Brentuximab-AVD Treatment for a Patient with Hodgkin Lymphoma and Cystic Fibrosis

Case Report

Ann Hematol Oncol. 2016; 3(1): 1072.

Brentuximab-AVD Treatment for a Patient with Hodgkin Lymphoma and Cystic Fibrosis

Petrini I¹*, Cervetti G², Galimberti S² and Cecconi N²

¹Department of Translational Medicine, Pisa University, Italy

²Department of Clinical and Experimental Medicine, Pisa University Hospital, Italy

*Corresponding author: Iacopo Petrini, Department of Translational Medicine, Pisa University, Italy

Received: January 08, 2016; Accepted: March 05, 2016; Published: March 10, 2016


A 22-year-old man with cystic fibrosis developed Hodgkin lymphoma with diffuse localizations. The use of the standard treatment, ABVD and radiotherapy, could be harmful because the risk of pulmonary toxicity. Therefore, we adopted a modified ABVD schedule with brentuximab vedotin instead of bleomycin. After one year, 15 moths the patient was in complete remission without impairments of lung function. This observation supports the use brentuximab vedotin-AVD schedule in patients with lung diseases, for which bleomycin toxicity could be harmful.

Keywords: Brentuximab; Cystic fibrosis; Hodgkin lymphoma


CT: Computed Tomography; FDG: Fluoro Deoxy Glucose; SUV: Standardized Uptake Values; IPS: International Prognostic Score; FVC: Forced Vital Capacity; FEV 1: Forced Expiratory Volume 1; MMEF: Maximum Midexpiratory Flow; BEACOPP: Bleomycin, Etoposide, Doxorubicin, Cyclophosphamide, Vincristine, Procarbazine and Prednisone; ABVD: Doxorubicin, Bleomycin, Vinblastine and Dacarbazine; GEV: Pegylated Liposomal Doxorubicin

Case Presentation

During November 2013, a 22-year-old man with cystic fibrosis was referred to our institution with a recent diagnosis of Hodgkin Lymphoma. Cystic fibrosis had been diagnosed earlier in the patient life with two heterozygous mutations: the mother’s allele carried the in-frame deletion of 3 nucleotides coding for a phenylalanine in 508 codon of the CTFR gene (ΔF508) whereas an uncommon and undetermined mutation was present in the father’s allele (molecular diagnosis from Galliera Hospital, Genova, in June 2000). During cystic fibrosis follow-up, a chest X-ray showed an irregular mediastinal profile and the computed tomography (CT) demonstrated a mass in the anterior mediastinum. The patient had mild breathing difficulties related to cystic fibrosis and Pseudomonas Aeruginosa was present in his sputum culture. The mass was removed by robotic surgery. The pathology report described a round-encapsulated tumor with a maximum diameter of 10 cm that was adherent to the parenchyma of the right superior lung lobe. The diagnosis was that of Hodgkin’s lymphoma: nodular sclerosis subtype, with areas of massive necrosis (CD30, PAX5 positive and CD15, CD20, CD3 and PAN-CK negative).

Baseline Fluorodeoxy Glucose (FDG) PET/CT showed hypercaptation in supradiaphragmatic lymph nodes and in the spleen: bilateral lateral cervical, retroclavicular, supraclavicular and mediastinal lymph nodes with maximum standardized uptake values (SUV) ranging from 3.5 to 10.7 and two focal lesions at the upper and lower pole of the spleen, SUV max 5.8. Blood counts, LDH, β2- microglubulin value, albumin levels and erythrocyte sedimentation rate were in the normal range. The patient did not refer any Hodgkin lymphoma related symptom. Therefore, the stage was IIIs A, according to the An Arbor classification with an International Prognostic Score (IPS) of 1 (sex male).

The treatment was decided thanking in consideration the risk of worsening lung fibrosis due to bleomycin that is present in the standard ABVD and BEACOPP schedules: the patient already had developed frequent episodes of pulmonary infections sustained by Pseudomonas Aeruginosa and impaired breathing capacity: forced vital capacity (FVC) 3400 (73%) forced expiratory volume 1 (FEV 1) 2640 (66%) FEV1/FVC 78%, maximum midexpiratory flow (MMEF) 2310ml/s (48%).

Initially, the patient received 2 cycles according to the IGEV regimen [1] without any hematological toxicity according to NIHCTCAE and without delay in schedule administration. However, the FDG-PET/CT documented the persistence of pathological lymphadenopathy (left latero cervical and supraclavicular), with an increase of the maximum standardize uptake values from 10.7 to 17 and a slight increase of node dimensions. Because of the response to chemotherapy was judged insufficient, a modified ABVD schedule was adopted with the replacement of bleomycin with brentuximab vedotin. The dose of brentuximab vedotin was 1.2 mg/kg every 14 days in combination with doxorubicin, dacarbazine and vinblastine. Prophylaxis was administered with daily fluconazole and twice a week sulfamethoxazole/trimethoprim for the entire duration of the treatment. A PET/CT was performed after 2 cycles of treatment showing a complete shutdown of FDG uptake. Patient received four additional cycles of AVD-brentuximab vedotin. The sixth cycle has been delayed of 1 week for an infective pulmonary complication: acute exacerbation of chronic obstructive pulmonary disease sustained by Staphylococcus Aureus that was successfully treated by tazobactam/ piperacillin and amikacin, according to antibiotic susceptibility test. Treatment toxicity included G3 neutropenia after the first and second cycles and a G1 neutropenia after the fifth cycle. The complete remission was confirmed after 1 month from the end of the treatment and currently maintained after 15 months follow-up. The respiratory function was preserved: FVC 4330 (93%) FEV 1 3200 (81%) FEV1/ FVC 83%, MMEF 2350 (48%) being all parameters comparable with those before the onset of the disease (Figure 1).

Citation: Petrini I, Cervetti G, Galimberti S and Cecconi N. Brentuximab-AVD Treatment for a Patient with Hodgkin Lymphoma and Cystic Fibrosis. Ann Hematol Oncol. 2016; 3(1): 1072. ISSN : 2375-7965