Sequential Pembrolizumab Followed By AVD in Advanced Hodgkin Lymphoma: A Retrospective Study from North India

Background: Hodgkin lymphoma (HL) is one of the most curable forms of cancer, with high treatment success rates. Advances in treatment options, including chemotherapy, radiation therapy, and immunotherapy, have significantly improved the prognosis for patients with HL.

Methods: We performed a retrospective study of 15 HL patients, including adolescents and elderly, treated at two tertiary centers in north India between 2023 and 2024. The treatment regimen consisted of the sequential administration of Pembrolizumab with Adriamycin, Vinblastine, and Dacarbazine (AVD). Pembrolizumab (IV, 200 mg) was administered every 21 days starting on cycle 1, day 1, followed by interim assessment with PET-CT. Patients who achieved partial or complete metabolic response were subsequently given six cycles of AVD (doxorubicin [IV, 25 mg/m2], vinblastine [IV, 6 mg/m2], and dacarbazine [IV, 375 mg/m2]).

Results: This study includes patients with a median age of 43 years, spanning from 16 to 74 years. The cohort comprises 66.7% males and 33.3% females. All patients were advanced stage (stage III or IV). The distribution of the International Prognostic Score (IPS) is as follows: 46.7% with scores of 0-1, 20% with a score of 2, 13.3% with a score of 3, and 20% with a score of ≥4. B symptoms are present in 46.7% of the patients. After three cycles pembrolizumab immunotherapy, the observed responses are: 46.6% with a complete response, 40.0% with a partial response, 6% with progressive disease, and 6% resulting in death. Following the administration of six AVD cycles of Pembrolizumab 14 patients are evaluable as 1 is still on treatment, the complete metabolic response is 78.5%, with 14.2 % showing refractory disease.

Conclusion: Sequential pembrolizumab followed by AVD is a promising first-line treatment for advanced-stage Hodgkin's lymphoma, but it doesn't always result in a fairytale outcome for every patient. Here, for the first time, we demonstrate that sequential Pembrolizumab-AVD therapy has shown a refractory response in 14.2 % patients, whereas it has achieved 100% complete response rates in studies conducted worldwide. This suggests potential regional differences in treatment efficacy or patient response. Further studies are needed to explore the underlying reasons and to optimize therapeutic strategies for Hodgkin Lymphoma in diverse populations.

No relevant conflicts of interest to declare.