Is Dose-Dense BV-ICE an Effective Salvage Option in Relapsed/Refractory Classical Hodgkin Lymphoma?

For patients with relapsed/refractory classical Hodgkin lymphoma (cHL), second-line therapy with a combination of intensive dose-dense brentuximab vedotin (BV) and ifosfamide, carboplatin, and etoposide (ICE) chemotherapy led to high rates of complete response (CR), according to findings published in Lancet Haematology.

ICE is the most commonly used chemotherapy-based salvage regimen in the U.S., corresponding study author Ajay Gopal, MD, of the University of Washington in Seattle, told ASH Clinical News. Dr. Gopal added that this study represents the first publication of results of BV-ICE and is “the first to show that higher-than-standard per-cycle dosing can be safely combined with short course chemotherapy.”

Dr. Gopal added that the BV-ICE regimen “may be preferred for younger, high-risk patients with cHL when rapid achievement of remission is required.” The researchers wrote that the combination may be particularly feasible in transplantation-eligible patients younger than age 60 with cHL in first relapse.

In this open-label, phase I/II study, Dr. Gopal and researchers examined the safety and activity of dose-dense BV-ICE as a second-line treatment in 45 patients with cHL. In the phase I portion, investigators conducted a 3+3 dose escalation study to identify a maximum tolerated dose of the regimen to be used in phase II.

Per study protocol, BV was intravenously administered on days one and eight at 1.2 mg/kg (dose level 1) or 1.5 mg/kg (dose level 2). Standard ICE doses were administered on days one through three for two cycles, with each cycle lasting 21 days.

The median age of patients in the study was 31 years. Approximately 96% of patients (n=43) received ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) as primary therapy, with or without omission of bleomycin. Nearly two-thirds of patients (64%; n=29) had primary refractory cHL at baseline, and 84% (n=38) were considered at high risk of relapse. Most patients in the study cohort were women (64%).

The first three patients in the phase I portion of the trial received BV 1.2 mg/kg and showed no signs of dose-limiting toxicities. In contrast, the next six patients treated with BV 1.5 mg/kg experienced dose-limiting toxicities. Given these findings, 1.5 mg/kg was established as the maximum tolerated dose and the recommended phase II dose.

After a median follow-up of 3.1 years, most evaluable patients (74%) achieved CR after two treatment cycles (TABLE). The researchers noted that this CR rate fell under the prespecified CR target of 78%. In a post hoc subgroup analysis of 28 patients with primary refractory disease, the overall response rate was 86%, while the CR rate was 68%.

The researchers noted relatively high rates of grade 3/4 hematologic adverse events (AEs), including:

  • neutropenia (73%)
  • anemia (13%)
  • thrombocytopenia (80%)

The most common grade 3/4, non-hematologic AEs included: febrile neutropenia (9%), sepsis (13%), increased alanine aminotransferase (11%), hyperglycemia (7%), pulmonary embolism (4%), and increased aspartate aminotransferase (4%).

Thirteen patients (29%) experienced serious AEs. One on-treatment death occurred, which the authors reported was caused by multisystem organ failure and deemed related to the therapy.

“Our data suggest that dose-dense BV-ICE is a rapidly administered and active salvage regimen for patients with relapsed or refractory cHL, despite a complete response in this trial lower than the prespecified phase II target,” the authors concluded. “Although cross-trial comparisons should be made with caution, activity results seem to be similar to previously presented BV chemotherapy salvage combinations delivered over much longer durations and can be considered in young (<60 years), transplantation-eligible patients for second-line therapy.”

Describing potential limitations of this study, Dr. Gopal acknowledged its single-arm, phase I/II design. “Intensive BV dosing with multi-agent platinum-based chemotherapy needs to be compared against BV anti-PD1 combinations in the second line,” he said.

Study authors reported relationships with Seagen, which sponsored and funded the trial.

Reference

Lynch RC, Cassaday RD, Smith SD, et al. Dose-dense brentuximab vedotin plus ifosfamide, carboplatin, and etoposide for second-line treatment of relapsed or refractory classical Hodgkin lymphoma: a single centre, phase 1/2 study. Lancet Haematol. 2021;8(8):e562-e571.