[Immune evasion mechanism and its clinical application value in Hodgkin's lymphoma]

Hodgkin's lymphoma (HL) is a unique malignancy in which rare malignant Hodgkin and Reed-Sternberg (HRS) cells are scattered in the inflammatory cell rich microenvironment. This extensive but ineffective inflammatory cell infiltrate indicates that HRS cells have developed mechanisms to evade immune surveillance. The immune escape mechanisms of HL provide prognostic biomarkers and opportunities to develop new drugs. The immune evasion mechanisms in Hodgkin lymphoma include a reduction of human leukocyte antigen (HLA) to affect first signal which is essential for T cell activation; an upregulation of negative co-stimulatory molecules to inhibit T cell activation; resistance to apoptosis or killing by expressing some molecules on HRS cells membrane; an immunosuppressive network formed by HRS cells regulating the microenvironment immune cells. Immune escape mechanisms of HRS cells provide new targets for the development of new drug and the new drug development strategies include drugs on HRS cells and drugs on microenvironment.

Rapid desensitization to brentuximab vedotin after severe anaphylaxis in the treatment of refractory Hodgkin's lymphoma

INTRODUCTION

Brentuximab vedotin is a monoclonal antibody drug conjugate used for the treatment of patients with Hodgkin lymphoma. Hypersensitivity reactions to brentuximab vedotin may include cutaneous, cardiovascular, respiratory, gastrointestinal and neurological signs and symptoms.

CASE REPORT

We present the case of a 23-year-old Mexican female with stage IV progressive classical nodular sclerosing Hodgkin lymphoma who received multiple previous chemotherapy regimens. Brentuximab vedotin at 1.8 mg/kg (180 mg total dose), for 21-day cycles was indicated. Within 5 min of infusion of the 5th cycle of brentuximab, she developed severe anaphylaxis (hives, angioedema, diaphoresis, tachycardia, dyspnea, hypoxemia and loss of consciousness), which was successfully controlled with epinephrine, steroids and antihistamines.Management and outcome: Intradermal skin test at a concentration of 0.1 mg/ml was positive. Due to the severity of the symptoms and the lack of access to alternative treatments, we performed a desensitization protocol. A total of 180 mg of brentuximab was given in three bag solutions in 12 steps, with an initial concentration dose of 1/100 of the total dose in a course of 5.56 h with no hypersensitivity reactions.

DISCUSSION

Severe anaphylaxis has been reported in 1.2% of patients receiving brentuximab vedotin. Patients who are treated by rapid drug desensitization with their first option therapy present a favorable survival rate with better cost-effectiveness in comparison to second-line treatment.