Faculty Q&A Discussion: Brentuximab Vedotin

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 Dr. Armitage: It is no surprise that brentuximab vedotin is really an exciting agent, and it gives us a new opportunity in treating classical Hodgkin lymphoma. What if this person Dr. Engert just presented was at the same point with nodular lymphocyte-predominant lymphoma and no CD30 positivity. What would you do in that case?

 Dr. Engert: Patients differ in terms of their immunophenotype, and some do not express much CD30, but they do express CD20, an antigen that is basically expressed on Hodgkin lymphoma cells. So these tumors are strongly CD20-positive, and rituximab (Rituxan) or other antibodies against CD20 have been used successfully in these patients.

 Dr. Armitage: When a patient with classical Hodgkin lymphoma goes into remission in a timely way after brentuximab vedotin, when should you just monitor that response and hope that the patient is one of those who appear to be cured? When is it better to do that, and when is it better to take other chances?

 Dr. Connors: My perspective is that we may be seeing our whole approach to treating the disease change with the availability of this new agent. Because in the case of a patient with primary progressive disease, until now, we did not have a way to achieve such good disease control that an allotransplant would be an attractive option. This may be a game-changing intervention with a greater depth of response that makes that intervention available.

I would have been very uncomfortable relying solely on the experimental intervention with brentuximab, however, and my choice would have been to proceed as Dr. Engert did, offering this patient what may or may not work, but at least giving her the best chance.

 Dr. Armitage: Are there patients for whom you would not do such a thing—for example, a 50-year-old patient with a mismatched unrelated donor—where you would either take the complete response and hope that it lasts or give ongoing brentuximab?

 Dr. Horwitz: In some ways, you can base that decision on a patient’s disease course. There are people who have more of a chronic Hodgkin lymphoma and respond to one treatment after another. With these patients, you have a sense of confidence that if you lose that remission, you could get another one. These are patients you can keep retreating, and I think in these people, there is sometimes a temptation to spare them the toxicity and the unknown risk of allotransplantation.

In the case of the patient described, however, you would be very surprised to achieve a remission from anything. In this case, you would be apprehensive about letting that remission pass without performing an allotransplant.

 Dr. Connors: This patient needs to have an honest appraisal of both the likelihood that an allotransplant is going to work and the potential toxicity involved. I hope the story turns out happy in the end, but there is still a very high chance she is going to relapse again, and all you can do is offer the best opportunity for remission. ■

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