Bv-AVD Esclation after Partial Response to ABVD Chemotherapy in Patinets with HL: A Retrospective Study
Authors: Almuqbil Amani , Alrajhi Abdullah , Alshehri Hassan , Motabi Ibraheem H , Tailor Imran K , Alzahrani Kamal , Marei Mohammed , Alnoamani Mohammed S , Alshehry Nawal F , Alhumaid Muhned 
Published: December 2024

Background:

The frontline treatment of classical Hodgkin's lymphoma is either chemotherapy alone or a combination of chemotherapy with radiotherapy (CMT). ABVD became the most widely used chemotherapy regimen since 1975 due to its effectiveness and excellent safety profile compared to other alternative protocols. Still, around 10-30% of patients will not or have a suboptimal response to first-line ABVD; escalated BEACOPP can be an option for patients with advanced stage with partial response after first-line treatment with 60-70% three years of PFS. Combining Brentuximab vedotin (Bv) with AVD recently became a preferred option for the first-line treatment of advanced-stage HL.

We are here in our study showing real-world data of patients with early unfavourable to advanced stage disease who received ABVD and then escalated to Bv-AVD due to partial response instead of escBEACOPP, given our previous experience with its toxicity profile.

Methods:

A descriptive study of adolescents and adults (14 years old and older) was conducted in a tertiary hospital (King Fahad Medical City) between July 2022 and July 2024.

Patients were diagnosed with cHL and received 2-3 cycles of ABVD as a frontline. Then, the mid-treatment assessment was done using FDG-PET, with their Deauville scores between 4 and 5. The treatment was escalated to BV-AVD for four cycles, with mid-treatment and end-of-treatment assessments using FDG-PET. Overall survival (OS) and progression-free survival (PFS) were calculated from the time of diagnosis using the Kaplan-Meier method.

Results:

We identified 13 patients with a median age of 29 (15-47), four females (30.8%), Bulky disease in 4 patients (30.8%), and advanced stage in 12 patients (92%, including 3 with unfavourable early stage). Nine patients (70%) responded well after four cycles of A-AVD using FDG-PET (Deauville 1-2), and two patients required consolidative radiotherapy. One patient discontinued Bv after developing grade 4 peripheral neuropathy and erectile dysfunction. One patient didn't respond after two cycles and required salvage therapy. One patient has not done the disease assessment up to this date, and the remaining last patient, unfortunately, died because of bleomycin toxicity while on the third cycle of BV-AVD before the mid-treatment assessment.

After a median of 11 months, the estimated two years OS and PFS were 80% and 73%, respectively including the patient who died due to Bleomycin toxicity.

Conclusion:

Our data suggests that administering BV-AVD following a partial response to ABVD would be more reasonable, as it showed promising and favourable responses to our patients. This is especially true considering the toxicity profile of escBEACOPP significantly affects cytopenia's and infertility. With BV, the risk of febrile neutropenia could be decreased using GCSF support with the protocol. However, peripheral neuropathy remains a concern, for which we recommend implementing additional supportive measures to mitigate this risk. Prospective studies and longer follow-ups are essential to validate these findings and optimize treatment strategies.