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PET-Adapted Treatment of Hodgkin Lymphoma
Combined-modality treatment — chemotherapy plus radiotherapy — has been a standard of care for patients with limited-stage bulky Hodgkin lymphoma. Investigators now report a single-arm, multicenter, phase 2 trial in which patients with stage I–II bulky disease received two cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) followed by interim restaging positron emission tomography scan (PET2). Patients with negative scans (Deauville score 1–3) then received four additional ABVD cycles, while patients with positive scans (Deauville score 4–5) received four cycles of escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) followed by 30 Gy involved-field radiation therapy. PET scans were centrally reviewed.
Of 94 evaluable patients, median age was 30 (range, 18–58) and most had stage II disease; 78% were PET2-negative and 22% were PET2-positive. Three-year progression-free survival (PFS; the primary endpoint) was 93.1% in the PET2-negative group and 89.7% in the PET2-positive group. Toxicities, including neutropenia and febrile neutropenia, were as expected for these regimens.
This PET-adapted study met the objective of maintaining ongoing remissions in PET2-negative patients treated with chemotherapy only without the addition of radiation therapy. Of note, similar durable response was achieved via chemotherapy intensification plus involved-field radiation therapy in PET2-positive patients, an improvement from prior studies of patients in this population not undergoing risk-adapted treatment escalation. The authors recommend eliminating bleomycin from cycles three to six in PET2-negative patients, consistent with current practice. The avoidance of radiotherapy is an important achievement that will decrease incident cardiovascular and second primary cancer events in the decades following curative treatment.
Importantly, a just-reported European trial in children and adolescents with early-stage classical Hodgkin lymphoma also showed that PET2-negative patients can be spared radiotherapy while maintaining very high 5-year event-free survival (Lancet Oncol 2023; 24:252).
In addition, another newly reported phase 2 trial showed 100% PFS with the addition of the immune checkpoint inhibitor nivolumab to four AVD cycles in patients with early-stage unfavorable Hodgkin lymphoma, although all patients in this study received 30 Gy involved-site radiation (J Clin Oncol 2023; 41:1193).
LaCasce AS et al.
Title: Positron emission tomography–adapted therapy in bulky stage I/II classic Hodgkin lymphoma: CALGB 50801 (Alliance).
Source: J Clin Oncol 2023 Feb 10; [e-pub]. (Abstract/FREE Full Text)