DR WILLIAMS: This is a patient that, like a lot of the T-cell lymphomas we see, they come to us after they’ve already had 1 or 2 lines of therapy. So this is a 76-year-old, came in for evaluation of relapsed peripheral T-cell lymphoma. It was PTCL unspecified, or NOS. So initially he had presented with Stage IIIA disease, received 6 cycles of CHOP, achieved a remission, but then relapsed 9 months after. Had bilateral cervical nodes. Biopsy confirmed it was the PTCL. And a PET-CT scan showed nonbulky adenopathy in his mediastinum, axilla and retroperitoneum.
So he’s had Type 2 diabetes, mild hypertension, but otherwise a very fit 76-year-old. So the question is what to recommend for his next line of therapy.
DR LOVE: So Chris, what would you be thinking?
DR FLOWERS: So I think this is a gentleman we’re thinking about approaches that are going to be able to extend his disease-free survival but not necessarily going to be a candidate for transplant or some other kind of therapy down the road to try and induce a very long-term remission. And so I think some of the things that you want to think about are whether or not he actually needs treatment right now and whether you can use some sort of watchful waiting approach for some period of time. That’s less commonly used in peripheral T-cell lymphoma but something that you need to think about particularly in an older patient.
I typically would think about single-agent chemotherapies in this situation, things like gemcitabine-based regimens or pralatrexate. But I think B-vedotin is something that you could also consider if this guy’s CD30-positive.
DR LOVE: What do we know about the incidence of CD30 positivity?
DR VOSE: It’s about 30%. It was in Lugano.
DR WILLIAMS: Yes. It was just something that — Lugano. And I think ASCO had a poster that was similar.
DR EVENS: But now isn’t there a question — does it matter?
DR VOSE: There’s a question whether it really matters or not. That’s something that’s not known and being potentially tested, people don’t necessarily have to be CD30-positive. By standard means.
DR EVENS: Or at least that we can detect. In other words, by flow or immunohistochemistry, there might be kind of subcellular levels of CD30.
DR VOSE: That can’t be detected by standard methods.
DR LOVE: And specifically the patients might respond to B-vedotin or do respond to B-vedotin?
DR VOSE: There’s some diffuse large cell data that they don’t necessarily have to be CD30-positive to respond.
DR FLOWERS: And there was a CTCL trial that looks like even in patients who had low levels or no levels of CD30 positivity, that they still responded in that situation.
DR WILLIAMS: I was going to say it’s sort of analogous to that older data from MD Anderson with denileukin diftitox where it didn’t matter if you were CD25-positive or not for the IL-2 receptor. You could respond. So —
DR EVENS: So there are ongoing studies in all those patient populations that were just discussed with brentuximab vedotin.
DR LOVE: Including CD30, quote, negative?
DR EVENS: I think that’s under discussion. I don’t know if that’s actively up and running, but I know they’re definitely looking at low expressers, “low” meaning like less than 1 to 5%.
DR VOSE: But for the diffuse large cell study, they don’t have to be CD30-positive. So…
DR LOVE: So getting back to this man, Julie, what would you be thinking?
DR VOSE: So similar thought pattern. We’re not going to cure this patient. He can’t have really super aggressive therapy, most likely, from what you’re saying. I probably — my top line nowadays for this type of patient is probably romidepsin, because I think they tolerate that better than pralatrexate. Gemcitabine is another opportunity, but single agent. Probably sequential single agent.
DR LOVE: What do you see in terms of tolerability, particular of romidepsin versus pralatrexate?
DR VOSE: The issue with pralatrexate is mucositis is a problem, and especially in older patients. They just don’t tolerate that very well at all. So that’s the problem with that particular agent. Romidepsin has some cytopenias, definitely fatigue, but it’s relatively well tolerated.
DR LOVE: And in terms of the pralatrexate mucositis, do you do anything to try to prevent it? How do you manage it? By dose reductions?
DR VOSE: Right. So you need to try to give vitamin B12 and folate, has to start at least 10 days before the first treatment, which is sometimes an issue with some of these aggressive T-cell lymphoma patients. And there’s some data about using ice chips, as we do with melphalan with pralatrexate. There’s also a little bit of data in patients that have developed mucositis to use leucovorin. And there are some data about using that, as well. So some things to try.
DR LOVE: So what happened with this patient?
DR WILLIAMS: So this patient actually got pralatrexate as second line. He received it from the local oncologist, gave him the same recommendation about single-agent therapy and got pralatrexate. And I’ve not seen the patient back, but my understanding is that had a partial response to it, some mucositis, but overall tolerated it reasonably well. Anticipation would be that at further progression will likely get romidepsin.
DR LOVE: What’s your experience in terms of tolerability of these 2 agents?
DR WILLIAMS: I find romidepsin is more user friendly, better tolerated.