Introduction: Monoclonal antibody nivolumab (NIVO) blocks Programmed Death-1 ligands avoiding overstimulation of T-cell activity therefore preventing autoimmunity. On May 2016, US Food and Drug Administration granted its accelerated approval in patients with Hodgkin’s lymphoma (HL) relapsed after both autologous stem cell transplantation (ASCT) and brentuximab vedotin (BV), based on the overall response rate (ORR) of 65% from the combined analysis of phase I CheckMate-039 and phase II CheckMate-205 trials. In the setting of allo-SCT, NIVO seems to be associated with increased transplant related toxicity and mortality, e.g. higher incidence of veno-occlusive disease and graft versus host disease (GVHD).
Case report: A 43 years-old male was diagnosed of classical HL stage IIA with bulky mediastinal disease in June 2008. After achieving a PET negative complete remission (CR) with ABVD x6 cycles and involved field radiotherapy, the patient presented an early relapse with stage IIIA disease. He was then treated with salvage second-line therapy with DHAP x3 cycles and consolidated with ASCT with BEAM as conditioning regimen. He achieved a second PET negative CR but experienced a second early relapse (<1 year) after the ASCT that was treated with NOVP x 6 cycles and consolidated with an allo-SCT from his HLA-identical brother in November 2009. In spite of developing clinical significant acute and chronic GVHD, the patient experienced two more relapses treated with BV (1.8 mg/kg iv every 21 days up to 10 cycles – disease progression) and bendamustine single drug (120 mg /m2 iv x2 days, 3 cycles) with disease progression. In September 2015, NIVO was requested through the name patient program in our country. At that time, the patient had progressive disease, stage IVA (bone marrow), no clinically relevant GVHD and no need for active immunosuppression. NIVO was started in October 2015 at a dose of 3 mg/kg iv every 2 weeks with very good tolerance and no reactivation of the prior history of GVHD. The patient achieved a PET negative CR after 6 cycles and nowadays has an excellent performance status under NIVO treatment, in continuous CR by PET CT 8 months after starting this latter therapy.
Conclusion: Our patient, treated in the absence of immunosuppression and almost 6 years after allo-SCT, has significantly benefited from NIVO with no relevant toxicity. Further studies on the role of NIVO before and after allo-SCT should be pursued.