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Below, week by week, is what OnCo's record of Relapsed and refractory classical Hodgkin lymphoma says about the first two months: the order is typical, the timing is yours to ask about. Relapsed or refractory classical Hodgkin lymphoma is Hodgkin lymphoma that comes back or does not respond after first-line chemotherapy. The standard path is salvage chemotherapy, often with brentuximab vedotin or a PD-1 antibody, then high-dose chemotherapy with an autologous stem cell transplant; for those who relapse again, nivolumab and pembrolizumab give lasting control in many. Sections appear only where the record has something to say. Orientation, not medical advice.
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Platinum-based chemotherapy (ICE, DHAP, GVD) increasingly combined with brentuximab vedotin or pembrolizumab, or brentuximab vedotin with nivolumab, to reach PET-negative remission.
High-dose chemotherapy with autologous stem cell transplantation for chemosensitive relapse; brentuximab vedotin maintenance for a year in high-risk patients (AETHERA).
Allogeneic transplantation for fit patients; bendamustine, gemcitabine or everolimus; CD30 CAR T cells and bispecific antibodies in trials.
PD-1 antibody with or without brentuximab vedotin as ongoing therapy; palliative radiotherapy for symptomatic sites.
This is a small group and there is no standard. Options, roughly in the order they are usually considered: re-treatment with a PD-1 antibody after a chemotherapy-induced response, because chemotherapy can restore sensitivity; an allogeneic transplant with reduced-intensity conditioning in a fit younger patient, which is the only treatment with curative potential; anti-CD30 CAR-T, which has produced responses in phase 1 and 2 studies and is not approved; gemcitabine-based or single-agent chemotherapy for control; involved-site radiotherapy for a symptomatic site, which is highly effective in a radiosensitive disease; and a clinical trial, which at this point is often the best available treatment. The conversation about aim belongs here explicitly. Palliative radiotherapy and low-intensity chemotherapy can give good quality of life for a long time in Hodgkin lymphoma, and early involvement of a palliative care team alongside oncology is recommended rather than deferred.
Pembrolizumab (KEYNOTE-204) or nivolumab (CheckMate 205); brentuximab vedotin if not previously given; PD-1 antibodies in China include penpulimab and others.
The aim of salvage treatment is not a response but a negative PET, because the proportion of patients cured by the transplant that follows depends more on the depth of the remission before it than on which salvage regimen produced it. Salvage regimens in use: brentuximab vedotin with bendamustine; brentuximab vedotin with nivolumab, which produces high complete response rates without chemotherapy; ICE or IGEV or DHAP or ESHAP. There is no randomised trial ranking them, and the choice is made on toxicity, on stem cell mobilisation and on what the patient has already had. Two to three cycles, then a PET; if it is negative, proceed to BEAM conditioning and autologous transplant; if it is positive, change salvage rather than proceeding. Consolidation after transplant with brentuximab vedotin is standard for patients at high risk of relapse, on the strength of AETHERA, which randomised 329 such patients to brentuximab vedotin or placebo and gave median progression-free survival of 42.9 against 24.1 months (hazard ratio 0.57). High risk means primary refractory disease, relapse within twelve months, or extranodal disease at relapse. Patients who received brentuximab vedotin in first-line treatment are a group in whom this is less clear.
Classical Hodgkin lymphoma has amplification of chromosome 9p24.1, which drives expression of PD-L1 and PD-L2, and it is the disease in which PD-1 blockade works best of all. Nivolumab. CheckMate 205 treated 243 patients after autologous transplant failure and reported an objective response of 69 per cent, with responses lasting in many. It is also active after both autologous transplant and brentuximab vedotin have failed. Pembrolizumab. KEYNOTE-204 randomised 304 patients with relapsed or refractory classical Hodgkin lymphoma to pembrolizumab or brentuximab vedotin and gave median progression-free survival of 13.2 against 8.3 months (hazard ratio 0.65), which established PD-1 blockade as preferred over brentuximab vedotin at this point for patients who have had one or the other. Combinations of brentuximab vedotin with nivolumab are used as a bridge to transplant and in later lines. Where a response is achieved in a fit younger patient who has already had an autologous transplant, an allogeneic transplant with reduced-intensity conditioning is considered, although PD-1 blockade before allogeneic transplant increases the risk of severe graft-versus-host disease and the timing has to be planned with the transplant team.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
Every term links to the glossary.