A Chinese patient with relapsed and refractory Hodgkin lymphoma treated with brentuximab vedotin
A 17-year-old girl presented with painless swelling of the right neck and supraclavicular lymph nodes accompanied with fever and fatigue in February 2007. The pathology report after lymph node biopsy indicated that the normal lymph node structure had disappeared and scattered distributions of Reed-Sternberg (RS) cells and Hodgkin disease (HD) cells occurred. Immunohistochemical staining showed that these cells were positive for CD30 (), paired box protein 5 (PAX5) (), and Epstein-Barr virus (EBV), and negative for CD15 and anaplastic lymphoma kinase (ALK). The patient was diagnosed with stage IIa HL, mixed cellularity subtype. Treatment with 4 cycles of ABVD was conducted as induction chemotherapy followed by bilateral neck and supraclavicular radiation therapy (36 Gy). The patient achieved complete remission (CR) but, after about 1 year, relapsed with inguinal and mediastinal lymph node involvement, as detected by positron emission tomography (PET)/computed tomography (CT) scan. Afterwards, 8 cycles of salvage chemotherapy with cyclophosphamide, vindesine, epirubicin, and prednisone (CHOP) were performed, and the patient achieved CR again.\nA PET/CT scan in April 2010 indicated relapse, with mediastinal, left axillary, retroperitoneal, pelvic cavity, and inguinal lymph node involvement and multiple nodules at the thoracolumbar vertebrae, right iliac crest, and right ischium. The patient was diagnosed with HL of nodular sclerosis subtype after a left inguinal lymph node biopsy. She then underwent 2 cycles of salvage chemotherapy with rituximab, cyclophosphamide, vindesine, epirubicin, prednisone, and etoposide (R-CHOPE) and underwent ASCT in December 2010. A PET/CT scan in June 2011 subsequently demonstrated relapse once more, with nodules in the liver, spleen, and lung (). The patient gradually developed pancytopenia during the treatment progress. Consequently, 2 cycles of salvage chemotherapy with gemcitabine, dexamethasone and nedaplatin (GDP) were given, but the disease persisted at the end of therapy. On October 20th, 2011, results of CT scan showed that the number and size of nodules in the lung significantly increased (). The patient exhibited persistent fever and systemic failure, and showed an Eastern Cancer Oncology Group (ECOG) score of 3.\nIn October 2011, the patient began brentuximab monotherapy, with a dose of 1.8 mg/kg, once every 3 weeks. Following the first course of brentuximab, the patient's body temperature dropped gradually after 4 days of treatment and returned to normal 1 week later. Because of bone marrow involvement, white blood cell, hemoglobin, and platelet counts decreased markedly before treatment. However, the patient continued with brentuximab therapy without interruption under the support of granulocyte colony-stimulating factor (G-CSF), thrombopoietin (TPO), and interleukin-11 (IL-11). Following the first course of brentuximab, CT scan showed that the lung nodules were significantly reduced in size and number (). After the second treatment, the patient began to recover from pancytopenia and regain physical strength, and her condition improved significantly. After the third course of treatment, the patient was capable of self-care, indicating an ECOG score of 2. PET/CT scan suggested partial remission (PR). After the fourth course of treatment, anemia began to improve, with hemoglobin increasing from 60 to 100 g/L. After physical activity palpitations disappeared, the patient's heart rate fell from 110–130 to 70–80 beats/min. Shrinkage was noted in multiple nodular shadows in double lung fields (). After the sixth course of treatment, hemoglobin count had nearly returned to normal, and lesions in the lungs, liver, spleen, bones, mediastinum, and abdomen significantly decreased. A PET/CT scan showed that the lung nodules had disappeared, and the maximum standard uptake values (SUVmax) of thoracolumbar vertebral nodules and liver and spleen nodules had decreased to normal (). The patient achieved CR, and the ECOG score was 1. The patient encountered reversible adverse reactions during treatment, including peripheral neuropathy, elevated aminotransferases, hair loss, and dry cough, and these adverse effects were controlled with symptomatic treatments. At the time this paper was submitted, the patient had never suffered from infection.