/immune checkpoint blockade, particularly in patients who had previously progressed on checkpoint blockade therapy, are warranted.

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Key Words

• Hodgkin’s lymphoma
• ibrutinib
• nivolumab

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MESH Headings Collapse

Grants

• P30 CA016058 NCI NIH HHS

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Affiliation(s)

Walter Hanel Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Polina Shindiapina Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
David A. Bond Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Yazeed Sawalha Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Narendranath Epperla Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Timothy Voorhees Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Rina Li Welkie Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Ying Huang Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Gregory K. Behbehani Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Xiaoli Zhang Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH 43210, USA
Eric McLaughlin Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH 43210, USA
Wing K. Chan Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Jonathan E. Brammer Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Samantha Jaglowski Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
John C. Reneau Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Beth A. Christian Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Basem M. William Blood and Marrow Transplant and Cell Therapy Program, OhioHealth, 500 Thomas Ln #A3, Columbus, OH 43214, USA
Jonathon B. Cohen Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, B4013, Atlanta, GA 30322, USA
Robert A. Baiocchi Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Kami Maddocks Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA
Kristie A. Blum Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Road NE, B4013, Atlanta, GA 30322, USA
Lapo Alinari Division of Hematology, Department of Medicine, The Ohio State University, 460 W 10th Ave., Columbus, OH 43210, USA

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Filling the Gap: The Immune Therapeutic Armamentarium for Relapsed/Refractory Hodgkin Lymphoma

Despite years of clinical progress which made Hodgkin lymphoma (HL) one of the most curable malignancies with conventional chemotherapy, refractoriness and recurrence may still affect up to 20–30% of patients. The revolution brought by the advent of immunotherapy in all kinds of neoplastic disorders is more than evident in this disease because anti-CD30 antibodies and checkpoint inhibitors have been able to rescue patients previously remaining without therapeutic options. Autologous hematopoietic cell transplantation still represents a significant step in the treatment algorithm for chemosensitive HL; however, the possibility to induce complete responses after allogeneic transplant procedures in patients receiving reduced-intensity conditioning regimens informs on its sensitivity to immunological control. Furthermore, the investigational application of adoptive T cell transfer therapies paves the way for future indications in this setting. Here, we seek to provide a fresh and up-to-date overview of the new immunotherapeutic agents dominating the scene of relapsed/refractory HL. In this optic, we will also review all the potential molecular mechanisms of tumor resistance, theoretically responsible for treatment failures, and we will discuss the place of allogeneic stem cell transplantation in the era of novel therapies.