Brentuximab Vedotin Plus ESHAP (BRESHAP) Versus ESHAP As Salvage Strategy for Patients with Primary Refractory or Relapsed Classical Hodgkin's Lymphoma. Preliminary Results from the Breselibet Prospective Clinical Trial
Authors: Sureda Anna , González Ana Pilar , Núñez Javier , Briones Javier , De la Cruz Fátima , Eva Domingo Domenech , Hernandez Francisca Maria , Terol María José , Amutio Elena , Cordoba Raul , Martínez Carmen , Moreno Miriam , Rodriguez Izquierdo Antonia , Del Campo Raquel , Greil Richard , Romero Samuel , Garcia-Sanz Ramón 
Published: November 2021

Abstract
Introduction. Patients with relapsed/refractory classical Hodgkin's lymphoma (RRHL) still represent a therapeutic challenge. Consolidation with autologous stem cell transplantation (auto-HCT) is the standard of care in this setting. The achievement of a metabolic complete remission (mCR) with salvage chemotherapy (CT) improves long-term outcome after auto-HCT. The introduction of new drugs has significantly changed the landscape of RRHL. Our cooperative group (GELTAMO) has already demonstrated that brentuximab vedotin (BV) + ESHAP (BRESHAP, García-Sanz R et al, Ann Oncol 2019) is able to achieve a mCR rate of 70% before auto-HCT in patients with RRHL. Nevertheless, the superiority of BV + CT vs CT alone has never been tested in prospective randomized clinical trials. Additionally, it is unknown if consolidation treatment with BV could eventually spare auto-HCT in a good risk group of RRHL patients.
Objectives. We have conducted a phase IIb prospective clinical trial (BRESELIBET, ClinicalTrials.gov ID: NCT04378647) that evaluates the efficacy of salvage therapy with BRESHAP vs ESHAP in patients with RRHL, followed by BV consolidation (instead of auto-HCT) in those who attained a mCR after salvage therapy.
Methods. 150 adult patients with classical RRHL after one line of therapy were to be included and randomized 1:1 in an open label design to receive either BRESHAP [BV (1.8 mg/m 2 iv, D1), etoposide (40 mg/m 2/day iv, D1-4), Solumedrol (250 mg/day iv, D1-4), Ara-C (2 g/m 2 iv, D5) and cisplatin (25 mg/m 2/day iv, D1-4)] (x3 cycles) or ESHAP (x3 cycles). Primary efficacy endpoint of the trial was mCR [Deauville Score (DS) of 1-2]. Those patients in mCR went on to receive up to a 16 doses of BV (1.8 mg/kg iv every 3 weeks) unless unacceptable toxicity or disease progression. Patients not achieving a mCR went off the trial. Herein we are reporting preliminary results of the first 43 patients treated within the trial.
Results. As of June 2021, 47 patients have been enrolled; 3 of them have been screening failures and one patient is still under screening. Among the remaining 43 patients [28 males, age at inclusion of 42 (18-64) years, median (range)], 15 were primary refractory, 15 had an early relapse (1 st CR &lt;12 months) and 13 a late relapse (1 st CR ≥12 months). Twenty-two patients were randomized into the BRESHAP arm and 21 into the ESHAP arm. There were no significant clinical differences at inclusion between both arms. Twenty-nine patients have completed salvage therapy and have had their disease status evaluated, 1 patient was discontinued from the trial because of an adverse event (AE) during second line therapy (BRESHAP arm), 2 patients progressed under therapy (both of them assigned to the BRESHAP arm) and 11 patients are still under treatment. Twelve patients (5 BRESHAP; 7 ESHAP) achieved a mCR as defined in the trial (41.3%, NS between both arms). All of them have started consolidation with BV; after a median of 4 (1-12) cycles, only one patient assigned to the BRESHAP arm has relapsed after the 3 rd cycle. 17 patients' disease did not achieve a mCR and discontinued treatment on the trial: 6 were DS3, 2 DS4 and 9 DS5. All patients with DS3 after salvage treatment were subsequently consolidated with auto-HCT off trial and are in continuous CR. Nine severe AEs were reported in 7 patients [fever (n=3), sepsis (n=2), pneumonia (n=1), pericardial effusion (n=1), diarrhea (n=1), vomiting (n=1)]. Grade 3-4 hematological toxicity was seen in 13 cases: neutropenia (n=9), thrombocytopenia (n=8) and anemia (n=7) with only 4 cases of grade 3-4 infectious episodes. Grade 3-4 non-hematological AE (≥5% of cases) were hypomagnesemia (n=2) and non-neutropenia fever (n=1). No treatment related deaths have been reported.
Conclusions. BRESELIBET trial is a randomized trial that tries to demonstrate the superiority of BRESHAP vs ESHAP in RRHL as well as the feasibility of a non-transplant option in patients achieving a stringent CR assessed by PET-CT. These initial results provide safety data as possible support for these two hypotheses and the trial enrollment continues.

Disclosures
Sureda: Takeda: Consultancy, Honoraria, Speakers Bureau; BMS: Consultancy, Honoraria; MSD: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Gilead Kite: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Amgen: Honoraria; Mundipharma: Consultancy. Núñez: Tekada: Consultancy; Incyte: Consultancy. De la Cruz: Abbvie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Beigene: Membership on an entity's Board of Directors or advisory committees; EUSA Pharma: Membership on an entity's Board of Directors or advisory committees; JANSSEN: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Kyowa Kirkin: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Eva: Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Terol: Janssen: Membership on an entity's Board of Directors or advisory committees, Other: Travel, Research Funding; Roche: Membership on an entity's Board of Directors or advisory committees, Other: Travel; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel; Takeda: Membership on an entity's Board of Directors or advisory committees, Other: Travel; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Research Funding; Roche: Consultancy; BMS: Consultancy; Hospital Clinico Valencia: Current Employment. Cordoba: ADCTherapeutics: Membership on an entity's Board of Directors or advisory committees; Kyowa-Kirin: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Kite: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Incyte: Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding. Greil: Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; AstraZeneca: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses; MSD: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Gilead: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Daiichi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Sankyo: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, Accommodations, Expenses, Research Funding; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Honoraria, Other: Travel, Accommodations, Expenses, Research Funding; Sandoz: Honoraria, Research Funding. Romero: Takeda: Honoraria; Alexion: Honoraria.