Combination chemotherapy and experimental immunotherapy in the treatment of Stage III-IV HIV-associated Hodgkin lymphoma

Does adding immunotherapy (brentuximab vedotin) to combination chemotherapy (AVD) better treat (HIV)-associated Hodgkin lymphoma?

Open to people ages 18 years and up

1. Age ≥ 18 years. Because no dosing or adverse event data are currently available on the use of brentuximab vedotin in combination with AVD in patients <18 years of age, children are excluded from this study
2. HIV-1 infection, as documented by licensed HIV rapid test performed in conjunction with screening (or ELISA test kit and confirmed by Western blot or other approved test). A measurable HIV viral load alone is not sufficient for documentation of the diagnosis of HIV. Alternatively, this documentation may include a record that another physician has documented that the participant has HIV infection based on prior ELISA and western blot, or other approved diagnostic tests
3. Histologic diagnosis of CD30-positive classical HL as defined by the 2008 WHO Classification of Hematological diseases. Nodular lymphocyte predominant Hodgkin Lymphoma is not eligible
4. Stage III or IV disease as defined by the Ann Arbor Staging System
5. Participants must have previously untreated HIV-cHL, with the exception of up to 14 consecutive days of steroids or 1 prior cycle of cyclophosphamide to reduce tumor burden and improve hyperbilirubinemia in the setting of lymphoma related liver involvement
6. Normal baseline cardiac ejection fraction ≥ 50%
7. Serum creatinine of ≤ 1.5 mg/dL. If creatinine >1.5 mg/dL (132 micromol/L), creatinine clearance must be ≥ 60 mL/minute according to MDRD/Cockroft-Gault formula
8. ANC ≥ 1000/µL and platelets ≥ 75,000/µL unless related to bone marrow involvement by HIV-cHL

9. A direct bilirubin level of ≤ 2.0 mg/dL (34 µmol/L). If, however, the elevated bilirubin is felt to be secondary to antiretroviral therapy, the total bilirubin must be ≤ 3.5 mg/dL (59 µmol/L), provided that the direct bilirubin is normal and the AST and ALT ≤ 3 x the upper limit of normal. Also, if the elevated bilirubin is thought to be secondary to cHL the patients should not be excluded from study participation

   10. Female subjects must have a negative pregnancy test within 1 week of enrollment and

   all subjects must agree to use two reliable methods of contraception simultaneously if conception is possible during the study

   • Should a woman subject become pregnant or suspect she is pregnant while the subject is participating in this study, she should inform her treating physician immediately. The patient will then be removed from protocol therapy
   • Subjects who father a child while participating in the study will be permitted to continue with the protocol. The subject, however, is required to notify the investigator if he fathers a child
     1. Ability to understand and the willingness to sign a written informed consent document
     2. Karnofsky performance status > 30% (given the aggressiveness of this disease and the often severely debilitated nature of the patients at initial presentation). See Appendix 20.519.5
        1. Measurable or non-measurable (evaluable) tumor parameter(s). Non-measurable tumor parameters will be defined as not having bi-dimensional measurements (i.e., gastric or marrow involvement) but can be followed for response by other diagnostic tests such as gallium, PET imaging and/or bone marrow biopsy
        2. Patients already receiving erythropoietin or GCSF for treatment of HIV-related cytopenia are eligible
        3. CD4 count ≥ 100 cells/µl and serum HIV viral load <50copies/ml
        4. Subjects are required to be on antiretroviral regimens that are in accordance with the current International AIDS Society guidelines concurrently with chemotherapy. Use of experimental antiretroviral agents or those containing zidovudine or ritonavir, cobicistat or similar potent CYP3 inhibitors are prohibited, as explained in Section 5.7. In order to be eligible, patients taking zidovudine or ritonavir, or cobicistat or other CYP3 inhibitors must change to a different regimen 7 days prior to therapy initiation. Subjects must be on HAART for at least 12 weeks prior to therapy. See section 10.3
        5. Patients will be required to obtain a pulmonary function test, despite the exclusion of bleomycin from protocol regimen. The subject's diffusing capacity of the lung for carbon monoxide (DLCO) adjusted for hemoglobin must be greater than 70% predicted to enter the study and to continue with brentuximab vedotin
        6. Negative for Hepatitis B, or if infected with Hepatitis B, receiving anti-Hepatitis B therapy. All subjects will be required to be screened for Hepatitis B. Per IDSA and AASD guidelines, those subjects that show no immunity, defined by the lack of Hepatitis B surface antibody, and show evidence of chronic infection (i.e., HBsAg+, HBcore+, HBsAB-) will be required to be on anti-Hepatitis B therapy during the study in order to be eligible. Patients will be permitted to enroll in the study provided normal liver function tests (see Section 9.3) and no evidence of cirrhosis. The exact Hepatitis B therapy will be at the discretion of the infection disease specialist or investigator. However all patients who present with acute hepatitis B or show normal transaminases and are HBsAg+ and IgM+ for Hepatitis core antigen will not be eligible for trial enrollment
        7. Patients diagnosed with Hepatitis C who are Hepatitis C antibody positive, whether Hepatitis C RNA level is measurable or not, must have no evidence of cirrhosis and have liver function tests that conform to Section 9.3

1. Patients with prior anthracycline therapy will be excluded
2. Female subjects who are pregnant or breast-feeding. Confirmation that the subject is not pregnant must be established by a negative serum b-human chorionic gonadotropin (b-hCG) pregnancy test result obtained during screening. Pregnancy testing is not required for post-menopausal or surgically sterilized women
3. Medical illness unrelated to HL, which in the opinion of the study physician will preclude administration of chemotherapy safely. This includes patients with uncontrolled infection (including opportunistic), chronic renal failure, myocardial infarction (MI) within the past 6 months, unstable angina, or cardiac arrhythmias other than chronic atrial fibrillation
4. Prior malignancy within 5 years of enrolment other than curatively treated cutaneous basal cell or squamous cell carcinoma, carcinoma in situ of the cervix, anal intraepithelial neoplasia, or cutaneous Kaposi's sarcoma (KS)
5. Grade 2 or greater peripheral neuropathy
6. Evidence of PML identified on the pretreatment MRI
7. Central nervous system disease
8. Patients with history of JC Virus identified in the CSF or previous history of PML will be excluded from the study
9. Cirrhosis secondary to any cause will be excluded